UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Medical services in Vancouver, 1886-1920 : a study in the interplay of attitudes, medical knowledge,… Andrews, Margaret Winters 1979

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1979_A1 A53.pdf [ 15.12MB ]
Metadata
JSON: 831-1.0100285.json
JSON-LD: 831-1.0100285-ld.json
RDF/XML (Pretty): 831-1.0100285-rdf.xml
RDF/JSON: 831-1.0100285-rdf.json
Turtle: 831-1.0100285-turtle.txt
N-Triples: 831-1.0100285-rdf-ntriples.txt
Original Record: 831-1.0100285-source.json
Full Text
831-1.0100285-fulltext.txt
Citation
831-1.0100285.ris

Full Text

MEDICAL SERVICES IN VANCOUVER, 1886-1920 A Study i n the I n t e r p l a y of A t t i t u d e s , Medical Knowledge, and A d m i n i s t r a t i v e Structures by MARGARET W. ANDREWS B.A., Denison U n i v e r s i t y , 1954 M.A., U n i v e r s i t y of B r i t i s h Columbia, 1968 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY i n THE FACULTY OF GRADUATE STUDIES (Department of H i s t o r y ) We accept t h i s t h e s i s as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA June 1979 ©Margaret W. Andrews, 1979 In presenting t h i s t h e s i s i n p a r t i a l f u l f i l l m e n t of the requirements for the degree of Doctor of Philosophy at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I f u r t h e r agree that permission for extensive copying of t h i s t h e s i s for s c h o l a r l y purposes may be granted by the Head of the Department of H i s t o r y or by h i s or her representative. This agreement does not authorize copying or p u b l i c a t i o n of t h i s t h e i s or of any part of i t f o r f i n a n c i a l gain, and my s p e c i f i c w r i t t e n permission i s required for any such copying or p u b l i c a t i o n . Department of H i s t o r y U n i v e r s i t y of B r i t i s h Columbia 2075 Wesbrook Place Vancouver, B.C., Canada ABSTRACT The establishment of the C i t y of Vancouver c o i n c i d e d w i t h the . development of new types of medical treatment made p o s s i b l e by b a c t e r i o l o g i c a l l y - b a s e d s c i e n t i f i c medicine. This t h e s i s d e s c r i b e s the development of medical s e r v i c e s i n Vancouver from 1886, the date of i t s i n c o r p o r a t i o n , to 1920 and thereby exposes the process i n which ' a p p l i c a t i o n s of s c i e n t i f i c d i s c o v e r y were in c o r p o r a t e d i n t o o r d i n a r y l i f e . I t comprises an examination of the environment i n which Vancouver's medical s e r v i c e s grew, of the nature and development of some s p e c i f i c medical s e r v i c e s , and of the i n t e r a c t i o n of s e r v i c e s d u r ing the 1918-1919 i n f l u e n z a epidemic. The s p e c i f i c s e r v i c e s s t u d i e d are: medical attendance, the c i t y ' s p r i n c i p a l h o s p i t a l , n u r s i n g s e r v i c e s provided by a v o l u n t a r y a s s o c i a t i o n , and the p u b l i c school hygiene program of the p e r i o d . As medical science and i t s p a r a l l e l technology grew i n scope and complexity, medical s e r v i c e s p r o l i f e r a t e d and became i n c r e a s i n g l y s p e c i a l i z e d , i n s t i t u t i o n a l i z e d , and subject to the d i r e c t i o n of medical experts; laymen l o s t c o n t r o l over the development of medical s e r v i c e s and the treatment of t h e i r own bodies. Although r e v o l u t i o n a r y i n e f f e c t , those changes occurred e a s i l y i n the period's growing c l i m a t e of f a i t h i n medicine and the commitment of i t s purveyors to h e a l i n g . That f a i t h was encouraged by medical personnel, i n Vancouver b u i l d i n g upon a favourable d i s p o s i t i o n toward h e a l t h p r o j e c t s e s t a b l i s h e d i n the c i t y ' s e a r l y days by s p e c u l a t o r s who had envisoned the c i t y which was to make t h e i r fortunes peopled with a h e a l t h y c i t i z e n r y . Popular acceptance of the new s t r u c t u r e of medical s e r v i c e s i s evidenced by increased demand fo r medical care and by a growth of mechanisms f o r spreading i t s cost w i d e l y enough to support an increased supply. The r e s u l t i n g a v a i l a b i l i t y of medical s e r v i c e c o n t r i b u t e d to the r e l a t i v e l y good s t a t e of h e a l t h which p r e v a i l e d . TABLE OF CONTENTS Chapter 1. Sickness and Health Chapter 2. Attendance by Physicians Chapter 3. H o s p i t a l Services Chapter 4. V i s i t i n g Nursing Chapter 5. School Medical Services Chapter 6. Influenza i n 1918-1919, a Case Study i n the I n t e r p l a y of Medical Services Conclusion Bibliography i v ACKNOWLEDGEMENT I am indebted to Capilano C o l l e g e f o r g i v i n g me the time (through leave of absence) and to the Canada C o u n c i l f o r g i v i n g me the money (through d o c t o r a l f e l l o w s h i p s ) which have l e t me devote myself to t h i s study. The pages which f o l l o w owe much to the kindness and i n g e n u i t y of a l l s o r t s of people whose work or i n t e r e s t s caused me, i n the course of research and w r i t n g , to ask t h e i r h elp. Although some are long-time acquaintances, others - no l e s s h e l p f u l - remained nameless to me, and I th e r e f o r e thank them a l l c o l l e c t i v e l y f o r t h e i r a s s i s t a n c e . I would l i k e , however, to thank two people i n d i v i d u a l l y : John M. N o r r i s , a mentor si n c e the beginning o f my a p p r e n t i c e s h i p i n h i s t o r y who has supervised my work on t h i s t h e s i s , and John L. Baker, my e d i t o r , c r i t i c , c o n s u l t a n t , and f r i e n d who has enriched a l l that f o l l o w s . v CHAPTER 1 SICKNESS AND HEALTH It i s c l e a r that the health of Western populations has improved i n the nineteenth and twentieth c e n t u r i e s . Although many of the s o c i a l a c t i v i t i e s which have supported that improvement were not consciously undertaken for the sake of pub l i c h e a l t h , there have been d e l i b e r a t e changes i n i n s t i t u t i o n s and i n personal health h a b i t s ; i n p a r t i c u l a r , the work of health s p e c i a l i s t s has come to be valued and supported. The growth and functioning of the medical services provided by such s p e c i a l i s t s i n Vancouver during the period 1886-1920 i s the subject of the present study. This f i r s t chapter portrays the environment i n which those services grew and were applied to the task of improving h e a l t h . I t s most important conclusion i s that people with power i n the c i t y believed health to be a s o c i a l matter - believed that the healt h of a l l c i t y r e sidents a f f e c t e d them personally and that health was subject to ma t e r i a l c o n t r o l . This conclusion derives from cons i d e r a t i o n of the actions and achievements of that period: there was l i b e r a l expense of money and e f f o r t on health education, s a n i t a r y engineering, and government i n s p e c t i o n of food and housing; the system of payment for medical services which evolved insured that they would be a v a i l a b l e for most who sought them; and the death rate i n the c i t y (a measure of the state of health of the whole population) remained r e l a t i v e l y low. 1 2 In the i n t e r p r e t a t i o n of i t s evidence, t h i s study genera l l y accepts conventional views of the 1970s about what promotes or hinders good h e a l t h . These views are, however, not completely s a t i s f a c t o r y i n t h e i r e x p l i c a t i o n of the r e l a t i o n s between mind and body, between the p h y s i c a l and s o c i a l environment and i n d i v i d u a l h e a l t h , and between medical treatment and improved h e a l t h ; a strong counter-current i n contemporary thought emphasizes the complex, s u b t l e , and even i d i o s y n c r a t i c nature of the causes of i l l h e a l t h .* The reader should bear i n mind that the conventional assumption that medical care has a p o s i t i v e e f f e c t on health may come to seem as f r u i t l e s s as the alchemists' hope to transmute base metals into gold. But even i f medical services had no m a t e r i a l r e l a t i o n to h e a l t h , the study of t h e i r development would be worthwhile for the evidence i t o f f e r s of the high value people i n our c u l t u r e place on health and of the a u t h o r i t y they consequently vest i n those they b e l i e v e to be purveyors of h e a l t h : i t has i n t r i n s i c value as a study i n the s o c i a l consequences of b e l i e f . * * * The health of Western populations (as measured by longevity) has improved remarkably since the middle of the nineteenth century. A t a b l e i n G.J. S t o l n i t z ' "A Century of I n t e r n a t i o n a l M o r t a l i t y Trends"^ makes ten comparisons regarding l i f e expectancy i n the 1840s and 1940s - for males and females i n each of Sweden, the Netherlands, France, Belgium, and England and Wales. In every case, a l a r g e r f r a c t i o n of the population i n the l a t e r period survived to age 60 than i n the e a r l i e r period survived to age 15: for example, nearly 80% of females i n England and Wales i n the 1940s survived to age 60, whereas fewer than 3 70% survived to age 15 i n the 1840s. This r i s e i n l i f e expectancy f i r s t became marked i n the l a t e nineteenth century, soon a f t e r the b i r t h of b a c t e r i o l o g i c a l medicine and at the time when i t s doctrines were beginning to be applied and taught by the healt h and s a n i t a t i o n departments which had been es t a b l i s h e d by governments e a r l i e r i n the 3 century. Further evidence for inc r e a s i n g long e v i t y i s given by the change i n c h i e f causes of death - from i n f e c t i o u s diseases to accidents and chronic diseases. In the United States death r e g i s t r a t i o n area i n 1900, there were 194 deaths per hundred thousand of population from t u b e r c u l o s i s , 31 from typhoid and paratyphoid fever, and 40 from d i p h t h e r i a ; i n 1950, there were 22 from t u b e r c u l o s i s , .1 from typhoid and paratyphoid fever, and .3 from d i p h t h e r i a . In co n t r a s t , there were 64 deaths per hundred thousand of population from cancer and 345 from major cardiovascular and renal diseases i n 1900, whereas there were 140 from cancer and 511 from major cardiovascular and renal diseases i n 1950.^ Those who e a r l i e r would have died young of i n f e c t i o u s diseases were s u r v i v i n g to die of degenerative diseases. To obtain an o u t l i n e of the state of health i n Vancouver from 1886 (the date of i t s incorporation) to 1920, we turn f i r s t to m o r t a l i t y s t a t i s t i c s . As one would expect, these give g e n e r a l l y the same i n d i c a t i o n s of improving h e a l t h - mainly, that i s , i n d i c a t i o n s of an aging population - as do s t a t i s t i c s f or other places i n the Western World. They show furthermore that Vancouver's death rates themselves were comparatively low. 4 A v a i l a b l e data for Vancouver i n t h i s period are f a i r l y p l e n t i f u l , but somewhat imperfectly a p p l i c a b l e . Before 1914, p r o v i n c i a l agencies tabulated v i t a l s t a t i s t i c s for un i t s which combined other nearby places with the c i t y of Vancouver. The Dominion censuses of 1891 and 1901, which gave m o r t a l i t y s t a t i s t i c s , l i k e w i s e used u n i t s which included more than j u s t the c i t y : Vancouver had about one t h i r d of the population of the 1891 New Westminster census d i s t r i c t , which also included the c i t y of New Westminster (about one s i x t h of the d i s t r i c t population) and other nearby places; Vancouver had about two t h i r d s of the population of the 1901 Burrard census d i s t r i c t , which also included the mainland coast as far north as Bennett and A t l i n . There are also some gaps i n the a v a i l a b l e data: although the C i t y of Vancouver Health Department kept records of deaths w i t h i n the c i t y , i t tabulated and published these only for the years a f t e r 1906; some such tabu l a t i o n s for years i n the 1890s were published by the p r o v i n c i a l Board of Health, but otherwise these data for 1906 and p r i o r years have come to hand only i n the case of some data for 1898 recorded i n the C i t y Clerk's correspondence and some for 1888 contained i n a promotional pamphlet w r i t t e n by the Mayor. Table 1 shows the death rates i n Vancouver for the periods 1895-1898 and 1907-1920. The annual rate f l u c t u a t e d between 9 and 18 deaths per thousand of population, with the lowest rates c o i n c i d i n g with the depression of 1913-1915^ and the highest rate c o i n c i d i n g with the in f l u e n z a epidemic of 1918. Figure 1 compares Vancouver's death rates with those of Chicago, Toronto, and "Urban Saskatchewan" (comprising Saskatchewan v i l l a g e s , towns, and c i t i e s , the larg e s t of which was one t h i r d the s i z e of Vancouver). In comparison with death rates for these 5 Table 1 DEATHS IN VANCOUVER 1895-98 AND 1907-20 Annual Rate Year Population* Deaths per 1000 1895 17,400 161 9.3 1896 18,400 192 10.4 1897 19,500 220 11.3 1898 21,000 267 12.7 1907 55,900 679 12.1 1908 63,200 590 9.3 1909 72,400 735 10.2 1910 86,000 890 10.3 1911 102,100 1163 11.4 1912 116,500 1192 10.2 1913 118,100 1179 10.0 1914 110,100 1013 9.2 1915 102,000 972 9.5 1916 97,000 1097 11.3 1917 99,200 1190 12.0 1918 105,800 1846 17.4 1919 115,900 1530 13.2 1920 123,900 1622 13.1 * Estimated mid-year population, being for each year the geometric mean of the bracketing year-end populations given i n the C i t y ' s 1922 Annual  Report, rounded to the nearest hundred. Sources: Vancouver, Annual Report, 1922, pp.68-69; M.H.O., 1911, p.17; 1916, p.12; 1919, p.12; 1920, p.12; C i t y C l e r k ( i n ) , v.12 (1898), pp.9601-9615 (Dr. MacLean, Medical Health O f f i c e r , Report for 1898); B r i t i s h Columbia, Board of Health, Report, 1897, p.1181. (Key to abbreviations may be found on page 45.) 6 Figure 1. Death Rates 1907-1920 Vancouver vs. Toronto, Chicago, Saskatchewan Towns (Annual Rates per 1000 Population) 7 and other urban places, Vancouver's were low i n the period 1907-1920." The only f i r m data r e l a t i n g to Vancouver death rates p r i o r to 1895 are the 1891 Dominion census reports.^ These show an annual rate of 6.1 deaths per thousand of population for the New Westminister d i s t r i c t , with rates of 14.0 for Canada, 13.9 for B r i t i s h Columbia, 11.8 for the V i c t o r i a d i s t r i c t , 23.7 for the Vancouver d i s t r i c t (which comprised most of Vancouver Island and the Gulf I s l a n d s ) , 21.8 for the Yale d i s t r i c t , and 28.3 for the Cariboo d i s t r i c t . ^ Because of the combination of urban and nonurban areas i n the New Westminster d i s t r i c t and i n other B r i t i s h Columbia d i s t r i c t s , these data require c a r e f u l i n t e r p r e t a t i o n ; i t i s h e l p f u l to compare them with 1901 census data, g i v i n g a t t e n t i o n to the age d i s t r i b u t i o n s of the populations and the d i s t r i b u t i o n of ages of death (shown i n figures 2 and 3). The 1901 census report shows an annual rate of 7.9 deaths per thousand of population for the Burrard d i s t r i c t , with rates of 15.1 for Canada, 9.8 for B r i t i s h Columbia, 16.7 for the V i c t o r i a d i s t r i c t (with 88% of i t s population i n the c i t y of V i c t o r i a ) , 16.6 for the New Westminster d i s t r i c t (with 27% of i t s population i n the c i t y of New Westminster), 11.4 for the Vancouver d i s t r i c t (with 38% of i t s population i n the c i t y of Nanaimo), and 5.1 for the d i s t i n c t l y nonurban Cariboo and Yale d i s t r i c t . ^ Considered a l l together, these data - e s p e c i a l l y the ones for the Yale, Cariboo, and V i c t o r i a d i s t r i c t s - give the impression that urban death rates were lower than nonurban i n 1891, that the urban rates rose while nonurban rates f e l l i n the 1890s, and that the d i f f e r e n c e s among the various age d i s t r i b u t i o n s are not great enough to account for the d i f f e r e n t death r a t e s . I t f o l l o w s , since Vancouver was urbanizing i n the 1890s ( i t s 8 Figure 2. M o r t a l i t y by Ages of the Dead, with Population by Age B r i t i s h Columbia Census D i s t r i c t s , 1891 a. b. -New Westminister District, Total population: 42,226 Ages 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 IT I Victoria District, Total population: 1 •1 1 1 1 1 1 1 1 1 1 1 1 > Ages 100 95 90 . 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 151413121110 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10111213141516171819 20 Percent of Population Deaths per 10,000 of whole population 1891 18,538 n T I T I T I ir i n — r r —1—I—I—1—I I I—F—1—I—I—1 1 151413121110 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 1011121314151617181920 Percent of Population Deaths per 10 ,000 of whole population d. Vancouver District, 1891 Total population: 18,229 Ages 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 Vale District, 1891 Total population: 13,661 -1—i—i—i—i—i—i—i—i—i—I—I—I—i—r™ Ages 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 . 25 20 15 10 5 0 151413121110 9 8 7 6 5 4 3 2 0 1 2 3 4 5 6 7 8 9 101112D14151617181920 Percent of Population Deaths per 10,000 of whole population IT I rr i —i—i—i—i—i—i—i—i— i i i—• i i i—i—r™ 151413121110 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 ID 11121314 IS 16171819 2D •Percent of population Deaths per 10,000 of whole population e. Cariboo District, 1891 Total population: 5,519 Ages 100 95 90 85 80 75 70 65 60 55 50 4S 40 35 30 25 20 15 10 5 0 r r I I I—I—I—T— —i—i—i—i—i—i—i—i—m LEGEND Scales are for five-year age groups. For n-year age groups, m u l t i p l y by n/5. > group value. s i g n i f i e s death rate for age greater than maximum scale 151413121110 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 1011121314151617181920 Percent of Population Deaths per 10,000 of whole population 9 Figure 3. M o r t a l i t y by Ages of the Dead, with Population by Age B r i t i s h Columbia Census D i s t r i c t s , 1901 a. b. Burrard District, Total population! 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 1901 42,060 Tl Tl Tl Tl J l n IT n — r " i — r ~ i — i Victoria District, 1901 Total population: 2 3 , 6 8 8 - i—i—i—i—i—r—i— r ~ r ~ 151413121110 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 10111213141516171S1920 Ages 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 T T IT IT r r l~T -1—I—I—i—i—r~ 151413121110 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 ID 11121314 151617181920 Percent of Population Deaths per 1 0 , 0 0 0 of whole population Percent of Population Deaths per 1 0 , 0 0 0 of whole population C . New Westminister District, 1901 Total population: 2 3 , 8 2 2 Ages 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 r rr i Vancouver District, Total population: 151413121110 9 8 7 6 5 4 3 2 1 0 1 2 3 4 S 6 7 8 9 ID 11121314 1516171819 20 Ages 100 95 90 85 80 , 75 70 65 60 55 50 4S 40 35 30 25 20 IS 10 - 5 0 r 1901 2 7 , 1 9 8 n Tl T l T l rr i r r -1514D121110 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 7 8 9 ID 11121314 151617181920 Percent of Population Deaths per 1 0 , 0 0 0 of whole population percent of Population Deaths per 1 0 , 0 0 0 of whole population Yale and Cariboo District, 1901 Total population: 61,889 Ages 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 n Tl Tl n in m rr r r -T I i — i T T T l 1 1 ~i—r i i i i i i — i — i — i — i — i — i — i — LEGEND Scales are for fiv e - y e a r age groups. For n-year age groups, m u l t i p l y by n/5. > group value, s i g n i f i e s death rate for age greater than maximum scale 151413121110 9 8 7 6 5 4 3 2 1 0 Percent of Population Deaths per 1 0 , 0 0 0 of whole population 10 population doubled i n that decade), that death rates there were probably lower before 1895 than a f t e r . The death rate i n Vancouver before 1920 was r e l a t i v e l y s t a b l e , but changes i n the d i s t r i b u t i o n of ages of death show that longevity and l i f e expectancy were not. (See figures 2(a), 3(a), 4, 5, and 6.) The rate of infant m o r t a l i t y (death i n the f i r s t year of l i f e ) decreased s i g n i f i c a n t l y between 1907 and 1920: i n the period 1907-1913, the average annual number of infant deaths per ten thousand of the whole population was 23.8; i n the period 1914-1920, i t was 15.6. Infant m o r t a l i t y n a t u r a l l y dominates the pattern of deaths i n the f i r s t ten years of l i f e : i n the period 1907-1913, the average annual number of deaths of people under ten years of age per ten thousand of the whole population was 33.4; i n the period 1914-1920, i t was 24.0. Deaths i n l a t e childhood and e a r l y adolescence occurred at f a i r l y s t a b l e , s l i g h t l y i n c r e a s i n g rates: i n the period 1907-1913, the average annual number of deaths of people aged 10 through 19 per ten thousand of the whole population was 4.4; i n the period 1914-1920, i t was 5.1. (Epidemic i n f l u e n z a increased death rates for people i n the prime of l i f e unusually i n 1918 and 1919; i f these years are excluded from the l a t t e r period, the average annual rate for the age group 10-19 drops to 3.9.) Deaths i n the prime of l i f e increased somewhat more: i n the period 1907-1913, the average annual number of deaths of people aged 20 through 49 per ten thousand of the whole • population was 42.9; i n the period 1914-1920, i t was 52.1. (With the exclusion of 1918 and 1919 from the l a t t e r period, t h i s rate was 42.2.) Death i n middle age and beyond increased s i g n i f i c a n t l y : i n the period 1907-1913, the average annual 11 Figure 4. M o r t a l i t y by Ages of the Dead Vancouver, 1907-1911 a. b. Vancouver, 1907 Total population: Ages 100 95 • 90 • 85 • 80 • " -f 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 55,900 Vancouver, 1908 Total population: 63,200 Ages 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 1 2 - 3 4 5 6 7 8 9 1 0 Deaths per 10,000 of whole population n T l T I T I 0 1 2 3 4 5 6 7 8 9 1 0 Deaths per 10,000 of whole population Vancouver, 1909 Total population: Ages 100 95 90 85 80 75 70 65 60 55 50 4S 40 35 30 25 20 15 10 5 0 1 2 3 4 5 6 7 8 9 1 D Deaths per 10,000 of whole population e. Vancouver, 1910 Total population: Ages 100 95 90 85 80 70 f 65 | 60 4-5 5 T 50 } 45 { 40 4-30 } It] " f 0 4-T l T l T I T I T l 10 Vancouver, 1911 Total population: Ages 100 j — 90 { 85 { 80 4— 70 4-65 { 60 4— 50 j -45 { 40 4— 30 f -25 { 11 f Deaths per 10.000 of whole population Daaths per 10,000 of whole population LEGEND Scales are for five-year age groups. For n-year age groups, m u l t i p l y by n/5. > s i g n i f i e s death rate for age group greater than maximum scale value. 12 Figure 5. M o r t a l i t y by Ages of the Dead and Cause of Death Vancouver 1912-1920 a. b. Vancouver, 1912 Total population! Ages 100 T 95 90 85 80 75 70 55 60 55 50 45 40 35 30 25 20 15 H I 1 I T w "87 r T ft i l l i i si T f r r Tttl is ?r-r i 10 Vancouver, 1913 Total population! Ages 100 Deaths per 10,000 of whole population 95 T"1 >°i! " H i 7oLJ2 65 60 55 50 45 40 35 30 25 20 15 10 s 4! 0 i i S I Vancouver, 1914 Total population: Ages 0 1 2 3 4 5 6 7 8 9 1 0 Deaths per 10,000 of whole population Deaths per 10,000 of whole population Vancouver, 1915 Total population: 102,000 Vancouver, 1916 Total population: Ages 100 • 95 90 85 80 75 70 65 111 1 Tl Tl ±K so T M rti Vancouver, 1917 Total population: Deaths per 10,000 of whole population Deaths per 10,000 of whole population Deaths per 10,000 of whole population LEGEND Scales are for five-year age groups. For n-year age groups, m u l t i p l y by n/5. value. >^ s i g n i f i e s death rate for age group greater than maximum scale V//////A Causes | of death: Heart Kidney Cancer Tuber- Ext e r n a l Other Disease Disease c u l o s i s 13 F i g u r e 5 ( c o n t i n u e d ) h. Vancouver, 1918 TotAl population: 105,800 Vancouver, 1919 Total population; Vancouver, 1920 Total population: Ages 100 95 90 85 80 75 70 85 60 55 50 45 40 35 30 25 20 15 10 1 VA T m ft! i 1 VA T \A ! S 3 ! > > S 3 ! > > « S \ i > 1 IN I i T f o 1 1 Ages ItEili ~j 0 1 2 3 4 5 6 7 8 9 1 0 Deaths per 10,000 of whole population Deaths per 10.000 of wHole population Deaths per 10,000 of whole population g 1 (Note s c a l e change). h' Vancouver, 1918 Total population: Ages 100 -p, 95 i 80 y. 7S I 70 T M I 60 i " T 50} 4 5 T 40 i -35 30 25 20 15 10 5 0 £i l m W 0 1 2 3 4 5 6 7 8 9 10111213141516171819 20 Deaths per 10,000 of vhole population Vancouver, 1919 Total population: Vancouver, 1920 Total population: 1 2 3 4 5 6 7 8 9 1011121314151617181920 Deaths per 10,000 of whole population Ages 100 95 90 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 0 T t 1 I 1 I 1 I T T T T H I Tin T r T T T 7 tHI I TNI I • ' ' i i i i i i i i i i i t i i i i i > 0 1 2 3 4 5 6 7 8 9 10 U121314 1516171819 20 Deaths per 10,000 of whole population LEGEND S c a l e s are f o r f i v e - y e a r age groups. For n-year age groups, m u l t i p l y by ri/5 . • v a l u e , > s i g n i f i e s death r a t e f o r age group g r e a t e r than maximum s c a l e Causes o f death: Heart K i d n e y Cancer Tuber- E x t e r n a l Other D i s e a s e D i s e a s e c u l o s i s 14 Figure 6a. Death Rates i n Whole Population for Age Groups (Shown Cumulatively) Vancouver 1907-1920 15 Figure 6b. D i s t r i b u t i o n of Ages of Death Vancouver, 1907-1920 '•VuMAli^'Vr'IY l& .:'::-.-[.:::.:::. .:.::: pi: -::7: j ~:::p-:.L- 7!7!:[-!:!E r - •~:~'i.'.:::LT 1 -.:.:-::!.::-:.: .:::.: j:::: :z :..: j:.::.: z:':':':\ EE'/EE / ; ••77-!:!:=-: !! 77: j:-7!7: : : :L ; : :-I . : : : : : : -:.:-r:t:.:::: -.Liz* :.:::.: i -•-j::.b:r /E/|/:7E ::::.: (-_:•;:. :rr:}.: z.zz •;:!!E|777' -::r:-r~7j: 77!7i777 EE!///// 777 ZZZIZV-ZZZ L j 7771777 E!7J7E! . i. i EEI777-:T::r.ir:::::: :::::::lz:z: ZZZ-ZlZVlZ . : i 1 < /EEEE EEEE • • —I- ::-:-:: t::::.:r '• - • • • ::::::.; j::::.':-: .::r:"i:.::: 777/7: :-::!t"!:v: .:.:.::/::.:: :.::: 1 -?.r i M : TEE:* : ; E E : . /E/j.EE .....\ EEIEE 7/71/77 • • — ! E/7|7.!/! 7//:l:7.!: 1 —t EE!:J77!7 r E l E 7 1 ::i.-:L.::: 1 .:.::-!:::::-„; i • • • • ! // !7;77E E/7 i ~ ::|::T: fin E7:!7Er E77/E i • . i i.... .. — • i — ^Ei7Er:77: : 7: r j:EEE .... i :::: r:::: • • I - - - - !!.7!:!77|:77! n 777fEE \ ^ ; 7L I . . .E7-!7E/ !777ri7777: ::::rsi E7:[EE 7EEE7: ::::=.[.:::: 1 • • -i ... _i r--t.-:::::. A «'/(tV E7lE7!: ::::.: 1: :::  :::::.[-:::: •-•""-I .— --pr::. :::: fa ..._._[.._._.. 77EJ7E: • E!!7|.E7! 77EE77 E7|:7E. -::-:1-T:.-.:.:::-1::.:::::: ::::-(::::::-:--7~..l:-~.z :77!J !7E !!/!:7i/!!:E :"-:rri:.;':" •.:.ZL".|::.-TL EEJ7E!: 1 -: :::: ::j.:::rr ! .:::.::::pr:: -:-:-|:::r.:.T .i.jij.:.::::: A n » :::::.lb:::.r r - 7E!j!EE 7E!:i7!:!7 E7|EE _:::::!:.—_ r 0 A ^es IC : >Jl9 ' rr™;:.:-". 77EE7 ... ^ 777|E!E ; 4 > ;,!Ej777 7!77E^ p:::: . : : : : • != : !E7J77 •! , " ! : ^ - rE7i/.:.:: /!7/)7;E ::.:: j.::.:" - c 1 1 t s !!7:7::j:777: :::-::(::=: n M 7E7J7E! E^JEEE E77I7E/!-/7!'!77:n^-^ :•••.[ « i ^ E ! - -: . : : : ; : : : : : l::::i:::-|:-:-—V . 1.: — , — l=:p:::::: .—::r.j:::-:.: zz:z:xz::::: ! — i — !EH^|E7!E!/|E/E!/!7 ":::.:i::.-.|-:::: :::::::-:|:::: p;-r|--rr: E7E7E7 :: :::.:i::; ::: .:-::::h:~: E E J E E E!7Ei7!!77 E7177:! :::•: i:.~: 7/7/!.!E!7JE!7 :|7E!' .!!//!/! 7 -!'7iE7i77/ ( fci/77 .E7JE7: .-.:•.-!=:.-: [? r ft 0 V;: t 0^) 1 1 ? 1 / 2 : ' 9 - 1 i-.-_r|—rr EEpE7 .IEE V | .r::::.|::::-C.......1 * \ i ' ' : ; E '" : ^ •: :-~i:::r:l:--:!.-.-: 7 \ 7/7:j77E 7EEE77 : : : : : " 7E!p7 EE.-:.:.p::'.::: EEpE!! 7!Et7E /7!!!.!!!/7!! i '—- i — : - . • : _ ! : : . : . : :|.:.:.:T.1 :.:::: 16 number of deaths of people aged 50 and above per ten thousand of the whole population was 29.2; i n the period 1914-1920, i t was 40.5. (Influenza had l i t t l e e f f e c t on t h i s r a t e ; with 1918 and 1919 excluded from the l a t t e r period, i t i s 40.0.) Figure 5 shows, along with the ages of the dead, the frequency of some causes of death for the period 1912-1920. The d i s t r i b u t i o n of causes of death w i t h i n each age group was reasonably consistent throughout the period (£ f o r t i o r i , so was the o v e r a l l d i s t r i b u t i o n ) , with the f o l l o w i n g notable exceptions. The rate of death i n 1918 and 1919 from causes other than the f i v e named was quite high, p a r t i c u l a r l y i n the age groups 10-39; t h i s i s c l e a r l y due to the i n f l u e n z a epidemic. The rate of death due to e x t e r n a l causes (acc i d e n t s , homicide, and s u i c i d e ) i n the age group 20-29 decreased over the period; perhaps t h i s , l i k e the enactment of workmen's compensation laws by the p r o v i n c i a l l e g i s l a t u r e i n 1891, 1902, and 1916, i n d i c a t e s a change i n expectation with respect to the safety of working people. The o v e r a l l rate of death due to external causes was somewhat lower during the war years, as would be expected with many men away on m i l i t a r y duty and many unemployed during the depression of 1913-1915. Useful as m o r t a l i t y f i g u r e s are as d i r e c t evidence of extreme i l l h e alth and i n d i r e c t evidence of improved h e a l t h , they t e l l l i t t l e about the prevalence of nonfatal forms of i l l h e a l t h . I t would be i d e a l to have data from medical examinations of a reasonable sample of the population, such as a goodly set of l i f e insurance applicants or army r e c r u i t s , but i t seems that no such record now e x i s t s . ^ Of the data which have come to hand, the best s u b s t i t u t e s are the C i t y Medical 17 Table 2 REPORTED INCIDENCE OF CONTAGIOUS DISEASES VANCOUVER 1908-1920 1908 1909 1910 1911 1912 1913 1914 Population* 63,200 72,400 86,000 102,100 116,500 118,100 110,100 Measles 327(3) 51.7 .5 418 57.7 790(2) 91.9 .2 498(3) 48.8 .3 1310(15) 112.4 1.3 155(1) 13.1 .1 102 9.3 TB 71(72) 11.2 11.4 66(71) 9.1 9.8 76(98) 8.8 11.4 137(122) 13.4 11.9 85(124) 7.3 10.6 202(128) 17.1 10.8 222(126) 20.2 11.4 Sc a r l e t Fever 51(1) 8.1 .2 168(10) 23.2 1.4 168(3) 19.5 .3 340(12) 33.3 1.2 125 10.7 73(2) 6.2 .2 60 5.4 Chicken Pox 164 25.9 112 15.5 193 22.4 67 6.6 50 4.3 96 8.1 442 40.1 Whooping Cough 89 14.1 258(6) 35.6 .8 85(1) 9.9 .1 50(1) 4.9 .1 114(10) 9.8 .9 123(2) 10.4 .2 118(5) 10.7 .5 Mumps 150 23.7 138(1) 19.1 .1 13 1.5 187 18.3 97(1) 8.3 .1 318 26.9 155 14.1 Diphtheria 93(8) 14.7 1.3 49(3) 6.8 .4 57(3) 6.6 .3 157(19) 15.4 1.9 126(11) 10.8 .9 67(4) 5.7 .3 16(1) 1.5 .1 Typhoid 83(7) 13.1 1.1 142(7) 19.6 1.0 265(27) 30.8 3.1 212(29) 20.8 2.8 163(21) 14.0 1.8 62(9) 5.2 .8 50(6) 4.5 .5 Smallpox 41 6.5 18 2.5 16 1.9 49 4.8 3 .3 11 .9 8 .7 Acute P o l i o . 0 0 30(2) 3.5 .2 4(2) .4 .2 5(1) .4 .1 2 .2 0 LEGEND: E n t r i e s are i n the form Reported Cases (Deaths) Cases per 10,000 Pop. Deaths per 10,000 Pop. 18 Table 2 (continued) 1915 1916 1917 1918 1919 1920 Population* 102,000 97,000 99,200 105,800 115,900 123,900 Measles 1252(9) 1101(8) 222(1) 1573(11) 31 652(8) 122.7 113.5 22.4 148.7 2.7 52.6 .9 .8 .1 1.0 .6 TB 246(143) 225(154) 288(158) 299(149) 407(156) 267(168) 24.1 23.2 23.0 28.3 35.1 21.5 14.0 15.9 15.9 14.1 13.5 13.6 Sc a r l e t Fever 23 35 131(2) 53(2) 65(1) 213(2) 2.3 3.6 13.2 5.0 5.6 17.2 .2 .2 .1 .2 Chicken Pox 391 177 286 178 309 156 38.3 18.2 28.8 16.8 26.7 12.6 Whooping Cough 195(8) 246(13) 84(3) 131(9) 75(2) 108(2) 19.1 25.4 8.5 12.4 6.5 8.7 .8 1.3 .3 .9 .2 .2 Mumps 27 67 386 113 18 124 2.6 6.9 38.9 10.7 1.6 10.0 Diphtheria 36(1) 67(2) 73(10) 74(1) 197(16) 178(17) 3.5 6.9 7.4 7.0 17.0 14.4 . 1 .2 1.0 .1 1.4 1.4 Typhoid 35(3) 30(3) 30(2) 37(5) 9(1) 24(2) 3.4 3.1 3.0 3.5 .8 1.9 .3 .3 .2 .5 .1 .2 Smallpox 5 0 10(3) 4 34 32 .5 1.0 .3 .4 2.9 2.6 Acute P o l i o . 0 12(1) 21(2) 2(1) 1 0 1.2 2.1 .2 .1 . 1 .2 .1 * Estimated mid-year population, being for each year the geometric mean of the bracketing year-end populations given i n the C i t y ' s 1922 Annual  Report, rounded to the nearest hundred. Sources: Vancouver, Annual Report, 1922, pp.68-69; M.H.O., 1910, n.p.; 1911, p.17; 1913, p.17; 1916, p.12; 1919, p.12; 1920, pp.12, 19. (Key to abbreviations may be found on page 45.) 19 Health O f f i c e r ' s annual t a b u l a t i o n of reported cases of i n f e c t i o u s diseases and the records of school medical examinations. The former have the defect of incompleteness, with respect both to the incidence of the diseases and to the type of i l l h e alth reported, and the l a t t e r that of g i v i n g no d i r e c t evidence concerning the health of the adult population; nevertheless, when considered along with the other s t i l l l ess systematic evidence presented below, these give at l e a s t an impression of the extent of nonfatal i l l h e alth i n Vancouver before 1920. From the t a b u l a t i o n of reported cases of i n f e c t i o u s diseases i n the C i t y Medical Health O f f i c e r ' s annual reports for the years 1908-1920 (summarized i n table 2), we may gather the f o l l o w i n g . There were cases of smallpox i n most years, but they were r a r e l y f a t a l . There were cases of chicken pox, mumps, s c a r l e t fever, whooping cough, and measles every year, sometimes i n epidemic proportions. Diphtheria took l i v e s every year, and i t s incidence and death rates i n 1919 and 1920 were the highest of any two consecutive years i n the period. Apart from three s i g n i f i c a n t outbreaks of p o l i o , there were few cases of that disease reported. Cases of t u b e r c u l o s i s were badly under-reported; not only do the figures themselves suggest t h i s , but the Medical Health O f f i c e r ' s report also e x p l i c i t l y , says so. (He estimated elsewhere that only h a l f the cases of t u b e r c u l o s i s were reported.H) The t u b e r c u l o s i s death rate i s s i g n i f i c a n t l y higher for the l a s t h a l f of the period than for the f i r s t h a l f ; i n p a r t i c u l a r , the annual number of deaths was i n c r e a s i n g from 1914 to 1916, while the c i t y population was decreasing. There was a sharp decrease between 1912 and 1913 i n the number of cases of 20 typhoid, coincident with the beginning of c o n s t r u c t i o n of a major sewer extension (described below). Figure 7 shows the geographical d i s t r i b u t i o n (by wards) of reported cases of d i p h t h e r i a , typhoid, t u b e r c u l o s i s , and measles i n the c i t y for the period 1911-1915, along with the d i s t r i b u t i o n of population. The highest incidence of measles i s i n the outer r i n g of wards, which presumably had a large population of c h i l d r e n . Incidence of d i p h t h e r i a was also high i n two of those wards (6 and 7). Incidence of typhoid and t u b e r c u l o s i s was highest i n the i n n e r - c i t y wards, typhoid i n wards 3 and 4, t u b e r c u l o s i s i n wards 2 and 3; those diseases -promoted by overcrowding, d i r t , and unwholesome d i e t - are c h a r a c t e r i s t i c of the poor, and most of the c i t y ' s many impoverished s i n g l e men and foreigners l i v e d i n wards 2, 3, and 4. (This surmise i s supported by the concentration i n these wards of the c i t y ' s population drop i n the years f o l l o w i n g 1913: such u n s k i l l e d workers were p a r t i c u l a r y l i k e l y to be forced to leave i n search of work with the onset of the pre-war depression; l i k e w i s e , t h e i r health p e r m i t t i n g , to be among the e a r l y m i l i t a r y e n l i s t e e s . ) The reports of the School Medical Health O f f i c e r show that he found school-aged c h i l d r e n s u f f e r i n g from decayed t e e t h , d e f e c t i v e eyesight and hearing, enlarged t o n s i l s , g o i t e r , undernourishment, anemia, and other kinds of i l l health which were d i s a b l i n g but r a r e l y f a t a l . These forms of i l l health p e r s i s t e d into the young-adult years: B r i t i s h Columbia Telephone Company records of medical examinations of employees for the period 1916-1920 show de f e c t i v e v i s i o n , decayed teeth, and enlarged t o n s i l s and adenoids to be common 21 F i g u r e 7. I n c i d e n c e of C e r t a i n Contagious D i s e a s e s Vancouver 1911-1915, by Wards •i—i—r—i—i \1 l-J 14 I f S 1 \ 1 1 [j<i i i i i n is 22 F i g u r e 7 ( c o n t i n u e d ) 23 health problems among i t s Vancouver employees-1^; the General Superintendent of Vancouver General H o s p i t a l stated i n 1919 that between 8% and 10% of the women admitted as students i n the h o s p i t a l ' s t r a i n i n g program for nurses were found to be unable to continue because they had such p h y s i c a l defects as heart murmurs, g o i t e r , t u b e r c u l o s i s , or f a l l e n arches, or were d i p h t h e r i a c a r r i e r s . ^ xhe prevalence of minor or chronic forms of i l l health among women with such respectable occupations shows that they were not confined to the poorest c l a s s e s , but rather were widely accepted as a normal part of l i f e - i n p a r t i c u l a r , that medical treatment was u s u a l l y sought only for sickness which was obviously acute. ^  This l a s t hypothesis i s supported by the persistence of high rates of death due to d i p h t h e r i a : a n t i t o x i n had been a v a i l a b l e since before 1900, and as ea r l y as 1910 had been administered free to those unable to p a y ; ^ a c h i l d with the sore throat and fever symptomatic of d i p h t h e r i a was apparently not thought to require medical a t t e n t i o n u n t i l the disease had progressed so far that a n t i t o x i n was u n l i k e l y to be e f f e c t i v e . In the period of t h i s study, there were many s o c i a l a c t i v i t i e s undertaken to promote good health for which the r e s p o n s i b i l i t y was generally believed to be c o l l e c t i v e : payment for services such as water supply, food i n s p e c t i o n , quarantine enforcement, and medical in s p e c t i o n of school c h i l d r e n was made from municipal revenue. Orthodox b e l i e f with respect to payment for attendance by doctors and nurses, on the other hand, was that i t should be made by the patient or by h i s or her family, and that nonpayment was a sign of economic or moral f a i l u r e . ^ 24 At the same t i m e , the o l d e r b e l i e f i n the duty o f c h a r i t a b l e g i v i n g to the s i c k poor i n p r o p o r t i o n to one's means remained i n f o r c e . The sim u l t a n e o u s o p e r a t i o n o f these two p r i n c i p l e s i n Vancouver c r e a t e d a complex but r e a s o n a b l y s a t i s f a c t o r y mechanism f o r p a y i n g m e d i c a l c o s t s . The p r i c e o f m e d i c a l s e r v i c e s was o f t e n beyond the means o f o r d i n a r y w o r k i n g people. Women over e i g h t e e n who were shop c l e r k s were to be p a i d ( a c c o r d i n g to a Minimum Wage Board r u l i n g o f 1918) $12.75 a week, and those who were l a u n d r y w o r k e r s , $ 1 3 . 5 0 ; ^ a woman workin g f o r the t e l e p h o n e company i n 1916 might be p a i d between $1.60 and $2.10 per day, and by 1920 ( w i t h the i n f l a t i o n o f t h a t t i m e ) , between $2.50 and $3.75;1^ a foreman o f a gang of l a b o u r e r s earned $3.00 a day i n 1914, a cement f i n i s h e r , $5.00, and a p l a s t e r e r , $6.00.^0 Some u s u a l minimum m e d i c a l charges i n 1918 were: $2.50 f o r a c o n s u l t a t i o n w i t h a d o c t o r , $1.50 a day f o r a p u b l i c - w a r d bed i n a h o s p i t a l , $4.00 or $5.00 per day f o r the p r i v a t e s e r v i c e s o f a graduate n u r s e . 2 ^ People e a r n i n g the wages of a shop c l e r k , a l a u n d r e s s , o r a p l a s t e r e r c o u l d pay f o r the treatment o f a minor i n j u r y w i t h o u t h a r d s h i p , but p a y i n g f o r treatment o f a severe i n j u r y would r e q u i r e them to d r a s t i c a l l y c u r t a i l normal spending f o r a long time: a j a n i t o r ' s i n j u r y by an e l e c t r i c fan i n 1913 brought a d o c t o r b i l l o f $ 4 0 ; 2 2 a p l a y g r o u n d mishap i n 1916 brought h o s p i t a l and d o c t o r b i l l s o f $125 e a c h ; 2 ^ a p a i n t e r ' s f a l l from s c a f f o l d i n g i n 1914 brought a h o s p i t a l b i l l f o r $190 and a d o c t o r b i l l f o r $ 3 5 0 . 2 4 The r e l a t i v e l y h i g h c o s t o f m e d i c a l treatment made s i c k n e s s or a c c i d e n t i n s u r a n c e - a g r a d u a l payment i n advance - an important means f o r people o f modest income to meet the s o c i a l e x p e c t a t i o n t h a t they pay 25 t h e i r own way. Insurance companies d i d o f f e r p o l i c i e s c o v e r i n g m e d i c a l c o s t s , and t h e r e were even schemes whereby advance payment c o u l d be made d i r e c t l y to a p r i v a t e h o s p i t a l f o r a guarantee of treatment t h e r e when 25 needed; a l l such schemes, however, were beyond the means o f w o r k i n g people g e n e r a l l y . There were, on the o t h e r hand, m e d i c a l a s s o c i a t i o n s or funds m a i n t a i n e d f o r the employees o f c e r t a i n companies ( t h e Canadian P a c i f i c R a i l w a y and some l a r g e c o n s t r u c t i o n f i r m s , i n p a r t i c u l a r ) which were more a f f o r d a b l e , a v o i d i n g as t h e y d i d the payment o f insurance-company p r o f i t s ; the employers a d m i n i s t e r e d these schemes, c o l l e c t i n g funds from p a r t i c i p a n t s by means o f d e d u c t i o n s from t h e i r pay p a c k e t s and u s i n g them to pay d o c t o r , h o s p i t a l , and pharmacy b i l l s . 2 ' ' (A h i d d e n c o s t to p a r t i c i p a n t s i n these was the f a i r l y h i g h r i s k t h e y r a n of i n c o m p l e t e coverage due to d e p l e t i o n o f funds, e s p e c i a l l y i n the case o f p l a n s w i t h o n l y a few p a r t i c i p a n t s . ) U nion membership was a l s o a s o r t of m e d i c a l i n s u r a n c e , s i n c e u n i o n funds were o f t e n used to a s s i s t s i c k members; t y p i c a l l y , a u n i o n committee to v i s i t s i c k members a l s o performed the i n s u r a n c e a d j u s t o r ' s f u n c t i o n - d e t e r m i n i n g whether u n i o n funds s h o u l d be s p e n t . 2 ^ Another way of s a v i n g to meet m e d i c a l expenses, l e s s d i r e c t than bank accounts or i n s u r a n c e schemes, was to accept employment w i t h companies which p r o v i d e d s i c k n e s s or a c c i d e n t b e n e f i t s and, presumably, p a i d lower wages than companies t h a t d i d n o t . The form i n which t h i s s o r t of s a v i n g was a v a i l a b l e i s e x e m p l i f i e d by the p l a n i n a u g u r a t e d i n 1916 by the B r i t i s h Columbia Telephone Company, i n which employees became e l i g i b l e f o r s i c k pay a f t e r two y e a r s ' c o n t i n u o u s employment. Maximum e n t i t l e m e n t s under t h i s p l a n were: f u l l pay f o r f o u r weeks and 26 h a l f pay f o r a f u r t h e r n i n e weeks f o r those who had been employed f o r o n l y two y e a r s ; f u l l pay f o r t h i r t e e n weeks and h a l f pay f o r a f u r t h e r t h i r t y - n i n e weeks f o r those who had been employed f o r t e n y e a r s or 29 m o r e / 3 The customary b e h a v i o u r of the B r i t i s h Columbia E l e c t r i c R a i l w a y Company p r o v i d e s a s i m i l a r example: t h i s company f r e q u e n t l y made payments to employees i n j u r e d on the j o b , the amount o f compensation v a r y i n g w i t h the Company's e s t i m a t e of the r o l e i t s own n e g l i g e n c e p l a y e d i n c a u s i n g the i n j u r y . T h i s b e h a v i o u r , w h i l e l e s s s y s t e m a t i c and comprehensive than the Telephone Company's p l a n , was n e v e r t h e l e s s a t t r a c t i v e , p a r t i c u l a r l y b e f o r e the Workmen's Compensation Act of 1916 took e f f e c t . 3 0 D u r i n g the p e r i o d o f t h i s s t u d y , t h e r e were t h r e e p r o v i n c i a l l e g i s l a t i v e a c t s r e l a t i n g to compensation f o r j o b - r e l a t e d i l l h e a l t h . The Employers' L i a b i l i t y Act of 1891, p a t t e r n e d on the 1880 B r i t i s h Act o f the same t i t l e , a p p l i e d t o most manual l a b o u r e r s (but not to domestic s e r v a n t s ) and a f f i r m e d t h e i r r i g h t to compensation from t h e i r employers i n case of o n - t h e - j o b i n j u r y r e s u l t i n g from employer n e g l i g e n c e ; a l t h o u g h i t l i m i t e d compensation to t h r e e y e a r s ' wages or $2000 at most, t h i s a c t p r o v i d e d an employee more p r o t e c t i o n than he or she had under common law: i t a l l o w e d employers to be h e l d l i a b l e f o r a c c i d e n t s caused by o t h e r employees, and d e n i e d t h a t employers were excused from l i a b i l i t y by an employee's c o n t i n u e d employment a f t e r knowledge o f job 31 h a z a r d s . The Workmen's Compensation Act o f 1902, which a l s o a p p l i e d o n l y to i n j u r i e s due to employer n e g l i g e n c e , set up an a r b i t r a t i o n procedure to which an employee c o u l d have r e c o u r s e i n s t e a d of h a v i n g to i n i t i a t e l e g a l a c t i o n a g a i n s t an employer; at the same tim e , however, i t 27 l i m i t e d compensation even f u r t h e r than the 1891 A c t - awards were l i m i t e d to $10 per week or 50% o f weekly e a r n i n g s , and to $1500 t o t a l at most; i t a p p l i e d o n l y t o c e r t a i n hazardous o c c u p a t i o n s , - and o n l y t o i n j u r i e s which prevented the i n j u r e d from d o i n g f u l l - t i m e work f o r at l e a s t two weeks. Both these A c t s were r e p e a l e d by the Workmen's Compensation Act o f 1916; t h i s a c t covered workers i n a l a r g e number o f o c c u p a t i o n s and gave a s s i s t a n c e t o those s u f f e r i n g from c e r t a i n j o b - r e l a t e d d i s e a s e s as w e l l as from i n j u r i e s . N e g l i g e n c e on the employer's p a r t was not a c o n d i t i o n f o r r e c e i v i n g a s s i s t a n c e under t h i s A c t , nor was the v i c t i m r e q u i r e d to i n i t i a t e a s u i t or a r b i t r a t i o n : i t was s u f f i c i e n t t h a t the Workmen's Compensation Board ( s e t up by t h i s A c t ) be p r e s e n t e d w i t h a c l a i m form accompanied by a p h y s i c i a n ' s c e r t i f i c a t e . Compensation was i n t e n d e d to cover l o s t wages and the c o s t o f m e d i c a l c a r e ; i t was p a i d from c o n t r i b u t i o n s from employers, employees (one cent per d a y ) , and the P r o v i n c e . 3 3 In b r o a d e n i n g f i n a n c i a l r e s p o n s i b i l i t y f o r m e d i c a l c a r e and making such r e s p o n s i b i l i t y independent of n e g l i g e n c e , the 1916 Act a t t r i b u t e d to freedom from j o b - r e l a t e d i l l h e a l t h something o f the c h a r a c t e r o f a r i g h t . I t marked a t u r n i n g : away from the a t o m i s t i c v i e w o f s o c i e t y embodied i n the d o c t r i n e t h a t payment f o r m e d i c a l s e r v i c e s was an i n d i v i d u a l r e s p o n s i b i l i t y , toward the more o r g a n i c v i e w which had g e n e r a l l y p r e v a i l e d i n w e s t e r n s o c i e t y f o r the m i l l e n i u m b e f o r e the i n d u s t r i a l r e v o l u t i o n . More s p e c i f i c a l l y , i t marked a t u r n i n g toward the compulsory h o s p i t a l and m e d i c a l c a r e p l a n s which now c o v e r the day-to-day needs of the whole p u b l i c . 28 S i n c e d o c t o r s d i d a good d e a l o f u n p a i d work ( b o t h i n and out of h o s p i t a l s ) , people w i t h no funds a v a i l a b l e to pay f o r m e d i c a l s e r v i c e s were not l e f t e n t i r e l y u n a t t e n d e d ; 3 4 f u r t h e r m o r e , the C i t y government made m e d i c a l c a r e a v a i l a b l e to the s i c k poor throughout the p e r i o d o f t h i s s t u d y . The H e a l t h Bylaw o f 1887 a u t h o r i z e d p r o v i s i o n of m e d i c a l a t t e n d a n c e , h o s p i t a l c a r e , and m e d i c i n e at C i t y expense, and e a r l y C i t y r e c o r d s i n d i c a t e t h a t men and women were employed to nurse the s i c k poor 35 • • • at home. P r i o r to the appointment of a M e d i c a l H e a l t h O f f i c e r l a t e i n the Summer of 1887, the C i t y bought m e d i c a l a t t e n d a n c e from d o c t o r s i n p r i v a t e p r a c t i c e , from t h a t time u n t i l the C i t y H o s p i t a l opened i n 1888, the M e d i c a l H e a l t h O f f i c e r a t t e n d e d poor p a t i e n t s h i m s e l f ; 3 ^ t h e r e a f t e r , C i t y expense f o r m e d i c a l attendance was m a i n l y i n the form o f s u b s i d i e s p a i d to the C i t y H o s p i t a l or to i t s s u c c e s s o r , Vancouver G e n e r a l H o s p i t a l , 3 ^ where treatment f o r the d e s t i t u t e was r o u t i n e l y p r o v i d e d w i t h o u t charge i n both i n p a t i e n t and o u t p a t i e n t d e p a r t m e n t s . 3 ^ The C i t y a l s o sometimes p a i d b i l l s f o r p a t i e n t s t r e a t e d at o t h e r Vancouver h o s p i t a l s . 4 0 Payments on b e h a l f o f the needy were a l s o made as a c t s o f p r i v a t e c h a r i t y , performed as a s o c i a l duty by a f f l u e n t and w o r k i n g c l a s s e s a l i k e . There was l i t t l e f o r m a l s t r u c t u r e to b r i n g need to the a t t e n t i o n o f p o t e n t i a l i n d i v i d u a l b e n e f a c t o r s i n Vancouver's e a r l y y e a r s , but l i t t l e was needed: the c i t y was s m a l l , and news o f a c c i d e n t or i l l n e s s spread q u i c k l y by word of mouth and through l o c a l newspapers. 4^ Three examples from the l a t e 1880s show the importance o f p r i v a t e g i v i n g and the way i t meshed w i t h C i t y a s s i s t a n c e . An o l d man was i n c a p a c i t a t e d by rheumatism; he l i v e d f o r some time w i t h f r i e n d s who a t t e n d e d to h i s 29 needs; when they c o u l d no l o n g e r do so, he was t r a n s f e r r e d t o the C i t y H o s p i t a l f o r care and t r e a t m e n t . 4 2 W h i l e h e l p i n g to p u l l a f i r e engine to a f i r e , a r e a l e s t a t e agent had h i s f o o t so b a d l y c r u s h e d t h a t i t had t o be amputated; he was i n the C i t y H o s p i t a l f o r f o u r months, had no a c c i d e n t i n s u r a n c e , and c o u l d not a f f o r d the p r i c e o f an a r t i f i c i a l f o o t ; f r i e n d s p u b l i c l y s o l i c i t e d d o n a t i o n s to p r o v i d e one f o r h i m . 4 3 A man i n j u r e d i n a p l a n i n g - m i l l a c c i d e n t was t a k e n to C i t y H o s p i t a l , where he was t r e a t e d by the C i t y M e d i c a l H e a l t h O f f i c e r and a t t e n d e d at n i g h t d u r i n g the s e r i o u s stages o f h i s i l l n e s s by members of the K n i g h t s of L abor; a Vancouver l a d y arranged f o r him to have an a r t i f i c a l l e g , and h i s shopmates p r e s e n t e d him w i t h "a purse of money". 4 4 As the c i t y grew, i n t i m a c y gave way t o anonymity. Newspapers no l o n g e r r e p o r t e d on the h e a l t h of o r d i n a r y c i t i z e n s , and i t was p o s s i b l e f o r people to have so few c l o s e s o c i a l c o n t a c t s t h a t t h e i r i l l n e s s e s would go u n n o t i c e d . 4 ^ I n c r e a s i n g l y , p r i v a t e g i v i n g f o r the b e n e f i t o f the s i c k poor was done through the c i t y ' s numerous v o l u n t a r y c h a r i t a b l e o r g a n i z a t i o n s - the Women's A u x i l i a r y of Vancouver G e n e r a l H o s p i t a l , the R o t a r y Club (which sponsored a t u b e r c u l o s i s c l i n i c ) , and the V i c t o r i a n Order of N u r s e s , f o r example. 4^ These were m i d d l e - c l a s s o r g a n i z a t i o n s and depended upon d o n a t i o n s from the a f f l u e n t f o r t h e i r o p e r a t i o n ; however, they a l s o staged t a g days and used s p e c i a l church c o l l e c t i o n s t o seek c o n t r i b u t i o n s from the g e n e r a l p u b l i c , p r o v i d i n g t h e r e b y an o p p o r t u n i t y f o r the i n c l u s i o n of w o r k i n g - c l a s s c h a r i t y i n t o the more fo r m a l s t r u c t u r e s c h a r a c t e r i s t i c of the i n c r e a s i n g l y i m p e r s o n a l c i t y . A l t h o u g h the system o f payment f o r m e d i c a l s e r v i c e s i n Vancouver was e f f i c i e n t enough to ensure t h a t they were a v a i l a b l e f o r a l l who were 30 w i l l i n g Co seek them, r e c e n t immigrants who were u n f a m i l i a r w i t h both l o c a l i n s t i t u t i o n s and the l o c a l language, people w i t h low wages and l a r g e f a m i l i e s dependent on them, people who were employed i n o c c u p a t i o n s not covered by compensation l a w s , and people who were s o c i a l l y i s o l a t e d a l l were unable t o use c e r t a i n o f the p r o c e d u r e s . F u r t h e r m o r e , the procedures f o r o b t a i n i n g c a r e , perhaps a l s o the i n s t i t u t i o n o f m e d i c a l p r a c t i c e i t s e l f , were so u n a p p e a l i n g to some people t h a t they were u n w i l l i n g t o seek m e d i c a l h e l p . 4 ^ A l l t h e s e reasons f o r e x c l u s i o n o f p o t e n t i a l consumers from the m e d i c a l s e r v i c e system were r a p i d l y b e i n g overcome: good h e a l t h was coming to be seen as a r i g h t , and f a i t h i n the b e n e f i c i a l e f f e c t s of m e d i c a l t r e a t m e n t was growing. The r e s u l t i n g d i s e q u i l i b r i u m between s u p p l y and demand can be p e r c e i v e d i n the c a l l s f o r c e n t r a l i z e d and government-funded p r o v i s i o n o f m e d i c a l s e r v i c e s which were f r e q u e n t by 1920. 4^ A f l o o d of people began to a r r i v e i n Vancouver when c o m p l e t i o n of the Canadian P a c i f i c R a i l w a y made i t p o t e n t i a l l y a major economic c e n t r e , and t h a t f l o o d c o n t i n u e d d u r i n g most of the y e a r s covered by t h i s s t u d y . While m u n i c i p a l a u t h o r i t i e s welcomed growth f e r v e n t l y , they were a l s o s e n s i t i v e to the h a z a r d s i t posed to p u b l i c h e a l t h ; as a r e s u l t , they moved w i t h c o m p a r a t i v e promptness to c r e a t e a p h y s i c a l environment c o n d u c i v e to good h e a l t h . For the c i t y ' s f i r s t few y e a r s , i t s b u i l d i n g s were m o s t l y one- and t w o - s t o r e y frame houses, w i d e l y spaced amid the stumps which marked the area's r e c e n t f o r e s t past and o f t e n set i n l a r g e y a rds e n c l o s e d by 31 f e n c e s ; the scene was d o t t e d w i t h domestic o u t b u i l d i n g s such as p r i v i e s , meat s a f e s , and w e l l s . ^ At f i r s t , r e s i d e n t s c o n t i n u e d to d i s p o s e o f t h e i r r e f u s e i n the way they had found n a t u r a l i n a s m a l l s a w m i l l town -u s i n g p r i v i e s and dumps, the l a t t e r ( e s t a b l i s h e d by consensus) o f t e n i n back l a n e s and vacant l o t s . W i t h i n months o f i n c o r p o r a t i o n , however, t h e r e were c a l l s f o r change;^ 0 a l e t t e r i n The Vancouver A d v e r t i s e r f o r 5 Ja n u a r y 1887 c a l l e d f o r " e f f i c i e n t d r a i n a g e at any c o s t " , d e s c r i b i n g the c i t y ' s "watershed" t h u s : "The whole r e f u s e o f the town, s o l i d and l i q u i d , i s thrown out on the face o f the h e a r t h ; the top s o i l i s about t h r e e f e e t deep and i s t h r o u g h l y s a t u r a t e d w i t h human and animal r e f u s e o f every d e s c r i p t i o n ; the p r i v y v a u l t s are f u l l t o o v e r f l o w i n g . People d r i n k i n g t h i s water are d r i n k i n g p o i s o n ! " T h i s was about the time o f the second m u n i c i p a l e l e c t i o n s , and the n e w l y - e l e c t e d C i t y C o u n c i l , some o f whom had as c a n d i d a t e s endorsed a sewerage system i n December 1886 at p u b l i c r e q u e s t , ^ 1 i n c l u d e d $25,000 f o r d r a i n a g e and sewerage i n a debenture p r o p o s a l put b e f o r e the v o t e r s i n March 1887.-^ T h i s measure was approved u n a n i m o u s l y , ^ 3 and the i n i t i a l segment of the c i t y ' s sewerage system, s e r v i n g the are a bounded by Columbia Avenue on the E a s t , Cambie S t r e e t on the West, H a s t i n g s S t r e e t on the South and Water S t r e e t on the No r t h was opened i n A p r i l 1888; c o m p r i s i n g 5,000 meters o f t i m b e r pipe and 150 meters of c a s t i r o n p i pe and emptying i n t o C o a l Harbour below the l o w - t i d e l e v e l , i t f o l l o w e d the most up-to-date models i n h a v i n g s e p a r a t e p i p e s f o r removal o f household wastes and r a i n w a t e r . ^ 4 Even b e f o r e c o m p l e t i o n o f t h i s segment, C i t y C o u n c i l was p l a n n i n g f o r e x t e n s i o n s to keep a b r e a s t w i t h p o p u l a t i o n growth. 32 P r o v i s i o n o f p i p e d water was undertaken e q u a l l y e a r l y . A l t h o u g h the m u n i c i p a l government b r i e f l y c o n s i d e r e d p r o v i d i n g water i t s e l f , the r e a l c o n t e n d e r s were two p r i v a t e companies. A f t e r months o f n e g o t i a t i o n s and mounting p u b l i c i n t e r e s t , the i s s u e was d e c i d e d at the p o l l s i n June 1887 , when the m u n i c i p a l v o t e r s d e f e a t e d a by-law which would have a u t h o r i z e d the c i t y to guarantee the i n t e r e s t on debentures o f the C o q u i t l a m Water Works Company, and t h e r e b y i n d i c a t e d t h e i r p r e f e r e n c e f o r the Vancouver Water Works Company's p l a n . The l a t t e r r e q u i r e d no guarantees from the C i t y and proposed to b r i n g water from the C a p i l a n o R i v e r a c r o s s B u r r a r d I n l e t , r a t h e r than from Lake C o q u i t l a m , f i f t y k i l o m e t e r s d i s t a n t . W o r k s t a r t e d i n the summer of 1888; water was to be brought from a r e s e v o i r c o n s t r u c t e d t e n k i l o m e t e r s upstream from the mouth o f the R i v e r and c a r r i e d a c r o s s B u r r a r d I n l e t t hrough 350 meters o f 1 2 - i n c h f l e x i b l e - j o i n t p i p e l a i d on the bottom at the F i r s t Narrows; the pipe would thus l i e i n about 20 meters o f water and be s u b j e c t e d to the s w i f t t i d a l c u r r e n t s (15 km/h) which p r e v a i l at t h a t p o i n t . C a p i l a n o R i v e r water flowed i n t o Vancouver i n March 1889; t h e r e had p r e v i o u s l y been no e n g i n e e r i n g achievement comparable to the underwater p o r t i o n o f t h i s p r o j e c t , which was completed by a l o c a l e n g i n e e r , Hugh F. K e e f e r , a f t e r the J e r s e y C i t y e n g i n e e r h i r e d to to the job ( t h e patentee o f the f l e x i b l e - j o i n t p i pe used) had f a i l e d i n h i s attempts and had abandoned the p r o j e c t a l t o g e t h e r . A l t h o u g h Vancouver's n a t u r a l s e t t i n g p r o v i d e d r e l a t i v e l y easy s o l u t i o n s to i t s sewerage and w a t e r - s u p p l y problems - t i d a l w aters f o r sewage d i s p o s a l were at hand, and the water of pure mountain streams flowed to the o p p o s i t e shore of B u r r a r d I n l e t -, i t o f f e r e d l i t t l e 33 assistance i n garbage and trash d i s p o s a l . C i t y o f f i c i a l s had d i f f i c u l t y f i n d i n g and keeping municipal scavengers to cart refuse to a dump,^ and had even more serious d i f f i c u l t y f i n d i n g a s u i t a b l e dumping ground; a f t e r r e j e c t i n g several a l t e r n a t i v e s ( i n c l u d i n g the use of a garbage scow) , they established a temporary dump i n 1888 on land between the C i t y Wharf and the r a i l r o a d tracks.^0 New problems associated with l i v i n g conditions emerged as the c i t y continued to grow, but the sense of having to solve problems from scratch passed; patterns of c i v i c a c t i o n and s o c i a l s t r u c t u r e which pre v a i l e d throughout the period of t h i s study had been e s t a b l i s h e d , i n p a r t i c u l a r the s t r i k i n g readiness of people with power to set up and maintain basic p u b l i c h e a l t h f a c i l i t i e s . . A f t e r the c i t y ' s f i r s t few years, municipal public health work was i n c r e a s i n g l y shaped by experts, p a r t i c u l a r l y the C i t y Medical Health O f f i c e r ; t h e i r p r o f e s s i o n a l i n t e r e s t i n work w e l l done r e i n f o r c e d the movement toward a comprehensive and e f f e c t i v e program. Although the predominant type of housing i n Vancouver was the detached occupant-owned home,^ the housing of the poor there was r a r e l y of that type, and was i n fact commonly unwholesome. As e a r l y as the 1890s, municipal a u t h o r i t i e s began to deal with housing as a p u b l i c - h e a l t h issue, condemning as unsanitary a row of shacks which were b u i l t on p i l i n g s over the t i d a l f l a t s of False Creek i n Chinatown and used the f l a t s as a cesspool.^ 2 Removal of a p a r t i c u l a r l y o f f e n s i v e row of houses did not ,of course, solve the problem of unwholesome housing. The poor, often immigrants from Europe or A s i a , continued to l i v e i n crowded and d i l a p i d a t e d b u i l d i n g s , i n c e l l a r s l a c k i n g daylight or 34 outside a i r , and i n lodging houses which, while comparatively spacious, were often also poorly l i t and v e n t i l a t e d , and often lacked adequate f i r e escapes or t o i l e t f a c i l i t i e s . * ^ 3 While continuing to condemn the most unsanitary b u i l d i n g s m u n i c i p a l a u t h o r i t i e s also attempted to impose housing standards through t h e i r powers of i n s p e c t i o n and l i c e n s i n g under the B u i l d i n g and Lodging-house by-laws.^5 For example, they denied on health grounds 113 of the 184 a p p l i c a t i o n s for lodging-house l i c e n s e s made i n 1911; the C i t y Health Department c r e d i t e d such s t r i c t enforcement with "a large amount of improvement" i n l i g h t i n g , s a n i t a r y conveniences, and beds and bedding i n lodging houses during the f o l l o w i n g year.66 The examples presented here i l l u s t r a t e a change i n a t t i t u d e that should be noticed: i n the 1890s, a u t h o r i t i e s opposed unwholesome housing p r i m a r i l y as a threat to community hea l t h ; by the 1910s, p r i m a r i l y as a threat to the health of those who occupied i t . Although they met with some success, the e f f o r t s of the Medical Health O f f i c e r and other municipal a u t h o r i t i e s to improve housing conditions were balked by the chronic housing shortage which accompanied the c i t y ' s rapid growth, by the reluctance of elected o f f i c i a l s to provide comprehensive by-laws and large budgets for the h e a l t h inspectorate, and by the uncooperativeness of some property owners.^8 Since unwholesome housing (being simply an a t t r i b u t e of poverty) i s fundamentally a consequence of greed, we cannot be surprised that t h e i r b a t t l e against i t was imperfectly s u c c e s s f u l . A municipal i n c i n e r a t o r for garbage, night s o i l , dead animals, and other forms of refuse was opened on the south side of False Creek i n 35 1891; a d d i t i o n a l i n c i n e r a t o r f a c i l i t i e s were b u i l t as the p o p u l a t i o n grew. However, the C i t y c o n t i n u e d throughout the p e r i o d o f t h i s s tudy to charge a fee f o r some o f i t s r e f u s e - d i s p o s a l work, and many r e s i d e n t s l e t r e f u s e accumulate on t h e i r p r o p e r t y or d e p o s i t e d i t i n the h a r b o r , on vacant l o t s , or i n p u b l i c t h o r o u g h f a r e s r a t h e r than pay to have i t ha u l e d away.^° Much a g a i n s t the wishes o f the M e d i c a l H e a l t h O f f i c e r , the C i t y C o u n c i l even a b e t t e d such p a r s i m o n i o u s r e s i d e n t s by p e r m i t t i n g manure and garbage t o be dumped on the shore o f the back reaches o f F a l s e C r e e k . ^ As the C i t y S a n i t a r y I n s p e c t o r p o i n t e d o u t , a c o m p l e t e l y t a x - s u p p o r t e d d i s p o s a l s e r v i c e would have been b e t t e r . ^ 2 Throughout the p e r i o d o f t h i s s t u d y , the m u n i c i p a l sewerage and water systems ( t h e Vancouver Water Works Company had been bought out by the C i t y i n 1891) expanded t h e i r f a c i l i t i e s . L o c a l e x t e n s i o n s were made as areas which had been on the o u t s k i r t s o f the c i t y became more h e a v i l y 7 ^  s e t t l e d : ' - 3 h e a l t h e x p e r t s had complained o f the inadequate s e r v i c e to the Mt. P l e a s a n t and F a i r v i e w areas ( i n wards 5 and 6) i n the decade around the t u r n of the c e n t u r y and to D i s t r i c t Lot 301 (ward 8) and H a s t i n g s Townsite (ward 7) a f t e r t h e i r a n n e x a t i o n to the c i t y i n the second decade of the c e n t u r y . ^ 4 A major e x t e n s i o n o f the water system was made i n 1908 when water from the Seymour R i v e r was brought from the N o r t h Shore of B u r r a r d I n l e t under the Second N a r r o w s . ^ i n 1911, Vancouver j o i n e d w i t h s e v e r a l a d j a c e n t m u n i c i p a l i t i e s and commissioned a l o n g - t e r m sewerage p l a n which s y s t e m a t i c a l l y a t t a c k e d two p e r s i s t e n t s a n i t a r y problems - the p o l l u t i o n o f the c i t y ' s beaches and the presence of sewage from n e i g h b o u r i n g m u n i c i p a l i t i e s i n i t s streams. The p l a n was implemented by the Vancouver and D i s t r i c t s J o i n t Sewerage and Drainage 36 Board, which was c r e a t e d and took i t s f i r s t a c t i o n s i n 1913; R.S. L e a , an e x p e r i e n c e d M o n t r e a l c i v i l e n g i n e e r and the o r i g i n a l a r c h i t e c t o f the p l a n , i n e v a l u a t i n g the work done up to 1917 ( a p p a r e n t l y at the r e q u e s t o f the B o a r d ) , judged "the sewers . . . s u p e r i o r to those o f the g r e a t m a j o r i t y o f c i t i e s anywhere i n the w o r l d and . . . e x c e l l e d by none."^^ The i n c r e a s i n g i n f l u e n c e o f e x p e r t s on p u b l i c h e a l t h work i s v e r y w e l l i l l u s t r a t e d by the development o f government c o n t r o l over the q u a l i t y of the l o c a l m i l k s u p p l y . P u b l i c i n t e r e s t i n pure m i l k was the r e s u l t o f campaigns by h e a l t h e x p e r t s , the g e n e r a l i t y o f B r i t i s h Columbians p a y i n g "a g r e a t d e a l more a t t e n t i o n t o the c r e a m - l i n e on the top of the b o t t l e than the d i r t on the bottom of i t " , as one e x p e r t o b s e r v e d ; ^ i n d e e d , w a t e r i n g of m i l k was the c h i e f c o m p l a i n t about the m i l k s u p p l y e a r l y i n Vancouver's h i s t o r y . ^ At the i n s t i g a t i o n o f the M e d i c a l H e a l t h O f f i c e r , the C i t y began i n the 1890s to take a c t i o n a g a i n s t the vending o f m i l k from d i r t y d a i r i e s and d i s e a s e d cows,79 but the b u t t e r f a t c o n t e n t o f m i l k c o n t i n u e d to be a m a t t e r o f equal c o n c e r n : i n 1896, f o r example, the C i t y C o u n c i l i n s t r u c t e d the C i t y M i l k I n s p e c t o r to p r o s e c u t e m i l k vendors who s o l d m i l k which was f i l t h y o r had l e s s than 3.5% b u t t e r f a t c o n t e n t . ^ 0 E x p e r t s were c o n v i n c e d by the 1910s t h a t a d i e t i n c l u d i n g m i l k w i t h a lower b u t t e r f a t c o n t e n t was s a t i s f a c t o r y or even d e s i r a b l e f o r good h e a l t h , ^ 1 but. m u n i c i p a l by-laws throughout the p r o v i n c e s t i l l r e q u i r e d from 3.5% to 4%.^2 In s p i t e of p u b l i c p r e o c c u p a t i o n w i t h the r i c h n e s s of m i l k , both the c i t y and p r o v i n c i a l governments passed l e g i s l a t i o n to ensure a s a f e m i l k s u p p l y , and by the end of the p e r i o d of t h i s s t udy, d a i r i e s , cheese f a c t o r i e s , and o t h e r p l a n t s u s i n g m i l k or cream were r e q u i r e d to submit 37 to an i n s p e c t i o n which included b a c t e r i o l o g i c a l a n a l y s i s of milk samples.^ 3 B r i t i s h Columbia was i n fact a North American pioneer and leader i n milk p r o t e c t i o n i n the 1910s, being p a r t i c u l a r l y a c t i v e i n e r a d i c a t i n g bovine t u b e r c u l o s i s : nearly a l l of Vancouver's milk supply came from t u b e r c u l i n - t e s t e d herds by 1917. Some health experts believed that i n s p e c t i o n provided i n s u f f i c i e n t p r o t e c t i o n for the c i t y ' s m i l k supply and pressed for pasteurization.^5 Raw m i l k sold to the public commonly contained 400,000 microorganisms per c.c. (Fresh milk c o l l e c t e d under the best of circumstances contained about 500 per c.c.; milk containing more than 1,000,000 per c.c. was considered s u i t a b l e only for c o o k i n g . ^ ) While most b a c t e r i a i n milk merely caused i t to s p o i l and were not pathogenic, microorganisms responsible for t u b e r c u l o s i s , typhoid, d i p h t h e r i a , s c a r l e t fever, or diarrhea did also appear. P u b l i c health experts opposed to p a s t e u r i z a t i o n , on the other hand, argued that pasteurized milk i s less n u t r i t i o u s than raw milk and even that the use of p a s t e u r i z a t i o n would a c t u a l l y encourage the production of unwholesome milk; they argued that d a i r y farmers who know t h e i r milk i s to be pasteurized w i l l handle i t c a r e l e s s l y , thereby increasing the l i k e l i h o o d that enough pathogenic organisms w i l l be present i n the milk to survive p a s t e u r i z a t i o n , which i n commercial p r a c t i c e k i l l e d at best 98% of the b a c t e r i a p r e s e n t . ^ By the end of the period of t h i s study, p a s t e u r i z a t i o n was gaining i n f l u e n t i a l support, most s i g n i f i c a n t l y through a change i n p o l i c y at Vancouver General H o s p i t a l . In 1917, h o s p i t a l t e s t s showed higher b a c t e r i a counts i n i t s milk than contract s p e c i f i c a t i o n s allowed, so h o s p i t a l o f f i c i a l s decided to l e t no tenders 38 for raw m i l k for i t s Infants' H o s p i t a l i n the f o l l o w i n g year and to use pasteurized milk instead, at l e a s t t e m p o r a r i l y . ^ The acceptance of p a s t e u r i z a t i o n by the c i t y ' s leading h o s p i t a l marks the c r y s t a l l i z a t i o n of a s i g n i f i c a n t body of expert opinion i n favour of i t , and l i k e l y d i d much to overcome general r e s i s t e n c e to i t s implementation. * * * Although i t i s d i f f i c u l t to know much about p r i v a t e and ordinary aspects of d a i l y l i f e i n e a r l y Vancouver, the evidence which has come to hand suggests that hygiene p r a c t i c e s and food preferences changed markedly during the years covered by t h i s study; i t may be that drug use did too, and i n any case a l l three were remarkably s i m i l a r to t h e i r counterparts of today by 1920. The probable e f f e c t which changes i n personal behaviour have on the state of health should be borne w e l l i n mind by anyone tempted to a t t r i b u t e the improvement i n health described e a r l i e r i n t h i s chapter s o l e l y to the e f f e c t i v e n e s s of medical s e r v i c e s . Coincident with the extension of municipal water and sewerage systems was the replacement of w e l l s , p r i v i e s , and commode sets by water c l o s e t s and s t a t i o n a r y bathtubs and wash basins. These new f a c i l i t i e s made personal and domestic c l e a n l i n e s s easier to achieve and therefore more l i k e l y , and hindered the spread of c e r t a i n communicable diseases, most notably typhoid f e v e r . ^ R i s i n g l e v e l s of expectation with respect to washing and t o i l e t f a c i l i t i e s (which encouraged municipal spending on water and sewerage systems) were evident before the turn of the century: i t had come to seem appropriate for P u b l i c L i b r a r y patrons to have access to a water c l o s e t and for nurses at the C i t y H o s p i t a l to have a 39 bathtub i n s t a l l e d for t h e i r u s e . 9 0 By 1912, the C i t y Plumbing Inspector could report: "people are no longer s a t i s f i e d with the meager equipment which was considered, only a few years ago, to be s u f f i c i e n t for a residence or apartment block, and conveniences which were thought to be l u x u r i e s are now regarded as ordinary n e c e s s i t i e s . " 9 1 Although there were homeowners who were u n w i l l i n g or unable to pay for the new f a c i l i t i e s (there were, for example, homeowners who delayed or avoided the cost of connecting t h e i r premises to sewers92) s t h e i r adoption made dramatic headway during the period of t h i s study. An idea of working-class d i e t i n Vancouver's e a r l i e s t years i s given by the "normal d i e t " i n e f f e c t i n the C i t y H o s p i t a l i n 1888 (when the well-to-do were r a r e l y p a t i e n t s t h e r e ) . I t s d a i l y content was: e i t h e r seven ounces of meat or twelve ounces of f i s h , a pint of soup which contained some vegetables, eighteen ounces of bread, ten ounces of potatoes, eight ounces of oatmeal mush, four ounces of vegetables, one ounce of molasses, and two p i n t s of coffee or tea; i t also included h a l f an ounce of butter and three ounces of cooked f r u i t three times a week.9 3 While quite d e f i c i e n t i n fresh f r u i t and vegetables, t h i s d i e t has the v i r t u e of supplying c a l o r i e s i n foods - g r a i n and potatoes -which include u s e f u l p r o t i e n and vitamins as w e l l . Over the years of t h i s study, the d i e t of ordinary people came to include increased amounts of fresh f r u i t s and vegetables, but also of "empty-calorie" foods - sugars and f a t s . The f o l l o w i n g menu, drawn up- by the telephone operators who managed the Seymour exchange c a f e t e r i a , and used there on 24 J u l y 1914, exemplifies the ordinary d i e t of that time: banana sandwiches, s l i c e d cucumbers, baked f i l l e t s of salmon with h o l l a n d a i s e 40 sauce, cold roast beef, potatoes, h a r i c o t beans, r o l l s , brown bread, b u t t e r , fresh r a s p b e r r i e s , oranges, ice cream, raspberry p i e , f r u i t l o a f cake, p l a i n l o a f cake, lady f i n g e r s , lemonade, c o f f e e , tea, and milk.94 Various drugs were a v a i l a b l e and widely used i n Vancouver. Chinatown opium dens served both O r i e n t a l and Occidental users.95 Morphine was f r e e l y a v a i l a b l e at drugstores, and i t was reported that most people who spent time as prisoners i n the C i t y J a i l were users of that d r u g . D r u n k e n n e s s and alcoholism were c l e a r l y not confined to people of low s o c i a l standing.9? Patent medicines, which were advertised e x t e n s i v e l y i n l o c a l newspapers and a v a i l a b l e at drugstores, might contain no drug more dangerous than a l c o h o l , or they might contain l e t h a l poisons.9^ By the turn of the century, there was s u f f i c i e n t r e c o g n i t i o n of the hazards inherent i n drug use to prompt establishment of a p r i v a t e i n s t i t u t i o n for the cure of a l c o h o l , morphia, opium, and tobacco habits.99 Moreover, although i t i s impossible to know i f use of drugs such as opium and morphine was s u f f i c i e n t l y extensive to c o n s t i t u t e a serious p u b l i c health problem, people came to b e l i e v e that i t was. In 1907, The Vancouver D a i l y Province, perhaps prompted by the a n t i - v i c e campaign then being conducted by H.H. Stevens ( l a t e r Conservative M. P. for Vancouver), included an a r t i c l e which reported drug use as apparently on the increase. 1°° The 1918 and 1919 annual reports of Vancouver General H o s p i t a l commented on the "alarming" prevalence of drug addiction.101 41 The s i n g l e most important force behind Vancouver's s o c i a l arrangements for promoting heal t h was the c o n v i c t i o n among those with power that health was a s o c i a l matter. They were led to t h i s c o n v i c t i o n by health experts (many of whom were powerful i n t h e i r own r i g h t ) and proceeded on the basis of i t to work for the increase and d i f f u s i o n of good h e a l t h ; t h e i r c h i e f means was education of the p u b l i c i n wholesome personal habits - not j u s t d i d a c t i c education, but also confrontation of the p u b l i c with experts at work: v i s i t i n g nurses, doctors i n w e l l - p u b l i c i z e d c l i n i c s . The r e s u l t i n g r i s e i n health-consciousness i s c h a r a c t e r i s t i c of the period. This process of education began with health experts, who, i n seeking to make good h e a l t h general, were merely extending t h e i r ordinary p r o f e s s i o n a l o b j e c t i v e s . Comments they made upon the state of public knowledge and concern regarding h e a l t h matters show c l e a r l y that they regarded the r i s i n g consciousness as an achievement of t h e i r own. Consider, for example, the f o l l o w i n g statement included i n the report of Henry Esson Young, P r o v i n c i a l Health O f f i c e r of B r i t i s h Columbia, to the P r o v i n c i a l Government i n 1919: The past year has been an eventful one i n p u b l i c - h e a l t h work. There has been a great awakening amongst the p u b l i c , with a consequent strengthening of the hands of those i n charge of of p u b l i c - h e a l t h work, and the r e s u l t has been the b r i n g i n g i n t o p r a c t i c a l e f f e c t many of the recommendations that have been made by health a u t h o r i t i e s from time to time. . . . Health-teaching by P u b l i c Health O f f i c e r s , i n c l u d i n g v i s i t i n g nurses, has made i n the l a s t few years a great impression upon the communities where i t has been c a r r i e d on. Such health education i s going to be recognized as of fundamental importance; i t i s l a r g e l y because of t h i s , and not because disease i s more s u c c e s s f u l l y t r e a t e d , that the great reduction i n the sickness and death-rate has been e f f e c t e d . Unless 42 backed by educational agencies, e f f o r t s at improvement i n public health have almost i n v a r i a b l y proved to be very t r a n s i t o r y i n t h e i r effects.102 To induce widespread change i n personal health habits required a s i g n i f i c a n t marshalling of c u l t u r a l and m a t e r i a l resources. For t h i s purpose, the most important c u l t u r a l resource was the pu b l i c school system, which reached i n t o n e arly every family: the gospel of good health was preached i n schools through such a c t i v i t i e s as l e c t u r e s on c l e a n l i n e s s , demonstrations of i n f a n t care, and toothbrush d r i l l s ; school nurses' v i s i t s to homes and parents' attendance at school medical examinations r e i n f o r c e d the i n s t r u c t i o n given the c h i l d r e n i n school and extended i t to the parents themselves. The press supported the general educational e f f o r t , p u b l i s h i n g expert advice and assessments of the state of health i n the c i t y and r e p o r t i n g enforcement of laws intended to l i m i t the spread of disease. U J Many people who were not e f f e c t i v e l y reached through the schools or the press (perhaps for reasons associated with poverty) received repeated home v i s i t s from nurses whose work included i n s t r u c t i n g them i n infant care and general hygiene. Such i n s t r u c t i o n was also part of the work of City-operated in f a n t - c a r e f a c i l i t i e s - for example, the Creche, which combined the functions of daycare centre ( s t a f f e d by nurses and with a doctor i n attendance) and employment agency for domestic servants h i r e d by the day.^- 0 4 H o s p i t a l outpatient c l i n i c s undoubtedly accompanied t h e i r medical care with at least some measure of i n s t r u c t i o n ; more important, they p u b l i c i z e d by t h e i r very operation the concern of c i v i c leaders for public health and the importance of s c i e n t i f i c knowledge. 43 The marshalling of ma t e r i a l resources f or t h i s d i d a c t i c p u b l i c health work was done mostly by conventional p o l i t i c a l means: school Trustees and administrators h i r e d nurses and approved the use of school time for health education; the C i t y Government employed nurses (or supported semiprivate c h a r i t i e s that d i d so), supported the c i t y ' s p r i n c i p a l h o s p i t a l s , and approved the expenditure of time by employees and o f f i c i a l s of the C i t y Health Department to p u b l i c i z e t h e i r work. C h a r i t i e s not h e a v i l y supported by government - the V i c t o r i a n Order of Nurses, the Vancouver General H o s p i t a l A u x i l i a r y , and the A n t i - t u b e r c u l o s i s League - also employed nurses whose work included teaching; although the budgets of these organizations were small i n comparison with public expenditures, they were important for t h e i r a b i l i t y to keep the questions of pub l i c h e a l t h and healt h education before P o l i t e Society. Thus, although those marshalling the resources of s o c i e t y were not a l l health experts, the plan they followed was thoroughly consonant with the experts' v i s i o n . This i s not s u r p r i s i n g , since h e a l t h experts -doctors i n p a r t i c u l a r - had many oppo r t u n i t i e s to influence p u b l i c p o l i c y : many doctors belonged to the s o c i a l and economic e l i t e of the c i t y and shared club, church, and c h a r i t a b l e a c t i v i t i e s with business and p o l i t i c a l leaders;! 0-* both C i t y Council and the School Board t y p i c a l l y included one or more d o c t o r s . M o r e o v e r , l i t e r a t e people i n our c u l t u r e generally, the powerful i n p a r t i c u l a r , had by that time become proselytes of science and were quick to support p r a c t i c e s a u t h o r i t i v e l y advocated i n i t s name. 44 The c o n v i c t i o n among the powerful that health i s a s o c i a l matter i s s e l f - r e i n f o r c i n g , p a r t i c u l a r l y where (as i n Vancouver during the period of t h i s study) there i s considerable speculation i n m a t e r i a l growth. Insofar as the business and p o l i t i c a l leaders of Vancouver believed t h e i r own health threatened by sickness anywhere i n the c i t y , they must also have considered that a l i k e b e l i e f on the part of p o t e n t i a l immigrants and investors made sickness a threat to t h e i r wealth. [T]he box d r a i n on the south side of Water Street [should be] extended to the top of the h i l l , near the C.P.R. o f f i c e s . The present surface d r a i n presents a most u n s i g h t l y appearance, and being on one of the p r i n c i p a l thoroughfares from steamer and r a i l , c a l l s for more than ordinary attention.107 [ I ] f we desire others to make t h e i r homes with us, we must give them s t r e e t s and sidewalks, water and l i g h t , sewerage and p r o t e c t i o n from f i r e , schools and h o s p i t a l s and a l l these e s s e n t i a l s to our h e a l t h , our p r o s p e r i t y and our comfort should be provided as r a p i d l y as our means permit.108 The fact i s w e l l known that the greatest and best advertisement a c i t y can have i s i t s health.109 Evidence of concern for p u b l i c health on t h i s basis i s abundant i n the l i t e r a t u r e of Vancouver boosterism. NOTES ON CHAPTER 1 Abbreviat ions: B.C.B.H. B.C.E.R. B.C.Tel.E.B.P. C i t y C l e r k ( i n ) C i t y Council D.N.-A. Health Comm. M.H.O. Province School Board U.B.C. V.C.A. V.G.H. V.G.H.,B.D. B r i t i s h Columbia, Board of Health. Annual Report U.B.C, B r i t i s h Columbia E l e c t r i c Railway Company Papers. B r i t i s h Columbia Telephone Company Employees' Benefit Plan Committee. Minutes. (At the Company's o f f i c e i n Burnaby, B.C.) V.C.A., Vancouver, C i t y Clerk's Correspondence (inward). V.C.A., Vancouver, C i t y Council. Minutes. The D a i l y News-Advertiser V.C.A., Vancouver, C i t y Council Health Committee. Minutes. Vancouver, Health Department. Medical Health O f f i c e r ' s  Annual Report. The Vancouver D a i l y Province. V.C.A., Vancouver Board of School Trustees. Minutes U n i v e r s i t y of B r i t i s h Columbia L i b r a r y , S p e c i a l C o l l e c t i o n s . Vancouver C i t y Archives. V.C.A., Vancouver General H o s p i t a l Papers (Add. Mss. 320). V.G.H., se r i e s A, Minutes of Board of D i r e c t o r s . 1. Rene Dubos, Man, Medicine, and Environment (New York, 1968), ch.4; Joseph Eyer and Peter S t e r l i n g , "Stress-Related M o r t a l i t y and So c i a l Organization" Review of Radical P o l i t i c a l Economics, v.9, Spring 1977, pp.1-44; David L. Dodge and Walter T. Martin, S o c i a l Stress and  Chronic I l l n e s s , M o r t a l i t y Patterns i n I n d u s t r i a l Society (Notre Dame, Ind., 1970); Ivan I l l i c h , Medical Nemesis, The Ex p r o p r i a t i o n of Health (London, 1975), pp.15-21. 45 46 2. George J . S t o l n i t z , "A Century of I n t e r n a t i o n a l M o r t a l i t y Trends", Population Studies, v.9, (1955), pp.24-55. (The table mentioned i s on p.29.) 3. S t o l n i t z , pp.29-33; Odin W. Anderson, "Infant M o r t a l i t y and S o c i a l and C u l t u r a l Factors: H i s t o r i c a l Trends and Current Patterns", i n E. Gartley Jaco (ed.), P a t i e n t s , Physicians and I l l n e s s , Sourcebook  i n Behavioral Sciences and Medicine (Glencoe, 111., 1958), pp.13-14; Odin W. Anderson, "Age S p e c i f i c M o r t a l i t y i n Selected Western European Countries with P a r t i c u l a r Emphasis on the Nineteenth Century", B u l l e t i n  of the H i s t o r y of Medicine, v.29, (1955), pp.239-254; George Rosen, A H i s t o r y of P u b l i c Health (New York, 1958), ch.7-8. 4. United States, Bureau of the Census, H i s t o r i c a l S t a t i s t i c s of  the United States, C o l o n i a l Time to 1957 (Washington, 1960), p.26; W i l l i a m H. G l a z i e r , "The Task of Medicine", S c i e n t i f i c American, v.228, no.4 ( A p r i l 1973), p.14; Marc Lalonde, A New Perspective on the Health  of Canada, A Working Document (Ottawa, 1974), c e n t r e f o l d . The l a s t contains charts showing the c h i e f causes of death i n Canada i n 1971 by age and sex. 5. Death rates often d e c l i n e when unemployment rates r i s e . See Eyer and S t e r l i n g , pp.32-33, for a d i s c u s s i o n of t h i s phenomenon i n the period 1870-1970. 6. In 1911, when Vancouver's death rate was 11.8 per thousand of population, Montreal's was 21, New York's was 18.4, Hamilton's was 13, Winnipeg's was 12.8, San Francisco's was 12.8, Tacoma's was 11.2, and Spokane's was 10.9. (M.H.O., 1912, p.3) 7. The promotional pamphlet Province of B r i t i s h Columbia,  Vancouver C i t y , i t s Progress and I n d u s t r i e s , with P r a c t i c a l Hints for  C a p i t a l i s t s and Intending S e t t l e r s , by David Oppenheimer (Vancouver, 1889; V.C.A. has a copy) contains the 1888 annual report of the C i t y Council Health Committee. The m o r t a l i t y figures given i n that report have not been used here, since meaningful m o r t a l i t y rates cannot be c a l c u l a t e d from them without knowledge of the age d i s t r i b u t i o n and s i z e of the Vancouver population; information on the former i s l a c k i n g , and estimates of the l a t t e r vary widely. 8. Canada, Dept. of A g r i c u l t u r e and S t a t i s t i c s , Census of Canada,  1891, v.2 (Ottawa, 1893), pp.2-5, 70-71. 9. Canada, Dept. of A g r i c u l t u r e , Census of Canada, 1901, v.4 (Ottawa, 1906), pp.2-5, 278-281. 10. There are, of course, quite a l o t of data on h o s p i t a l p a t i e n t s , but the population sample comprising these people i s h i g h l y biased toward serious i l l h ealth and i s therefore not u s e f u l here. 11. B.C.B.H., 1913, p.U18. 47 12. M.H.O., 1910, n.p.; 1911, p.33; 1912, p.54; 1913, p.24; 1914, p.23; 1915, p.23; 1916, p.19; 1917, p.19; 1918, p.19; 1919, p.19; 1920, p.21. 13. For example, B.C.Tel.E.B.P., 28 August 1917, 26 September 1917, 9 January 1918, 25 A p r i l 1918, 1 August 1918, 8 October 1918, 8 November 1918, 20 February 1919, 7 March 1919, 7 A p r i l 1920, 22 October 1920, 8 November 1920. 14. M.T. MacEachern, A Survey of the Nursing Question with S p e c i a l Considerat ion of the Problems A r i s i n g therefrom and t h e i r A p p l i c a t i o n i n the Vancouver General H o s p i t a l (Vancouver, 1919; Univ. of B.C., Woodward L i b r a r y , Memorial Room has a copy), p.20. 15. This i s also shown by the medical examinations given prospective army r e c r u i t s ; the P r o v i n c i a l O f f i c e r of Health, Henry Esson Young, said a f t e r the War: " I t was the biggest disgrace t h i s Dominion ever had to face to discover that one-third of her sons were reje c t e d for army service because they were p h y s i c a l l y u n f i t . Most of these were reject e d owing to some small cause due to lack of care i n e a r l i e r years." (Province, 15 January 1921, p.2.) 16. Health Comm., 26 February 1896; "For the diminished frequency and m o r t a l i t y of Diphtheria . . . c r e d i t . . . must be given to the r u l e of t h i s Department i n f u r n i s h i n g a n t i t o x i n g r a t i s to the physicans for those unable to pay, so that i t s use has been much more general and l i b e r a l , both for c u r a t i v e and immunizing purposes." (M.H.O., 1910, n.p.) 17. This b e l i e f i s i m p l i c i t i n the wording of Dr. E. Newton D r i e r ' s w r i t t e n recommendation to Vancouver General H o s p i t a l concerning a former patient's account: "Mrs. Appleyard i s absolutely unable to pay t h i s account. I know t h e i r circunstances. They are honest people and would pay i f they could." (V.G.H., se r i e s C, v.3, f i l e 9, note dated 13 J u l y 1905.) 18. Province, 5 December 1918, p.22; 27 February 1919, p.3. 19. B.C.Tel.E.B.P., 1 November 1916, 8 December 1916, 27 February 1920. 20. School Board, v.4, B u i l d i n g Committee Minutes, Reports of the Grounds Superintendent (included at the end of the B u i l d i n g Committee Se c t i o n ) , 9 October 1914, 13 November 1914. 21. B.C.Tel.E.B.P., 25 A p r i l 1918; The Canadian Nurse, v.14, (1918), p.88 (Report of 1917 Annual Meeting of Vancouver Graduate Nurses' A s s o c i a t i o n ) ; V.G.H.,B.D., 25 J u l y 1918. For further evidence about doctors' fees, see B.C.Tel.E.B.P., 9 January 1917, 29 January 1917. 22. B.C.E.R., box 56, f i l e B1178, L e t t e r from J.[?] H a r r i s to the Claims Agent, 30 August 1913. 48 23. School Board, v.5, 26 September 1916. 24. School Board, v.4, B u i l d i n g Committee Minutes, 17 January 1915. 25. Telephone Talk, v.6, January 1916 and A p r i l 1916, i n s i d e back cover (Advertisements for Canada Accident Assurance Company); B.C. Medical L i b r a r y Service, K e i t h L i b r a r y , College of Physicians and Surgeons of B r i t i s h Columbia, B r i t i s h Columbia Medical C o u n c i l , Minutes, 26-29 March 1913; V.G.H., ser i e s C, v.2, f i l e 8 (1906 Letterbook), L e t t e r from the Secretary of Vancouver General H o s p i t a l to the Secretary-Treasurer of Calgary General H o s p i t a l , 20 J u l y [1906]. 26. Accident insurance could be purchased i n 1916 for annual premiums i n the $20-$40 range. The weekly minimum wage set i n 1918 for female r e t a i l c l e r k s over 18 years of age added up to $663 a year, more than most such c l e r k s a c t u a l l y received. I t i s obvious that with room and board costing $390 per year and carfare $50, the purchase of accident (or other s i c k - b e n e f i t ) insurance was out of the question for these women. Two c l e r k s stated that they spent nothing on insurance, h o l i d a y s , amusements, medicine, d e n t i s t r y , newspapers, magazines, s t a t i o n e r y , or postage. (Telephone Talk, l o c . c i t . ; The B r i t i s h  Columbia F e d e r a t i o n i s t , 6 December 1918, p . l ; Province, 27 February 1919, p.3.) 27. Province, 9 January 1919, p.2; V.C.A., Add. Mss. 16, 1904 Daybook of Dr. Henri E v a r i s t e Langis, pocket i n s i d e back cover (an order from the Ironside, Rannie and Campbell [construction] Company for medical care of i t s employees); V.G.H.,B.D., 21 May 1915, 29 June 1916; V.G.H., series A, House Committee Minutes, 14 November 1918. 28. The B r i t i s h Columbia F e d e r a t i o n i s t , 1 November 1918, p . l , 8 November 1918, p . l ; U.B.C, Papers of Amalgamated Tr a n s i t Union, D i v i s i o n 101, part 2, Box 14, Minutes of Regular Meeting of 25 March 1908. 29. Telephone Talk, v.6, September 1916, p.9. For a report on the f i r s t nineteen months of operation of the plan, see idem, v.8, May 1918, p.4. 30. B.C.E.R., box 14, f i l e B310i, L e t t e r from the Claims S o l i c i t o r to the General Manager, 10 January 1913; f i l e B310k, L e t t e r s between R.H. Sperling and George Kidd, 12 December 1908, 18 February 1909, 26 March 1909. 31. B r i t i s h Columbia, Revised Statutes, 1897 , c.69; John G. Fleming, The Law of T o r t s , (2nd ed.; Sydney, A u s t r a l i a , 1961), pp.454-55, 457, 458. 32. B r i t i s h Columbia, Statutes, 1902, c.74. 33. B r i t i s h Columbia, Statutes, 1916, c.77; Fleming, p.463. 49 34. See ch.2. 35. Vancouver, By-law #7, sec.4 (a copy appears i n B r i t i s h  Columbia Gazette, 24 March 1887, p.167); C i t y C o u n c i l , v . l , 4 J u l y 1887; v.2, 18 J u l y 1887. 36. C i t y C o u n c i l , v . l , 27 September 1886, 11 October 1886, 8 November 1886; v.2, 1 August 1887, 16 August 1887. 37. Oppenheimer, p.34. Thereafter, the Medical Health O f f i c e r remained responsible for the treatment of the s i c k poor (Health Comm., Minute Book for 1899-1906, i n s e r t i o n at back of book, "Duties of Medical Health O f f i c e r " [24 June 1904]), but seems to have done very l i t t l e of that kind of work: f o r example, he reports treatment of only four paupers i n 1897 ( C i t y C l e r k [ i n ] , v.12 [1898], p.9612). 38. See ch.3, f i g . 2 and the di s c u s s i o n of H o s p i t a l financing i n ne x t - t o - l a s t s e c t i o n . 39. C i t y C l e r k ( i n ) , v.3 (1890), p.2488 (L e t t e r from A.M. Robertson to the Mayor and Counci l , 16 January 1890); V.G.H..B.D., v . l (1902-1909), i n s e r t f o l l o w i n g p.5 (By-laws of the Corporation of the  Vancouver General H o s p i t a l , 10 October 1902); V.C.A., pamphlet 1907-25 (By-laws of Vancouver General H o s p i t a l , 11 January 1907); Vancouver General H o s p i t a l , Annual Report, 1915, p.29. R.T. Williams' D i r e c t o r y  of B r i t i s h Columbia for 1899, p.624, has the folowing entry for C i t y H o s p i t a l : " C i t y H o s p i t a l . . . admits patients s u f f e r i n g from any disease or accidents; those without means are admitted free by obtaining a c e r t i f i c a t e from the H o s p i t a l Board at the C i t y H a l l and signed by one phys i c i a n ; those with means by payment of $5 weekly." Vancouver General H o s p i t a l o f f i c i a l s estimated i n 1916 that public ward charges were ge n e r a l l y 80% unpaid. (There were those who were not c l e a r l y poor who also received free treatment: i n November 1916, 12% of p r i v a t e ward and 26% of semi-private ward charges were unpaid. [V.G.H., s e r i e s A, v.19, Finance Committee Minutes, 19 December 1916.]) 40. Health Comm., 15 December 1888, 5 February 1896, 15 A p r i l 1896, 5 May 1897, 21 J u l y 1897. 41. For example, The Vancouver News, 7 October 1886; D.N.-A., 18 September 1887 , p.4; 2 October 1887, p.3. 42. D.N.-A, 7 J u l y 1887, p.4. 43. D.N.-A, 27 J u l y 1887, p.4; 22 November 1887, p.4; 4 December 1887, p.4. 44. D.N.-A, 22 January 1888, p.4. 45. Telephone Talk, v.4, February 1914, p.17; Province, 28 October 1918, p.16. 50 46. Churches also served as ve h i c l e s for such c h a r i t y ; the Anglican Church, for example, subsidized and s o l i c i t e d public donations for St. Luke's Home, a small h o s p i t a l and nurses' home which admitted between 140 and 200 patie n t s per year i n 1901, 1907, 1909 and 1910. Between 6% and 17% of these were nursed free, a further 6% to 11% were charged reduced fees, and of patients charged regular fees many, (19% i n 1894) did not pay t h e i r b i l l s . (St. James' Anglican Church [Vancouver], Papers of St. Luke's Home, Patient Register for 1894; St. Luke's Home [Vancouver], Annual Report, 1901, 1907, 1909, 1910. [Copies are located at the Church mentioned.J) 47. B.C.B.H., 1916, p.H9; Vancouver Board of School Trustees, Annual Report, 1911, pp.63-64. 48. Province, 20 December 1918, p.15; 27 December 1918, p.7; 12 February 1919, p.5; The Vancouver D a i l y Sun, 5 March 1919, p . l . 49. V.C.A., Photograph C o l l e c t i o n , STR P223 N136, SC P59 N8 (views North and Northwest from Jackson Street near Hastings S t r e e t , 1887) 50. The Vancouver News and D a i l y A d v e r t i s e r , 3 A p r i l 1887; The  Vancouver News, 24 March 1887. 51. I b i d . , 7 December 1886. 52. I b i d . , 2 March 1887. 53. I b i d . , 30 March 1887. 54. C i t y C o u n c i l , 9 May 1887, 15 June 1887, 20 June 1887; D.N.-A, 2 August 1887, p.4; C i t y C l e r k ( i n ) , v . l (1888), pp.516-519, 523-524 (Le t t e r s from E. Mohun to the Mayor and Cou n c i l , 4 February 1888, 16 A p r i l 1888). 55. C i t y C o u n c i l , 11 J u l y 1887; C i t y C l e r k ( i n ) , v . l (1887), p.13 (L e t t e r from E. Mohun to the Chairman of the Board of Works, 28 November 1887); v . l (1888), pp.509-511 ( L e t t e r [from E. Mohun] to the Mayor and Cou n c i l , 22 January 1888). 56. C i t y C o u n c i l , 6 September 1886. 57. Margaret W. Andrews, unpublished paper "Boosterism and Makeshift Government: Vancouver P u b l i c Health Ser v i c e s , 1886-1888", pp.31-35. (V.C.A. has a copy.) 58. Louis P. Cain, "Water and S a n i t a t i o n Services i n Vancouver: An H i s t o r i c a l Perspective", BC Studies, no.30, Summer 1976, pp.27-32; James W. Morton, Capilano, The Story of a River (Toronto, 1970), chap.3. 59. D.N.-A., 4 October 1887, p.2; Health Comm., 13 January 1888, 10 February 1888, 16 March 1888. 51 60. Health Comm., 16 March 1888, 27 A p r i l 1888, 4 May 1888; D.N.-A., 8 May 1888, p.5. 61. Deryck W. Holdsworth, "House and Home i n Vancouver: Images of West Coast Urbanism, 1886-1929", i n G i l b e r t A. S t e l t e r and Alan F.J. A r t i b i s e (eds.), The Canadian C i t y , Essays i n Urban H i s t o r y (Toronto, 1977), pp.186-211. 62. C i t y C l e r k ( i n ) , v.10 (1896), p.8640, (Evidence given by Dr. A l f r e d Poole at a Coroner's inquest); Health Comm., 30 September 1896; v.17 (1900), pp.13297-13298 (Submission from M. Maclean, Medical Health O f f i c e r , to F.J.Deane, Secretary to the Royal Commission on Chinese and Japanese Immigration, 15 November 1900). 63. Health Comm., 6 June 1900; M.H.O., 1911, pp.4, 10; 1912, p.15. 64. M.H.O., 1912, p.6. 65. M.H.O., 1910, n.p.; 1912, p.15; 1913, pp. v i i - v i i i . 66. M.H.O., 1911, pp.4-5; 1912, pp.20-21. 67. M.H.O., 1910, n.p. 68. Health Comm. 6 October 1896; C i t y C l e r k ( i n ) , v.17 (1900), pp.13298-13299 (Submission from M. Maclean, Medical Health O f f i c e r , to F.J. Deane, Secretary to the Royal Commission on Chinese and Japanese Immigration, 15 November 1900); M.H.O., 1911, pp.4-6; 1912, p.11; 1913, p p . v i - v i i i . 69. Health Comm., 4 November 1891, 5 October 1898; V.C.A., Map C o l l e c t i o n , map #3 (Map of Vancouver, drawn by A l l a n K. Steuart, 1893); M.H.O., 1911, pp.10-11. 70. Health Comm., 4 September 1895, 16 June 1897, 15 March 1899; M.H.O., 1911, pp.10-11; 1912, pp.8, 13. 71. M.H.O., 1911, p.5; 1913, p . v i . 72. M.H.O., 1912, p.13. 73. M.H.O., 1912, pp.5, 8, 13; 1911, p.9; Province, 5 March 1919, 74. Health Comm., 20 October 1897; V .G.H.,B.D., 10 November 1904; p. 20. Province, 22 February 1906; M.H.O., 1910, n.p.; 1911, p.9. 75. Cain, pp.32-33. 76. Vancouver and D i s t r i c t s J o i n t Sewerage and Drainage Board, Annual Report, 1919, pp.18, 19, 26 (the quotation i s on page 18); Cain, p. 34. 52 77. B.C.B.H., 1917, pp.G209. 78. The Vancouver D a i l y A d v e r t i s e r , 22 May 1886; The Vancouver  News, 11 March 1887. 79. Health Comm., 12 June 1894, 24 J u l y 1894, 4 November 1896, 19 A p r i l 1899. 80. Health Comm., 4 November 1896. 81. B.C.B.H., 1913, pp.U46-U47, 1917, p.G205. 82. B.C.B.H., 1913, p.U42, 1917, p.G209. These by-laws kept milk from H o l s t e i n cows (judged to be p a r t i c u l a r l y s u i t a b l e f or babies) o f f • the market, since i t seldom possessed even 3% b u t t e r f a t . (B.C.B.H., 1917, p.G205.) 83. Vancouver, By-law #210 (Licensing of M i l k , 1894) and i t s successive amendments; B r i t i s h Columbia, S t a t u t e s , 1913, c.43 (Milk A c t ) ; 1920, c.23 (Regulation of Creameries and D a i r i e s ) . 84. B.C.B.H., 1913, pp.U41, U44, U47; B.C.B.H. 1917, p.G215. 85. For a sample of expert opinion both for and against p a s t e u r i z a t i o n , see B.C.B.H., 1913, pp.U42,U46, 1917, p.G205. 86. B.C.B.H., 1917, pp.G201, G204. 87. B.C.B.H., 1917, pp.G207, G209. 88. V.G.H..B.D., 25 May 1917, 18 February 1918. 89. B.C.B.H., 1917, p.G157. 90. Health Comm., 6 A p r i l 1898, 15 June 1898. 91. M.H.O. 1911, p.14. 92. C i t y C l e r k ( i n ) , v . l (1888), pp.468-470, (Monthly report of Joseph Huntly, Health Inspector, for A p r i l 1888); v.60 (1916), f i l e L-M, l e t t e r from John Linden to the Health Committee, n.d. 93. Health Comm., 15 December 1888. 94. Telephone Talk, v.4, August 1914, p.10. 95. The D a i l y World, 7 June 1901, p.2; Province, 13 A p r i l 1907, p.20. 96. I b i d . 97. M. A l l e r d a l e Grainger, Woodsmen of the West, (1908; r p t . Toronto, 1964), c h . l ; B.C.E.R., box 146, f i l e s 562 and 564, Accident Reports dated 24 June 1912, 31 January 1914, 21 February 1914; Province, 53 27 February 1919, p.16; St. James Anglican Church (Vancouver), Papers of St. Luke's Home, Patient Register. The l a s t l i s t s both occupation and cause of admission for patients admitted between 2 November 1913 and 31 December 1917; occupations l i s t e d for patients admitted for " a l c o h o l " included: logger, cook, landlady, c l e r k , b a r r i s t e r , and gentleman. 98. F r u i t - a - t i v e s , advertised as "fr e s h f r u i t j u i c e s , concentrated and increased in strength, combined with the f i n e s t tonic . . . a p o s i t i v e and r e l i a b l e remedy for headaches and co n s t i p a t i o n " , contained enough a l o i n , belladona and s t r i c h n i n e to k i l l a four-year-old c h i l d . (Province, 22 March 1919, pp.3, 13.) 99. Henderson's D i r e c t o r i e s for 1898-1900, l i s t i n g s for The Keely I n s t i t u t e ; The D a i l y World, 5 March 1901, p.5 (an advertisement des c r i b i n g the Keely I n s t i t u t e i n S e a t t l e ) . The operation of the Keely I n s t i t u t e in Vancouver was s h o r t - l i v e d . 100. 13 A p r i l 1907, p.20. Reports of Stevens' a n t i - v i c e campaign: Province, 20 February 1907, p.2; 12 March 1907, p.20; 8 May 1907, p . l . 101. Vancouver General H o s p i t a l , Annual Report, 1918, p.23; Province, 13 February 1919, p.7. 102. B.C.B.H., 1918-1919, pp.B5, B7. 103. Province, 9 February 1907, p.15; 7 October 1918, p.16; 31 December 1918, p.20. 104. The Vancouver Sun, 20 January 1915, p.3. 105. Robert A.J. McDonald, "Business Leaders in E a r l y Vancouver, 1886-1914", Unpublished Ph.D. t h e s i s , U n i v e r s i t y of B r i t i s h Columbia, 1977, appendices A and B; C.W. Parker (ed.) Who's Who and Why, a Biographical D i c t i o n a r y of Notable Men and Women i n Western Canada, (Vancouver, 1911). 106. For example, W.J. McGuigan was mayor; J.M. Lefevre, W.D. Brydone-Jack, W.B. McKechnie, and W.D. Mcintosh were aldermen; and W.D. Brydone-Jack, F.C. McTavish, and W.H. Lang were school trustees. 107. D.N.-A., 27 May 1887, p . l . 108. The Vancouver News, 29 March 1887. 109. The Vancouver News, 20 March 1887. This and the preceding two quotations are from early booster l i t e r a t u r e , but public health continued to be linked with c i t y growth in the more soph i s t i c a t e d booster l i t e r a t u r e of l a t e r years - for example, E l l i o t S. Rowe, "Vancouver 1886-1911", B r i t i s h Columbia Magazine, vol.7 (1911), pp.427-28. NOTES ON FIGURES, CHAPTER 1 Key to abbreviations may be found on page 45. Sources for Figure 1: Ontario, Board of Health, Annual Report, 1919, p.256; C i t y of Chicago, Dept. of Health, Report, 1919-1920, p.527; Saskatchewan, Bureau of Publ i c Health, Annual Report, 1919-1920, p.102; M.H.O., 1911, p.17; 1916, p.12; 1919, p.12; 1920, p,12; Vancouver, Annual Report, 1922, pp.68-89. [There i s a typographical e r r o r i n the l a s t named source; the population f i g u r e for 1916 should read 95,922.] Sources for Figure 2: Canada, Dept. of A g r i c u l t u r e and S t a t i s t i c s , Census of Canada, 1891, v.2 (Ottawa, 1893), pp.2-5; idem, v.4 (Ottawa, 1897), pp.70-71. Sources for Figure 3: Canada, Dept. of A g r i c u l t u r e , Census of Canada, 1901, v.4 (Ottawa, 1906), pp.2-5, 278-282. Note on Figures 4 and 5: For each year, "Total Population" value i s estimated mid-year population, being the geometric mean of the bracketing year-end populations given i n the C i t y ' s 1922 Annual Report, rounded to the nearest hundred. Sources for Figure 4: M.H.O., 1920, p.12; 1911, p.18; 1914, p.15. Sources for Figure 5: M.H.O., 1912, pp.35, 36, 38, 39, 40; 1913, pp.6, 7, 9, 10, 11; 1914, pp.8, 9, 11-13, 15; 1915, pp.8-9, 11-13; 1916, pp.6, 7, 9, 10-12; 1917, pp.6, 7, 9-11; 1918, pp.6, 7, 9-11; 1919, pp.6, 7, 9-12; 1920, pp.6, 7, 9-13. Sources for Figure 6: Vancouver, Annual Report, 1922, pp.68-69; M.H.O., 1911, p.17; 1916, p.12; 1919, p.12; 1920, p.12; Canada, Dept. of A g r i c u l t u r e and S t a t i s t i c s , Census of Canada, 1891, v.2 (Ottawa, 1893), pp.70-71; Canada, Dept. of A g r i c u l t u r e , Census of Canada, 1901, v.4 (Ottawa, 1906), pp.278-281. Sources for Figure 7: M.H.O., 1911, pp.17, 26, 27; 1912, pp.30, 44-46; 1913, pp.12, 18-20; 1914, pp.14, 21, 22; 1915, pp.14, 21, 22. 54 CHAPTER 2 ATTENDANCE BY PHYSICIANS In Vancouver's f i r s t t h i r t y - f o u r years, medical attendance there acquired the character which nearly s i x t y years l a t e r s t i l l t y p i f i e s t h i s most h i g h l y valued of a l l health s e r v i c e s . By 1920, Vancouver had an adequate supply of w e l l t r a i n e d and w e l l paid doctors whose services were normally d e l i v e r e d i n the impersonal s e t t i n g of a downtown o f f i c e ; t h e i r patients had a wide range of s o c i a l , economic, and ethnic backgrounds; and medical care for patients who could not a f f o r d to pay was subsidized by those who could. Although medical attendance would i d e a l l y be studied from h i s t o r i c a l documents o r i g i n a t i n g with i t s r e c i p i e n t s , i t s ordinary and p r i v a t e nature makes such documents rare and t h e i r discovery a matter of chance; t h i s chapter w i l l instead use documents prepared from the p r a c t i t i o n e r s ' point of view. In the f i r s t s e c t i o n here, inferences are drawn from a c o l l e c t i v e study of Vancouver doctors; i n the second, from the medical work of an i n d i v i d u a l doctor whose d a i l y records have survived i n part. Since i n t h i s chapter medical attendance i s being considered as a s o c i a l process, i t s s c i e n t i f i c aspects (which were changing r a p i d l y during the period studied) are not discussed i n any d e t a i l here.^ 55 56 i The doctors studied i n t h i s s e c t i o n were selected thus: a doctor was selected i f there was a year between 1898 and 1920 ( i n c l u s i v e ) i n which he or she was l i s t e d as resident i n Vancouver i n the r e g i s t e r printed every year or two by the College of Physicians and Surgeons of B r i t i s h Columbia and also l i s t e d i n the most complete Vancouver d i r e c t o r y a v a i l a b l e , or i f he or she was l i s t e d i n the c l a s s i f i e d s e c t i o n of any of those d i r e c t o r i e s and also r e g i s t e r e d by the College as licensed to p r a c t i c e i n the province. The 332 doctors thus selected w i l l be r e f e r r e d to as i f they were a l l the doctors p r a c t i c i n g i n Vancouver during those years, although i t i s u n l i k e l y they were: doctors who a r r i v e d i n Vancouver a f t e r the compiling of one d i r e c t o r y and l e f t before that of the next are not included, nor are those who neither informed the College of t h e i r residence i n Vancouver nor advertised i n the c l a s s i f i e d s e c t i o n of the d i r e c t o r y . The documents used for s e l e c t i n g the doctors are also the p r i n c i p a l source of information about them. The College's r e g i s t e r s l i s t each doctor's medical l i c e n s e s , current place of residence, and u n i v e r s i t y degrees. The d i r e c t o r i e s c o n s i s t e n t l y give a doctor's address or addresses; they sometimes give h i s or her medical s p e c i a l i t i e s , medical c r e d e n t i a l s , c o n s u l t i n g hours, employer, or partner; and they report some temporary absences. The r a t i o of doctors to population i n Vancouver from 1898 to 1920 varied from 12 to 18 per 10,000 (with an increasing trend of about .1 per 10,000 per year). (See figure 1.) A r a t i o of 5 doctors per 10,000 57 Figure 1. Doctors i n the Population Vancouver 1898-1920 loo-- ! M : , , i ^ . / N M i . i i ' ! i ; h 1 ' i ! — ; i i i M i i ; y i -: r - GOjooo d e ' i -1 lO^Q / -j-—Z 1 --I I I ' ' ' • i I I • • : — i "ZQfiOO — — 1 1 1 — . - r - l — 1 - r - H - t — _ _ , — H - H - l — _ _ _ , _ . ( „ -I—f—1 — I l l \ l i _ l — f— = z S 00 t £ 3 1 Z 3. > 3 " G ? \Q 9 Zp j ZD-» 1 M M — H - + -M 1 1 i i ! \—\—\~ I I I : - 1 — r i—I—1- t—t~ J-—l-t i ! ! i ! i 1 1 i ! i M M i ! i M i M M I i M M 1 i '< r T i M M 1 ! ! Nkl ! M i ! • 1 i i i ! ! I i 1 1 i i i M M I i i * ^ d o c 1 i ! 1 i i i M M > j ! ! i i ! I ' l l : ' ' • ! j i 1 M M M M M ! i i ! j ! i 1 ! i ! ! •• \ '< ' i l i 58 of population was asserted to be d e s i r a b l e by Abraham Flexner i n h i s i n f l u e n t i a l report of 1910 on medical education i n the United States and Canada, 4 and i t i s tempting to conclude immediately from t h i s a s s e r t i o n that Vancouver had an overabundance of doctors. However, i t i s not reasonable to compare the actual r a t i o for Vancouver with Flexner's suggestion, since the l a t t e r applies to an area i n c l u d i n g both r u r a l and urban population. Nevertheless, two observations discussed below, namely the short duration of medical p r a c t i c e s and the w i l l i n g n e s s of doctors to give generously of t h e i r time, do lead to the conclusion that Vancouver doctors were underemployed. I t was often possible during the period of t h i s study for a woman i n Vancouver to be attended by a female doctor, and there was some f e e l i n g that t h i s should be customary.^ However, there were never enough female doctors i n town: there was one p r a c t i c i n g i n 1899 and 1900, but no others from 1898 to 1904; between 1905 and 1920, there was always at least one, and sometimes as many as f i v e . Most of the doctors p r a c t i c i n g i n Vancouver during the period of t h i s study were tra i n e d at the M c G i l l or Toronto medical schools, whose programs were considered " e x c e l l e n t " by Flexner. Nearly a l l the rest also had respectable t r a i n i n g i n Canada, B r i t a i n , or the United States.^ (See table 1.) Thus, by the standards of the day, Vancouver doctors were w e l l t r a i n e d . The 332 doctors studied here had among them 424 periods of medical p r a c t i c e i n Vancouver; 243 doctors had one period of Vancouver p r a c t i c e , 87 had two, one had three, and one had four; 211 of the 424 periods of 59 Table 1. PLACE OF MEDICAL TRAINING OF DOCTORS PRACTICING IN VANCOUVER 1898-1920* Degree-granting Doctors who r e g i s t e r e d i n B.C.: i n s t i t u t i o n before 1910 1910-1920 T o t a l M c G i l l 62 38 . 100 Toronto 45 36 81 Manitoba 20 14 34 Queen's 14 18 32 Other Canadian i n s t i t u t i o n s 10 6 16 U. S. i n s t i t u t i o n s 25 16 41 B r i t i s h i n s t i t u t i o n s + 18 14 32 Other i n s t i t u t i o n s 0 4 4 Information l a c k i n g 1 1 2 * Doctors who had medical degrees from more than one i n s t i t u t i o n are counted for each. + Figures include doctors with B r i t i s h l i c e n s e s and no medical degree Sources: College of Physicians and Surgeons of B r i t i s h Columbi Master Register; College of Physicians and Surgeons of B r i t i s h Columb Reg i s t e r , 1898, 1899, 1901, 1902, 1903, 1904, 1905, 1906, 1907, 1908, 1909, 1910-11, 1912-13, 1913-14, 1914-15, 1916-17, 1918, 1919, 1920; Henderson's P u b l i s h i n g Co. (pub.), Vancouver D i r e c t o r y , 1901, 1903-1920; Henderson's P u b l i s h i n g Co. (pub.), B r i t i s h Columbia  D i r e c t o r y , 1898, 1900, 1902; Rowland E. Green (pub.), Vancouver  D i r e c t o r y , 1899-1900. 60 p r a c t i c e were for one, two, or three years. (See f i g u r e 2.) Some of these periods of p r a c t i c e continued to the end of the period of t h i s study (those represented by shading i n figure 2), but more were ended by a doctor's d e c i s i o n to go elsewhere, perhaps i n the hope of greater f i n a n c i a l success. Consider t h i s from the p a t i e n t s ' point of view: since the t y p i c a l medical p r a c t i c e i n Vancouver between 1898 and 1920 had continued for only a few years, the p r o b a b i l i t y of a sustained r e l a t i o n s h i p with a s i n g l e doctor was low. Since the c i t y ' s population as a whole was l i k e l y quite mobile, i t i s unreasonable to assume that such a r e l a t i o n s h i p was expected by p a t i e n t s , but i t s absence was nevertheless a weakness i n the system of medical attendance: f a m i l i a r i t y with the medical h i s t o r y of patients and t h e i r f a m i l i e s was very important when diagnosis depended almost e n t i r e l y upon a doctor's personal powers of observation and deduction; geographic m o b i l i t y deprived many i n Vancouver of the opportunity for such f a m i l i a r i t y to develop. Of the 332 doctors, 71 (21%) had, before s e t t i n g up p r a c t i c e i n Vancouver, p r a c t i c e d i n B r i t i s h Columbia i n places outside the other urban centers ( V i c t o r i a and New Westminster). Experience with such non-urban p r a c t i c e became less common with the passage of time: among those who were lice n s e d i n B r i t i s h Columbia before 1910 (189 of the 332), 59 (31%) had had a non-urban p r a c t i c e i n B r i t i s h Columbia before coming to Vancouver; among those who became li c e n s e d i n B r i t i s h Columbia from 1910 to 1920 (143 of. the 332), only 12 (8%) had. Doctors who knew of working-class l i f e through the close proximity i n e v i t a b l e i n the province's small mining and a g r i c u l t u r a l towns l i k e l y had a c l o s e r 61 Figure 2. Duration of Doctors' P r a c t i c e s Vancouver 1898-1920 20 |( 11)116 Tni i i I 6 <4> 10 0 | J 4 (2) 1 (1) J3 (3) 1 (1) i * (4) 2 (1) 1 ( I 7 L E G E N D 7TTTrrn t u n i r means: n practices were maintained for y years continuously, m of the practices continuing to 1920. 62 rapport with working-class patients than was po s s i b l e f or doctors with only urban experience. Figure 3 shows the geographical d i s t r i b u t i o n of Vancouver doctors' o f f i c e s i n 1902, 1911, and 1920, r e s p e c t i v e l y . 7 Most of these o f f i c e s were located i n the v i c i n i t y of the "M" formed by G r a n v i l l e , Hastings, and Main S t r e e t s . With the passage of time, the density of o f f i c e s increased on the G r a n v i l l e Street leg of the "M": nearly h a l f the doctors i n Vancouver had o f f i c e s i n the 700 block of G r a n v i l l e i n 1920. There were doctors' o f f i c e s scattered i n the o u t l y i n g r e s i d e n t i a l areas i n a l l three years: i n 1902, there were a few i n the secti o n of the West End between Coal Harbour and Robson Str e e t ; i n 1911, there were some i n the secti o n of the West End between Robson Street and Davie S t r e e t , some across False Creek ( i n K i t s i l a n o and along Broadway from G r a n v i l l e Street to Main S t r e e t ) , some i n the eastern part of the c i t y near V i c t o r i a Drive, and some outside the c i t y boundaries i n Cedar Cottage; i n 1920, there were o f f i c e s even f a r t h e r from the centre of town, but o f f i c e s i n r e s i d e n t i a l areas were c l e a r l y becoming less popular with doctors. Of the 29 doctors p r a c t i c i n g i n Vancouver i n 1898, 19 (66%) l i v e d and worked at the same place; only 25 (12%) of the 202 doctors of 1920 Q did so. S p e c i f i c a l l y , although doctors' o f f i c e s were concentrated i n the c e n t r a l core of the c i t y throughout the f i r s t two decades of the century, most o f f i c e s located there had l o s t t h e i r domestic character by the end of the second decade.^ Along with other p r i v i l e g e d c i t i z e n s , doctors had come to f e e l that downtown residences were undesirable and had moved to such uncongested areas as the West End, Shaughnessy, and 64 Point Grey. i U The combination of c i t y growth, separation of doctors' o f f i c e s from t h e i r homes, and concentration of these o f f i c e s i n the downtown area promoted a more formal and impersonal r e l a t i o n s h i p between doctor and p a t i e n t . At the turn of the century, i t was l i k e l y that the doctor consulted by an i n d i v i d u a l or family l i v e d and worked nearby, was encountered frequently i n everyday l i f e , and could e a s i l y be fetched by a neighbour or family member i n case of need; by the end of the second decade of the century, i t was more l i k e l y that people would not frequently encounter t h e i r doctors except on a p r o f e s s i o n a l basis and that when they needed medical a t t e n t i o n they would e i t h e r t r a v e l to a downtown o f f i c e or summon a doctor by telephone. i i The sources used i n the above c o l l e c t i v e study of doctors t e l l nothing about the type of person who sought medical attendance, h i s or her reason for doing so, the kind of a t t e n t i o n given by a doctor, or the way medical attendance was financed. For t h i s more personal sort of information, we turn to a set of nine daybooks kept i n the years from 1885 to 1904 by a Vancouver doctor, Henri E v a r i s t e L a n g i s . ^ A gregarious bachelor, Langis was fond of theatre, romantic verse, 1 o and evenings with f r i e n d s . He was born near Rimouski, Quebec on 25 October 1857; h i s ancestors included men a c t i v e i n Quebec a f f a i r s i n the seventeenth century. He attended primary school i n Rimouski, then continued h i s formal education at the Quebec Seminary, at Laval U n i v e r s i t y , and f i n a l l y at the V i c t o r i a Medical College i n Cobourg, 65 Ontario (part of the Ecole de Medecine et Ch i r u r g i e of Montreal); he received the M.D. degree i n 1883 . Before pu t t i n g down roots i n Vancouver, he moved from place to place for a number of years. A f t e r graduation, he became an employee of the Canadian P a c i f i c Railway, working i n the the Ontario Lakehead and then i n Yale, Port Moody, and Vancouver, B r i t i s h Columbia.* 3 Perhaps i n A p r i l 1886 , and c e r t a i n l y p r i o r to the f i r e which destroyed Vancouver i n June of that year, he l e f t on a t r i p which included Honduras and New Orleans;*- 4 he may have been looking for a place to set up p r a c t i c e . He was c e r t a i n l y looking for work i n C a l i f o r n i a i n September 1886 , when he tr a v e l e d on foot for a day and a h a l f to a mine 50 kilometers northeast of Sacramento; he did not get a job there, but was working l a t e r i n the month, perhaps i n San F r a n c i s c o . ^ Upon h i s return to Vancouver i n 1887 , he formed a medical partnership with W.J. McGuigan (another former C.P.R. d o c t o r ) , which la s t e d u n t i l the l a t t e r 1 s death i n 1 9 0 8 . 1 6 H£ s i n t e g r a t i o n i n t o the anglophone community i s i l l u s t r a t e d by h i s appointment i n 1888 to the f i r s t Medical Board of the C i t y Hospital*- 7 and by h i s adoption of E n g l i s h as h i s preferred language.*** He gained a reputa t i o n as an able surgeon and o b s t e t r i c i a n . ^ His income, which increased from $2500 i n 1888 to $9500 i n 1 9 0 4 , 2 0 appears to have been remarkably good for a doctor of h i s day: e a r l y i n the twentieth century, the average physi c i a n i n Chicago charged fees comparable to h i s and earned from $1500 to $3000 per year; Chicago eye, ear, nose, and throat s p e c i a l i s t s earned from $3000 to $ 6 0 0 0 . 2 1 66 He adopted a s c i e n t i f i c approach to medicine e a r l i e r than many doctors: he bought a microscope i n 1885, at which time microscopes were not yet used i n course work by most American medical schools.^2 During h i s years of p r a c t i c e i n Vancouver, he l i v e d i n the downtown premises he and McGuigan shared as o f f i c e s . He moved to a farm near P a r k s v i l l e on Vancouver Island i n 1909,23 and spent most of h i s remaining years t h e r e h e died i n 1937 at the age of 79. Langis' patients i n Vancouver included Chinese, Japanese, Native Indians, and people of assorted European n a t i o n a l i t i e s . In view of the second-class s o c i a l status of O r i e n t a l s and Native Indians, i t i s worth n o t i c i n g that members of these ethnic groups d i d rece i v e treatment, sometimes even non-emergency treatment. Table 2, showing n a t i o n a l i t y of the babies Langis d e l i v e r e d during two two-year periods, gives the cl e a r e s t a v a i l a b l e i n d i c a t i o n of the ethnic background of h i s p a t i e n t s . Langis frequently attended another group of second-class c i t i z e n s , the women of the c i t y ' s r e d - l i g h t d i s t r i c t . He attended Laura Scott and her employees from 1890 through 1904, f i r s t at 54 and then at 111 Dupont 2 5 S t r e e t . He did not have such sustained contact with other bawdy houses, but d i d record v i s i t s to "Helen" at Sadie Talbot's and to " P e a r l " , "Thelma",^ and a number of other women l i v i n g on Dupont Stree t . I t i s u n l i k e l y that more than a handful of Vancouver doctors attended p r o s t i t u t e s as r e g u l a r l y and ext e n s i v e l y as Langis. Table 3 shows the occupations of about h a l f of Langis 1 p a t i e n t s i n March 1888 (those whose occupations could be ascertained from c i t y d i r e c t o r i e s ) ; i t suggests that , although h i s p r a c t i c e included people 67 Table 2 ETHNICITY OF BABIES DELIVERED BY DR. LANGIS 1893--1894 1903--1904 Ethnic group Langis engaged Langis .engaged (categories Before Not Before Not are Lang i s ' ) labour before labour before Canadian 6 4 50 18 Eng l i s h 11 3 6 2 French Canadian 7 2 5 2 Jewish 5 3 3 1 German 8 1 1 -American 1 1 3 4 I r i s h 1 2 2 1 S c o t t i s h 3 1 - -New Foundlander 2 - 2 -Danish 3 - 1 -Swedish - - 2 2 P o l i s h - 2 - 1 Syrian 1 - - -Greek - - - 1 A u s t r a l i a n - - 1 -Chinese - - 1 -Japanese - - - 1 French - - 1 -B r i t i s h - - 1 -American/Canadian - - 3 -Irish/Canadian - - 3 -English/Canadian - • - 1 1 Greek/English - - 1 -I t a l i a n / E n g l i s h - - 1 -Belgian/American - - 1 -Halfbreed - - - 1 Unknown 9 6 1 1 Total 57 25 90 36 Sources: Daybooks [see note 11], 1893, 1894, 1903, and 1904, sections for O b s t e t r i c a l Records. 68 Table 3 OCCUPATIONS OF DR. LANGIS1 PAYING AND NONPAYING PATIENTS, MARCH 1888 Occupations of paying p a t i e n t s (16 p a t i e n t s ) Carpenter (2) Hotel P r o p r i e t o r Sawmill Foreman Sawmill Tallyman CPR Locomotive Engineer Hotel Employee CPR Draughtsman Hotel Clerk Ship Captain Storekeeper/Postmaster CPR Engineer CPR S t r i k e r Bartender Hotel Keeper Dry Goods/Grocery Store Partner Note: Occupations are not known for 25 p a t i e n t s ; 16 of these paid Langis' b i l l s and 9 did not. Occupations of nonpaying p a t i e n t s (11 p a t i e n t s ) Farmer P l a s t e r e r Restranteur Carpenter/Builder Clerk CPR Engine Turner Boarding House Operator C l o t h i n g Store Partner Hotel Partner Lumberman Sawmill Boom Tender Sources: Daybooks [see note 11], 1888; E. Mallandine and R.T. Williams (pub.), The B r i t i s h Columbia D i r e c t o r y , 1887; R.T. Williams (pub.), Vancouver C i t y D i r e c t o r y , 1888. 69 with a wide range of occupations, u n s k i l l e d workers were patients r e l a t i v e l y i n f r e q u e n t l y . However, since the occupation of about h a l f the patients i s unknown, and since d i r e c t o r y compilers were l i k e l y to omit people l i v i n g i n boarding houses or other temporary housing (a type of accommodation favoured by u n s k i l l e d workers), t h i s conclusion i s open to doubt. Table 4 shows the sex of Langis' p a t i e n t s i n 1890 and 1891, together with the proportion of males and females i n the c i t y according to the 1890-1891 census. I t seems that women received, i n proportion to t h e i r number, less frequent medical care than men. Since the need for medical care due to accidents among men i s presumably at le a s t o f f s e t by that due to pregnancy among women, the discrepancy should not be a t t r i b u t e d to a d i f f e r e n c e i n need, but rather to a d i f f e r e n c e i n the importance assigned by so c i e t y to the two sexes' r e c e i v i n g medical care: men rather than women u s u a l l y provided family incomes, and women who did support themselves had lower incomes than men, therefore less to spend on medical attendance. A few occurrences of names i n Langis' daybooks span several years ( f o r example, the records of h i s d e l i v e r y of the P i e r r e T a r d i f s 1 f i r s t c h i l d i n 1893 and of t h e i r seventh eleven years l a t e r ) , but most span only a year or two. The apparently short duration of Langis' contact with most of h i s patients i s i n accordance with the geographic m o b i l i t y one would expect i n a population which included many immigrants seeking to better t h e i r fortunes. 70 Table 4 SEX OF DR. LANGIS' PATIENTS 1890 1891 V i s i t s to patients known to be female 160 335 V i s i t s to patients known to be male 549 828 V i s i t s to patients whose sex i s not known 11 43 V i s i t s to females as a percentage of a l l v i s i t s 22% 28% V i s i t s to females as a percentage of v i s i t s to patients whose sex i s known 23% 29% V i s i t s to males as a percentage of v i s i t s to patients whose sex i s known 77% 71% Note: According to the 1891 census, the population of Vancouver was 13,709; 8,942 males (65%) and 4,767 females (35%). Sources: Daybooks [see note 11], 1890 and 1891; Canada, Dept. of Trade and Commmerce, Census of Canada, 1921, v . l , (Ottawa, 1924). p.340. 71 Langis made himself h i g h l y a v a i l a b l e to h i s p a t i e n t s . There i s no record of h i s stated o f f i c e hours, but at le a s t one Vancouver doctor of 9 7 the period advertised morning, afternoon, and evening hours, Langis attended patients on a l l seven days of the week and at night. On occasion, he would v i s i t a patient several times a day, day a f t e r day. ° He was also prepared to spend time t r a v e l i n g to patie n t s outside Vancouver: he frequently went across Burrard I n l e t to Moodyville, and he made c a l l s on Lulu Island and i n Port Hammond and Steveston.29 Langis' work load made t h i s use of h i s time f e a s i b l e . In 1885, he o r d i n a r i l y saw from one to three patients a day, and there were frequently days when he saw no patients at a l l . 3 0 In 1888, he o r d i n a r i l y saw from three to f i v e patients a day, s i x or seven on a busy day, and only one on a slow day. In 1903 and 1904, he o r d i n a r i l y saw from f i v e to twelve patients a day, three on a slow day. Although Langis 1 records u s u a l l y do not i n d i c a t e a pa t i e n t ' s complaint, exceptions occur frequently enough to give a sense of the kind of medical work he performed; he de l i v e r e d babies, treated accident v i c t i m s with d i s l o c a t i o n s , f r a c t u r e s , and crushed limbs, treated those s i c k with smallpox and other i n f e c t i o u s diseases, gave v a c c i n a t i o n s , plugged teeth, and performed surgery ranging from c i r c u m c i s i o n and tons i l l e c t o m y to mastoid and abdominal operations.31 As t h i s l i s t i n d i c a t e s , Langis' patients came to him for healin g and sometimes for o b s t e t r i c a l or preventive health care. Langis was c a l l e d on to heal those who suffered from i l l h ealth which stemmed from the widespread r e c r e a t i o n a l use of alcohol and sex 72 t y p i c a l of a town containing a large number of s i n g l e men, many there a f t e r months i n logging or mining settlements.^2 i t i s l i k e l y that some of the accident cases treated by Langis were the r e s u l t of drunkenness, and he was also asked to t r e a t the d i r e c t e f f e c t s of over-consumption of a l c o h o l . He received the f o l l o w i n g note at 2 a.m. from the bartender of the A t l a n t i c S a l o o n . ^ Dear S i r . W i l l you k i n d l y t r e a t Mr Rose, he has bean Drinking hard, and need some attendance. K i n d l y send b i l l to me and oblige Yours t r u l y G.C. Dittherner What treatment Langis gave i n t h i s case i s not recorded, but he d i d send an a l c o h o l i c to h o s p i t a l for a few days on at least one occasion.^5 Patients came to Langis with s y p h i l i s . Although h i s daybooks do not i n d i c a t e the nature of the treatment he gave these patients ( i t was presumably the approved treatment of the day - prolonged dosing with potassium i o d i d e , mercury, or both-^^), they do reveal the psycho l o g i c a l response of a patient to s y p h i l i s , and perhaps the disease's impoverishing e f f e c t . One J u l i e n LeBlanc was examined by Langis i n March 1887 and found to have s y p h i l i s . LeBlanc paid h i s b i l l , but did not again seek Langis 1 assistance u n t i l February of the f o l l o w i n g year. By then, h i s apparent nonchalance had changed to concern. He saw Langis s i x times i n February and four times i n March. (These v i s i t s are marked as paid.) He saw him twice i n A p r i l and f i v e times i n J u l y . (These v i s i t s are marked "n.g." - no good.) A f t e r mid-July, LeBlanc disappears 73 from Langis 1 records. Many sorts of preventive medical attendance, i n c l u d i n g prenatal care, have become i n c r e a s i n g l y accepted by the pub l i c during the course of the twentieth century. Considering which of Langis 1 patients arranged for prenatal care may y i e l d some i n s i g h t i n t o the beginnings of t h i s acceptance. In both 1893-1894 and 1903-1904, 70% of the women Langis attended i n c h i l d b i r t h had engaged him p r i o r to the onset of labour, and therefore had the advantage of some prenatal care.37 (See fi g u r e 4.) Ethnic background does not seem to determine who sought prenatal care (see table 2), nor does economic p o s i t i o n (as indi c a t e d by occupation): the wives of a dyer, a steward, a peddler, a t i n s m i t h , and a watchman booked i n advance; the wives of a stonemason, a paperhanger, a j e w e l l e r , and a commercial t r a v e l l e r did not; three labourers' wives booked i n advance, f i v e d i d not. 38 On the other hand, the high proportion of premature b i r t h s and d i f f i c u l t d e l i v e r i e s among women who booked i n advance (t a b l e 5, data for 1893 and 1894) does suggest that women who had reason to expect d i f f i c u l t y with t h e i r pregnancy or d e l i v e r y were l i k e l y to book i n advance. Figure 4 i n d i c a t e s that women who had already given b i r t h (and therefore knew whether they d i d so e a s i l y or not) were more l i k e l y to book i n advance than women pregnant for the f i r s t time. A woman who turns to a doctor during pregnancy must b e l i e v e that he can increase her comfort and the safety of h e r s e l f and her c h i l d . E a r l i e r i n the nineteenth century, d i s t r u s t of doctors and t h e i r methods 74 Figure 4. Number of Previous B i r t h s by Mothers Attended at D e l i v e r y by Dr. Langis, with F r a c t i o n Engaging Him p r i o r to Labour 1893 and 1894 1903 and 1904 Totals: Births attended by Langis: 83 Engagement prior to labour: 58 (70%) 5 or more Births attended by Langis: 127 Engagement prior to labour: 90 (71%) 5 or more not known not known LEGEND Overall height of bar indicates number of mothers attended with number of previous births shown. Height of shaded portion of bar indicates number who engaged Langis prior to onset of labour. Figure in shaded portion is its percentage of total height. 75 Table 5 OBSTETRICAL PROBLEMS AMONG DR. LANGIS' PATIENTS 1888 1891 D e l i v e r i e s 9 30 Langis engaged before labour Miscarriages and s t i l l b i r t h s 1 (11%) 3 (10%) Premature b i r t h s 1 (11%) 1 (3%) D i f f i c u l t d e l i v e r i e s 1893 1894 D e l i v e r i e s 46 37 Langis engaged before labour 31 27 Miscarriages and s t i l l b i r t h s * 2 (6%) 4 (15%) Premature b i r t h s * 5 (16%) 4 (15%) D i f f i c u l t d e l i v e r i e s + * 7 (23%) 8 (30%) - Data unavailable * These data for 1893 and 1894 only a v a i l a b l e for patients who engaged Langis before labour. Percentages here r e f e r to that group. + For example: shoulder presentation, hemorrhaging, or use of forceps. Source: Daybooks [see note 11], 1888, 1891, 1893, and 1894, sections for O b s t e t r i c a l Records. 76 was common on t h i s continent. That so many of Langis 1 patients sought h i s assistance before the onset of labour - not j u s t when i t s pains might have made them ready to c l u t c h at any chance of r e l i e f - suggests a high l e v e l of popular b e l i e f i n the be n e f i t s of medical attendance, and presumably r e f l e c t s popular awareness of the incr e a s i n g e f f e c t i v e n e s s of of m e d i c i n e . ^ I t i s i n t e r e s t i n g that t h i s awareness was not confined to ethnic and occupational groups with high s o c i a l s t a t u s . Between 1894 and 1903, Langis' o b s t e t r i c a l patients began to arrange to have t h e i r babies i n h o s p i t a l s . (The f i r s t evidence of h o s p i t a l d e l i v e r y appears i n the 1903 daybook; the preceding daybook was for 1894.) Table 6 ind i c a t e s that most of Langis' o b s t e t r i c a l p a t i e n t s i n 1903 and 1904 s t i l l preferred to have t h e i r babies at home, and that women having a f i r s t baby were more l i k e l y to go to h o s p i t a l than those who had already given b i r t h . (Perhaps t h i s was because they had fewer domestic r e s p o n s i b i l i t i e s than women with c h i l d r e n . ) During the years covered by the nine daybooks, there were f i v e unmarried women among Langis' o b s t e t r i c a l p a t i e n t s ; one was mentioned i n hi s records for 1893 and four i n those for 1904. None of these women engaged h i s services i n advance, two had t h e i r babies i n h o s p i t a l , and a l l f i v e were pregnant for the f i r s t time. Langis received payment for attending two of the women - from the woman h e r s e l f i n one case and from a l o c a l contractor i n the other. The socal standing of the remaining three was l i k e l y quite low: one was a wa i t r e s s , one was apparently a Native Indian, and Langis i n d i c a t e d that the c h i l d of the t h i r d was c o l o u r e d . ^ That these women, although stigmatizad by pregnancy outside 77 Table 6 ANALYSIS OF DELIVERIES BY DR. LANGIS 1903-1904 No. of previous b i r t h s 0 1 2 3 4 5 or more Not known Total Delivered d e l i v e r e d i n h o s p i t a l 40 23 6 11 3 11 33 12 1 0 0 1 1 5 Percent in h o s p i t a l 30 6* 15 Langis engaged before labour 90 10 11 Not before 37 10 27 Total 127 20 16 * This i s the percentage of a l l d e l i v e r i e s known to be preceded by one or more previous b i r t h s . Source: Daybooks O b s t e t r i c a l Records. [see note 11], 1903 and 1904, sections for 78 marriage, sought a doctor's attendance shows again the g e n e r a l i t y of expectation that t h i s health service would be a v a i l a b l e . In the days before p e r i o d i c medical examination of the seemingly healthy became common, the l i f e insurance medical examination was for many the only occasion when a doctor had an opportunity to i d e n t i f y i n c i p i e n t health problems and recommend treatment. L i k e other doctors, Langis performed many of these examinations, some for large l i f e insurance companies and some for benevolent a s s o c i a t i o n s . ^ The t y p i c a l l i f e - i n s u r a n c e medical examination of the day consisted of a u s c u l t a t i o n and percussion of the bare chest, accompanied by close questioning of the applicant about h i s habits and health and about the health of h i s family; sometimes, p a r t i c u l a r l y i f the p o l i c y applied for c a r r i e d large b e n e f i t s , the applicant's urine was also a n a l y z e d . ^ Langis received no payment for a large part of h i s medical work; table 7 i n d i c a t e s the numbers of h i s paid and unpaid v i s i t s i n the month of March (as a sample) of some years; table 3 shows the occupations (based on information i n c i t y d i r e c t o r i e s ) of a number of Langis' patients i n March 1888, and i n d i c a t e s that there was no c l e a r d i f f e r e n c e i n s o c i a l or economic standing between those who paid and those who d i d not. Of those who did pay, the well-to-do tended to pay i n f r e q u e n t l y , while working-class patients paid.at frequent i n t e r v a l s and often paid a large b i l l i n i n s t a l l m e n t s . ^ There i s no i n d i c a t i o n that Langis neglected patients who did not p a y . ^ Although medical care could be had from Langis without payment, f a i l u r e to pay was not respectable; people even paid on behalf of others for whom they f e l t r e s p o n s i b i l i t y or a f f e c t i o n - Chinese servants, employees, family members, and 79 Table 7 AMOUNT OF MEDICAL ATTENDANCE GIVEN BY DR. LANGIS FOR WHICH HE WAS PAID Period V i s i t s , Paid v i s i t March 1885 86 19 (22%) March 1887 46 19 (41%) March 1888 111 65 (59%) March 1890 ' 67 36 (54%) March 1891 116 68 (59%) March 1893 176 54 (31%) March 1904 209 81 (39%) Note: The number of v i s i t s which were paid for may be underestimated. Langis 1 monthly records of cash received sometimes show payments from patients when there i s no corresponding i n d i c a t i o n of payment i n h i s record of d a i l y v i s i t s . This i s p a r t i c u l a r l y common for 1891-1904. His records for 1894 and 1903 seem so c l e a r l y inaccurate that they have been omitted from t h i s summary. Source: Daybooks [see note 11], 1885, 1886-1888, 1888, 1890, 1891, 1893, and 1904. 80 mistresses. ' Group medical insurance plans helped guarantee that medical b i l l s would be paid. Langis 1 daybooks show q u a r t e r l y payments from the Ancient Order of F o r e s t e r s , commencing i n 1891 and varying i n ' amount only s l i g h t l y from one quarter to a n o t h e r t h e consistency of amount suggests that these payments were based on the number of A.O.F. members i n Vancouver. His daybooks also show payments from the Independent Order of Foresters and the Canadian Order of F o r e s t e r s p a y m e n t s from these groups show no regular pattern, so i t i s l i k e l y that Langis provided medical care for t h e i r members on a f e e - f o r - s e r v i c e b a s i s . Group medical insurance plans were also e s t a b l i s h e d by companies: Langis 1 d a i l y e n t r i e s mention the Hastings M i l l Company; the telephone company; K e l l y , Douglas, and Company; and, most frequently, Ironside, Rannie, and Campbell. ^ The last-named company (contractors s p e c i a l i z i n g i n r a i l r o a d s and p u b l i c works) had a plan which provided both medical and h o s p i t a l care for employees who contributed to one of the company H o s p i t a l Funds; these funds were administered by the company, and a company o f f i c i a l signed the order for medical care which was presented to a doctor by a s i c k or in j u r e d employee Langis appears not to have increased h i s fees i n the years from 1888 to 1904. The increase i n h i s income i n t h i s period was due to the growth of h i s p r a c t i c e , p a r t i c u l a r l y h i s p r a c t i c e of o b s t e t r i c s and surgery, which paid w e l l . With t h i s s p e c i a l i z a t i o n , h i s p r a c t i c e also included an increasing proportion of h o s p i t a l v i s i t s . The changes i n Langis 1 p r a c t i c e r e f l e c t fundamental changes i n the world of medicine: there was i n the years covered by Langis 1 daybooks such growth i n 81 medical knowledge and technology, i n the number and s o p h i s t i c a t i o n of medical i n s t i t u t i o n s , and i n the expertise of medical personnel that the increased l i k e l i h o o d that medical a t t e n t i o n would provide cure or r e l i e f of sickness encouraged people to seek i t and to submit themselves even to i t s s p e c i a l i z e d forms, h o s p i t a l i z a t i o n and surgery.^3 * * * The adequacy of medical attendance may be measured by determining whether there are enough doctors to meet the demand for that s e r v i c e , whether the doctors are competent, and whether the people who need the service receive i t . I t i s c l e a r that there were more than enough doctors to meet the demand i n Vancouver during the period of t h i s study, and that they had, for the most part, been w e l l t r a i n e d by the standards of the day. -It i s less c l e a r that those who needed medical attendance received i t : although Langis' p r a c t i c e shows that no group of people ( i n p a r t i c u l a r , no group determined by income, s o c i a l standing, or e t h n i c i t y ) was s y s t e m a t i c a l l y excluded, and that medical attendance was a v a i l a b l e to those who could not pay for i t , there were nevertheless those who did not go to doctors because of fear, s u p e r s t i t i o n , ignorance, or unwillingness to receive c h a r i t y . Two patterns of change i n doctors' c o l l e c t i v e behaviour during t h i s period do point to an increase i n the use of medical attendance: an increasing frequency of separation of o f f i c e from residence (noted i n sect i o n i ) and a decreasing frequency of partnership p r a c t i c e - ^ suggest that the affluence of doctors i n Vancouver increased over these years. An increase i n t h e i r fees would e x p l a i n t h i s , but i t seems u n l i k e l y they 82 would have made such an increase, given t h e i r apparent underemployment (Langis, who did i n fact become more wealthy, does not seem to have increased h i s fees); i t i s more l i k e l y that incomes rose because pr a c t i c e s increased i n s i z e . Since, as we have seen, the doctor-population r a t i o did not change s i g n i f i c a n t l y over these years, i t seems c l e a r that the f r a c t i o n of the population r e c e i v i n g medical attendance increased - that there was an increased demand for t h i s s e r v i c e . During the period of t h i s study, doctors' routine attendance on patients u n l i k e l y to pay t h e i r b i l l s was the basis of a system whereby those who could a f f o r d to pay for medical care subsidized those who could not. This system worked because s o c i a l a t t i t u d e s which equated r e s p e c t a b i l i t y with economic s e l f - s u f f i c i e n c y motivated people to pay for medical attendance, e i t h e r i n d i v i d u a l l y or through group plans which spread the cost of high medical b i l l s and compelled saving. However, the system worked imperfectly: the same s o c i a l a t t i t u d e s led many people of l i m i t e d means to f a i l to seek a doctor's care u n t i l t h e i r cases were desperate; moreover, the power of s o c i a l opinion was not completely e f f e c t i v e , and some who could have paid t h e i r doctor b i l l s d i d not. This, and a growing sense of the s o c i a l waste inherent i n untreated i l l h e a l t h , encouraged the development of the new, less i n d i v i d u a l i s t i c s o c i a l a t t i t u d e s expressed i n the proposals - frequent a f t e r the end of the F i r s t World War - for a state medical s e r v i c e . ^ NOTES ON CHAPTER 2 Abbreviation: Daybooks Vancouver C i t y Archives, Henri E v a r i s t e Langis Papers (Add. Mss. 16), Daybooks. 1. Studies of medical attendance tend to emphasize the state of medical knowledge, the r o l e of government, the growth of medical i n s t i t u t i o n s and org a n i z a t i o n s , or the co n t r i b u t i o n s of great physicians. I have found the fo l l o w i n g works h e l p f u l i n w r i t i n g t h i s chapter - they describe medical attendance i n i t s s o c i a l s e t t i n g and see i t as subject to economic, p h i l o s o p h i c a l , p s y c h o l o g i c a l , and p o l i t i c a l i n f l u e n c e s : W i l l i a m C. Rothstein, American Physicians i n the Nineteenth Century, from Sects to Science (Baltimore, 1972); Ruth G. Hodgkinson, "The S o c i a l Environment of B r i t i s h Medical Science and P r a c t i c e i n the Nineteenth Century" i n Wi l l i a m C. Gibson (ed.), B r i t i s h Contributions to  Medical Science (London, 1971), pp.29-53; Noel Parry and Jose Parry, The  Rise of the Medical P r o f e s s i o n , A Study of C o l l e c t i v e S o c i a l M o b i l i t y (London, 1976), ch.7 and 9. I know of no good i n t e r p r e t i v e studies of medical attendance i n Canada. The fo l l o w i n g works are us e f u l for fa c t u a l information: Robert E. McKechnie I I , Strong Medicine (Vancouver, 1972); T.F. Rose, From Shaman to Modern Medicine, a Century of the Healing A r t s i n B r i t i s h Columbia (Vancouver, 1972); R.G. Large, Drums and S c a l p e l , from Native Healers to Physicians on the North  P a c i f i c Coast (Vancouver, 1968); H.L. B u r r i s , Medical Saga - The B u r r i s  C l i n i c and E a r l y Pioneers (Vancouver, 1967); Emily Carr, "Doctor and De n t i s t " i n her The Book of Small (1942; r p t . Toronto, 1966), pp.138-141 of the e d i t i o n c i t e d ; Charles G. Roland, "Diary of a Canadian Country P h y s i c i a n : Jonathan Woolverton (1811-1883)", Medical H i s t o r y , v.15 (1971), pp.168-180; W i l l i a m Perkins B u l l , From Medicine Man to Medical  Man, a Record of a_ Century and a_ Half of Progress i n Health and  S a n i t a t i o n as Exemplified by Developments i n Peel (Toronto, 1934). 2. Unless otherwise i n d i c a t e d , the m a t e r i a l i n t h i s s e c t i o n i s drawn from the Master Register of the College of Physicans and Surgeons of B r i t i s h Columbia, (at the College's o f f i c e i n Vancouver); the College's (published) Registers for 1898, 1899, 1901, 1902, 1903, 1904, 1905, 1906, 1907, 1908, 1909, 1910-11, 1912-13, 1913-14, 1914-15, 1916-17, 1918, 1919, 1920; the Vancouver d i r e c t o r i e s published by Henderson's P u b l i s h i n g Company for 1901 and 1903-1920; the B r i t i s h Columbia d i r e c t o r i e s published by Henderson's P u b l i s h i n g Company for 1898, 1900, and 1902; and the Vancouver d i r e c t o r y published by Rowland E. Green for 1899-1900. 83 84 3. The "physicians and surgeons" c l a s s i f i e d sections of c i t y d i r e c t o r i e s between 1898 and 1920 also included advertisements of 54 people who were not r e g i s t e r e d with the College of Physicians and Surgeons. Most of these (41) advertised i n only one d i r e c t o r y ; 7 advertised i n two; 3 advertised i n three; 2 advertised i n four; and one advertised i n s i x . Five of these unlicensed "doctors" also advertised as d e n t i s t s ; one shared an o f f i c e with a licensed doctor; the women (three i n number) may have been midwives. A p l e n t i f u l supply of l e g a l l y q u a l i f e d doctors undoubtedly l i m i t e d the success of these p r a c t i t i o n e r s , and t h e i r careers were l i a b l e to be c u r t a i l e d by prosecution under the Medical Act. The infrequency with which an unlicensed person advertised for more than one year suggests that these or other influences were f a i r l y e f f e c t i v e i n i n h i b i t i n g t h e i r p r a c t i c e of medicine. 4. Abraham Flexner, Medical Education i n the United States and  Canada (1910; r p t . New York, 1960), p.14. Canada as a whole had 9.7 doctors per 10,000 population; the United States had 17.6 per 10,000 population. In the l a t t e r country, small towns were more l i k e l y to have a s u p e r f l u i t y of doctors than large c i t i e s (Flexner, pp.14, 320). 5. The Vancouver D a i l y Province, 13 December 1916, p.4; Vancouver C i t y Archives, Vancouver Board of School Trustees, Minutes, v.6, Management Committee Minutes, 25 January 1915 and 29 January 1917. 6. Flexner considered the education given by the Manitoba and Queen's medical schools less good than that given by the Toronto or M c G i l l medical schools, but as representing "a d i s t i n c t e f f o r t toward higher i d e a l s " (Flexner, p.325); B r i t i s h medical t r a i n i n g i n general was good; that given i n the United States ranged from the exc e l l e n t t r a i n i n g given at Johns Hopkins to the worthless t r a i n i n g given at "degree m i l l s " (Flexner; Physicans' Panel on Canadian Medical H i s t o r y , a d i s c u s s i o n held 7 October 1966 i n Lac Beauport, sponsored by Schering Corporation and the Canadian Medical A s s o c i a t i o n , published June 1967, n.p., 5th and 6th pages; F.N.L. Poynter (ed.), The E v o l u t i o n of Medical P r a c t i c e i n B r i t a i n [London, 1961], pp.11-14, 31-32, 50-55). 7. Some doctors who pra c t i c e d i n the Vancouver area outside the c i t y boundaries are included on these maps. 8. This i s i n f e r r e d from the lack of separate o f f i c e addresses i n the d i r e c t o r y e n t r i e s for them. 9. For a d e s c r i p t i o n of the atmosphere of doctors' o f f i c e s which were located i n homes, see "The Doctor's Wife", Canada Lancet, v.20 (1888), pp.176-179. 10. Walter G. Hardwick, Vancouver (Don M i l l s , Ontario, 1974), pp.87-88, pp.105-106. 11. There i s a daybook devoted to e n t r i e s for each of the years 1885, 1888, 1890, 1891, 1893, 1894, 1903, and 1904. In a d d i t i o n , there i s one containing e n t r i e s for 1886, 1887, and 1888. 85 12. Port Moody Gazette, 9 August 1884. Apart from the Daybooks, and the copy of of Williams' D i r e c t o r y mentioned below, there are only three items i n h i s docket at the Archives. A theatre program and a l e t t e r from a young c h i l d are two of these. The f o l l o w i n g note i s w r i t t e n i n the margin of the 1891 Daybook, pages for 12-22 September: "Sarah, l a divi n e Sarah - played l a s t night as [ i l l e g i b l e ] play La Tosca to night Sept 22 [ i l l e g i b l e ] " . The words of "Three Knights", a poem or song, are w r i t t e n i n the (otherwise unused) June and J u l y cash record s e c t i o n of the 1885 Daybook. Newspaper c l i p p i n g s of "The Shooting of Dan McGrew" and "Salut a l'Empereur" are inserted near the back of Langis 1 copy of Williams' Vancouver C i t y D i r e c t o r y for 1888. 13. A d d i t i o n a l b i o g r a p h i c a l information on Langis may be found i n The News-Herald, 12 June 1937, p . l ; The D a i l y Province, 12 June 1937, p.5; The Vancouver Sun, 12 June 1937, p.3; L e t t e r from H.E. Langis to R.E. McKechnie i n F.W. Howay and E.O.S. S c h o l e f i e l d , B r i t i s h Columbia  from the E a r l i e s t Times to the Present (Vancouver, 1914), v . l , pp.615-617; College of Physicans and Surgeons of B r i t i s h Columbia, Master Reg i s t e r ; W.D. K e i t h , St. Paul's H o s p i t a l , Vancouver, B.C.: the  H i s t o r y of the Medical S t a f f 1920-1940 (n.p., [1950]), p.2; U n i v e r s i t y of B r i t i s h Columbia L i b r a r y , Woodward L i b r a r y Memorial Room, "Biographies of E a r l y B r i t i s h Columbia Doctors" ( t y p e s c r i p t , 3 v o l s . ) ; Vancouver C i t y Archives, Add. Mss. 54, v.13, f i l e L-29. 14. "Biograph i e s of E a r l y B r i t i s h Columbia Doctors"; The  Vancouver A d v e r t i s e r , 18 January 1887. There are no e n t r i e s i n the 1886-1888 Daybook dated between 19 A p r i l 1886 and 6 September [1886]. 15. Daybooks, 6 September [1886], the facing page, and 21 September 1886 to 4 December 1886. 16. K e i t h , p.3; "Biographies of E a r l y B r i t i s h Columbia Doctors". 17. Vancouver C i t y Archives, Vancouver General H o s p i t a l Archives Book for 1886-1901, 23 September 1888. 18. From 1888 on, the Daybook e n t r i e s were w r i t t e n only i n E n g l i s h . E a r l i e r , they were w r i t t e n i n a mixture of En g l i s h and French. 19. The News-Herald, 12 June 1937, p . l ; The D a i l y Province, 12 June 1937, p.5. 20. Daybooks, 1888 and 1904, monthly cash account s e c t i o n s . 21. "Incomes of Physicans", Dominion Medical Monthly and Ontario  Medical J o u r n a l , v.18 (1902), p.220. 22. Daybooks, 1885, monthly cash account s e c t i o n ; Rothstein, p.262. 23. K e i t h , p.2. 86 24. The Vancouver d i r e c t o r y shows that Langis was again p r a c t i c i n g i n the West Hastings Street area of Vancouver i n 1919. There i s no mention of him i n P a r k s v i l l e or Vancouver d i r e c t o r y l i s t i n g s for the years 1920 through 1923. He i s l i s t e d as a resident of P a r k s v i l l e from 1924 to 1937. In 1937, he i s l i s t e d i n the Vancouver d i r e c t o r y at the address of a nephew. 25. For example: "Rosa (L. Scott) [$]3" (Daybooks, 21 November 1893), and "Laura Scott, g i r l pd." (Daybooks, 28 August 1904). 26. Daybooks, 3 and 4 March 1904, 14 March 1893, 24 and 26 November 1904. 27. Henderson's Vancouver D i r e c t o r y , 1901, p.766, l i s t i n g for Herbert W. Riggs. The general p r a c t i t i o n e r of the day was expected to be a v a i l a b l e at any time. (James Gregory Mumford, A Doctor's Table Talk [Boston, 1912], p.52.) 28. Daybooks, 8-16 J u l y 1887 and 13-19 November 1904. 29. Daybooks, 8 March 1893, 6 A p r i l 1893, 17 January 1893, 19 March 1894, 8 May 1894. 30. Langis accounted for h i s small p r a c t i c e thus: "The f i r s t few years the c l i e n t e l e was not very b i g , as most of the heads of f a m i l i e s worked for the C.P.R. and were attended by t h e i r own [C.P.R.] surgeons." L e t t e r from H.E. Langis to R.E. McKechnie, l o c . c i t . 31. Daybooks, 13 August 1887, 23 August 1887, 6 March 1893, 2-8 October 1904, 28 November-3 December 1904, 8 A p r i l 1893, 2 June 1887, 15 September 1904, 18 September 1904, 11-14 October 1904; Daybooks, 1904, pocket i n s i d e back cover (order from the Ironside, Rannie, and Campbell company, dated 4 December 1904); The News-Herald, 12 June 1937, p . l . 32. For evidence of the r e c r e a t i o n a l use of alcohol and sex i n Vancouver during t h i s period, see M. A l l e r d a l e Grainger, Woodsmen of the  West, (1908; r p t . Toronto, 1964), p.15; McKechnie, p.139. 33. For evidence of accidents r e s u l t i n g from drunkenness, see U n i v e r s i t y of B r i t i s h Columbia L i b r a r y , S p e c i a l C o l l e c t i o n s , B r i t i s h Columbia E l e c t r i c Railway Papers, box 146, f i l e 562, accident reports for 20 September 1913, 19 December 1913, 14 January 1914, 23 December 1914. There i s no reason to be l i e v e Langis d i d not tr e a t s i m i l a r l y caused accidents. 34. Daybooks, 1904, pocket i n s i d e back cover. 35. Daybooks, 20-22 October 1904. 36. "Treatment of S y p h i l i s " , Canada Lancet, v.20 (1888), pp.245-246; R.W. Taylor, "Some P r a c t i c a l Points i n the Treatment of S y p h i l i s " , Canada Lancet, v.22 (1890), p.244; "The Best Method of Administering Potassium Iodide", Dominion Medical Monthly and Ontario  Medical J o u r n a l , v.25 (1905), pp.281-283. 87 37. For a d e s c r i p t i o n of the care recommended e a r l y i n the century for pregnant women by a M c G i l l l e c t u r e r , see David James Evans, O b s t e t r i c s , A Manual for Students and P r a c t i t i o n e r s (2nd ed.; P h i l a d e l p h i a , 1909), pp.59-61. 38. Daybooks, 1893, 1894, 1903, 1904, sections for O b s t e t r i c a l Records. 39. During the nineteenth century, the p o p u l a r i t y of Thomsonianism, patent medicines, and, to a l e s s e r extent, homeopathy, in d i c a t e s a r e j e c t i o n of regular physicans and t h e i r methods. (Rothstein, passim.) 40. I r o n i c a l l y , the p r a c t i c e of o b s t e t r i c s was slow to improve. The maternal death r a t e , although i t declined markedly among c h a r i t y patients i n h o s p i t a l s , improved very l i t t l e among p r i v a t e patients i n B r i t a i n and America during the years covered by Langis 1 daybooks (Evans, p. 123), and Flexner complained as l a t e as 1910 that o b s t e t r i c a l t r a i n i n g of doctors was inadequate to meet the needs of mother and c h i l d (Flexner, pp.117-118). 41. Daybooks, 1893 and 1904, sections for O b s t e t r i c a l Engagements and O b s t e t r i c a l Records; Daybooks, 29 January 1893 and 15 March 1904; Daybooks, 1893, sec t i o n of monthly accounts, entry for 26 A p r i l . 42. "With the great growth of l i f e and f r a t e r n a l insurance during the past few years, p r a c t i c a l l y every p h y s i c i a n i s engaged to some degree as examiner for some company or a s s o c i a t i o n . " (Review of Charles Lyman Green, The Medical Examination for L i f e Insurance ..., Dominion  Medical Monthly and Ontario Medical J o u r n a l , v.24 [1905], p.229.) 43. For example, Daybooks, 23 June 1888, 26 J u l y 1888, 27 November 1888, 29 November 1888. 44. Frank W. Foxworthy, ed., L i f e Insurance Examination (St. Lou i s , 1924), p.40; George W i l k i n s , Hints as to Medical Examination for  L i f e Assurance, (Montreal[, 1880s?]). I am pleased to thank J.M. Champagne, Underwriting Supervisor of the Canadian Foresters L i f e Insurance Society, and E l i z a b e t h Gibson, L i b r a r i a n of the Sun L i f e Assurance Company of Canada, for sending me copies of turn-of-the-century medical examination forms, which were also informative. 45. For example, the Daybooks show that Charles Doering (a partner i n a brewery) or members of h i s family had 34 v i s i t s from Langis i n 1894. Doering paid Langis $62.50 on 16 January 1894 and $75.00 on 4 December 1894. In contrast, C.E. Maddams (according to Langis, a steward; according to the d i r e c t o r y , a porter) had h i s eighth c h i l d d e l i v e r e d by Langis on 3 May 1894. Maddams paid $20 on 13 May and $5 on 14 J u l y . 46. Patients who had not paid continued to receive care from Langis. For example, Jennie Wilson was v i s i t e d by him on 11, 12, and 14 March 1888, even though a b i l l for $60 sent the preceding August had not 88 been paid (Daybooks, 1886-1888). 47. For example ( a l l c i t a t o n s r e f e r to Daybooks): "Mrs Dan Ross, Chinaman" (5 August 1905); "A.B. M a c N e i l l , Chinaman" (5 and 7 October 1904); "Jas Summers [of the White Swan Hotel] (white servant) [$]10" (20 June 1891); "T.D. Cyrs [ p r o p r i e t o r of the G r a n v i l l e Hotel] (H. Pinard) pd" (3 October 1893); "W.E. O'Brien pd mother" (13 October 1904); "Blanche Lewis Annie pd" [Both Blanche and Annie Lewis l i v e d at 138 Dupont S t r e e t , i n the house of Blanche Wood] (19 September 1904); "Fred Martin a lady" (10 September 1904). 48. Recorded payments received from A.O.F. were: 10 Oct 1891 32.25 6 Jan 1894 41.00 6 J u l 1903 104.50* Jan 1892 33.75 5 Apr 1894 36.00 17 Oct 1903 108.50 21 Jan 1893 39.25 10 J u l 1894 40.75 13 Jan 1904 103.50 7 Apr 1893 38.25 8 Oct 1894 37.75 6 Apr 1904 105.75 3 Aug 1893 38.25 5 Jan 1903 104.00 5 J u l 1904 110.00 10 Oct 1893 38.50 8 Apr 1903 104.25 18 Dec 1904 104.50 *: Apparently i n e r r o r , t h i s i s recorded as from the I.O.F. (Daybooks, monthly cash account s e c t i o n s ) . 49. Recorded payments received from I.O.F. were: 8 Dec 1891 7.50 24 Feb 1893 21.75 9 Jun 1894 10.00 28 Dec 1891 25.00 2 Mar 1894 25.00 Recorded payments received from C.O.F. were: 15 Jan 1894 21.00 19 J u l 1894 10.00 23 Oct 1894 22.50 10 May 1894 10.00 (Daybooks, monthly cash account s e c t i o n s ) . 50. Daybooks, 28 May 1887, 2 October 1888, 30 June 1904, and 10, 15, 22, 24, 25, 29, and 31 August 1903. 51. Daybook for 1904, pocket insi d e back cover (orders for medical care). 52. The usual charge for a v i s i t was $2.50, but i t might be $5.00 i f made during the night. Charges for a confinement v a r i e d from $15.00 to $40.00. Charges for operations ranged from $15.00 to $20.00 for minor ones to $125.00 for major ones. In p r a c t i c e , Langis seemes to have used a s l i d i n g system of fees: he sometimes marked accounts "paid" when h i s cash r e c e i p t s showed that the patient had paid less than the amount due. 53. For a c l e a r d i s c u s s i o n of the i n t e r r e l a t i o n s h i p science and medical attendance, see Rothstein, ch.13-15. of medical 89 54. 4 (14%) of the 29 doctors i d e n t i f i e d i n t h i s study as p r a c t i c i n g i n Vancouver i n 1898 p r a c t i c e d i n partnership, 10 (10%) of the 101 doctors of 1909 d i d , and only 2 (1%) of the 202 doctors of 1920 di d . 55. For examples of such proposals, see The D a i l y Province, 20 December 1918, p.15; 27 December 1918, p.7; 12 February 1919, p.5; The  Vancouver D a i l y Sun, 5 March 1919, p . l . NOTES ON FIGURES, CHAPTER 2 For "Daybooks", see page 83. Sources for Figures 1-3: College of Physicians and Surgeons of B r i t i s h Columbia, Master Register ; College of Physicians and Surgeons of B r i t i s h Columbia, Register, 1898, 1899, 1901, 1902, 1903, 1904, 1905, 1906, 1907, 1908, 1909, 1910-11, 1912-13, 1913-14, 1914-15, 1916-17, 1918, 1919, 1920; Henderson's P u b l i s h i n g Co. (pub.), Vancouver  D i r e c t o r y , 1901, 1903-1920; Henderson's P u b l i s h i n g Company (pub.), B r i t i s h Columbia D i r e c t o r y , 1898, 1900, 1902; Rowland E. Green (pub.), Vancouver D i r e c t o r y , 1899-1900; Vancouver, Annual Report, 1922, pp.68-69. (The data i n figure 1 r e f e r to the beginning of the years i n d i c a t e d : the number of doctors c i t e d as p r a c t i c i n g at the beginning of a year was determined from the c i t y d i r e c t o r y for that year in d i c a t e d above; the population c i t e d as at the beginning of a year i s that given i n the 1922 Annual Report as at the close of the preceding year.) Sources for Figure 4: Daybooks [see note 11], 1893, 1894, 1903, and 1904, sections for O b s t e t r i c a l Records. 90 CHAPTER 3 HOSPITAL SERVICES The C i t y of Vancouver has never been without h o s p i t a l f a c i l i t i e s : there was a company h o s p i t a l for Canadian P a c i f i c Railway employees before A p r i l 1886, the c i t y ' s date of in c o r p o r a t i o n ; Anglican and Roman Cat h o l i c h o s p i t a l s were b u i l t during the next few years;* and more than a dozen small h o s p i t a l s were established as community services or as business enterprises i n the f i r s t two decades of the twentieth century. 2 This chapter examines the development of medical and supporting a d m i n i s t r a t i v e services from 1886 to 1920 i n Vancouver's p r i n c i p a l h o s p i t a l - the C i t y H o s p i t a l ( p h y s i c a l l y descended from the C.P.R. Hos p i t a l ) before 1902, Vancouver General H o s p i t a l since then. Medical services and h o s p i t a l a d m i n i s t r a t i o n were both transformed i n that period; a c a s u a l l y run municipal boarding house for the s i c k became an e f f i c i e n t business c o n t r o l l e d by doctors and devoted to the d e l i v e r y of up-to-date services by medical s p e c i a l i s t s . The C i t y H o s p i t a l was f i r s t housed i n a small frame b u i l d i n g on the Hastings Road, near the present i n t e r s e c t i o n of Powell Street and Hawks Avenue. These premises had been b u i l t and used by the C.P.R. for i t s h o s p i t a l a f t e r i t s previous f a c i l i t y was destroyed i n the f i r e which devastated Vancouver i n June 1886. By the end of 1886, the C.P.R. had 3 put the management of t h i s h o s p i t a l into the hands of the C i t y . 91 92 The small frame b u i l d i n g d i d not match the v i s i o n s of c i v i c grandeur which f i l l e d the minds of Vancouver c i t i z e n s i n the months surrounding the f i r s t a r r i v a l of t r a i n s from the E a s t : 4 guided apparently by a boosterish concern for appearances, C i t y Council determined e a r l y i n 1887 that a new h o s p i t a l should be b u i l t , ^ even though the e x i s t i n g b u i l d i n g was r a r e l y f u l l . The C i t y purchased ten l o t s on Beatty, Cambie, and Pender Streets from the C.P.R. (having refused a g i f t of property on the c i t y ' s o u t s k i r t s from the same company, apparently i n the b e l i e f that a c e n t r a l l o c a t i o n was e s s e n t i a l 7 ) and t r a n s f e r r e d the C i t y H o s p i t a l i n September 1888 to a new Q b u i l d i n g erected on t h i s s i t e . By 1901, many doctors, p o l i t i c i a n s , and other concerned c i t i z e n s believed the C i t y H o s p i t a l b u i l d i n g (which included some additions made a f t e r 1888) to be obsolete; moreover, i t s neighbourhood had become congested and " u n d e s i r e a b l e " T h e C i t y once again purchased land from the C.P.R. - f i v e and a h a l f acres at the present s i t e of Vancouver General H o s p i t a l i n the then sparsely s e t t l e d F a irview d i s t r i c t . * 0 New h o s p i t a l b u i l d i n g s there came into use i n January 1906.**-Di r e c t municipal a d m i n i s t r a t i o n was inconvenient - both for Aldermen (who found themselves concerned with such d e t a i l s as the ca l c i m i n i n g of h o s p i t a l w a l l s and the r e n t a l of a s u i t a b l e home for h o s p i t a l nurses*- 2) and for doctors working i n the h o s p i t a l . By 1898, the h o s p i t a l Medical Board (an advisory body of doctors appointed by the C i t y Council) were apparently d i s s a t i s f i e d with Municipal su p e r v i s i o n , p a r t i c u l a r l y with the Council's making new appointments to the Board without con s u l t i n g them: the Board suggested i n that year that the 93 h o s p i t a l be governed by "a commission". 1 3 While new h o s p i t a l premises were under d i s c u s s i o n , the form of h o s p i t a l governance again came into question: at a pub l i c meeting i n December 1901, the Vancouver Medical A s s o c i a t i o n presented a plan which not only c a l l e d for a new h o s p i t a l b u i l d i n g , but also c a l l e d for the h o s p i t a l to be governed by a Board of Di r e c t o r s c o n s i s t i n g of people 1^ chosen by the c i t y and p r o v i n c i a l governments, the Medical Board, and h o s p i t a l s u b s c r i b e r s . ^ This plan of governance was embodied i n an act of inc o r p o r a t i o n for Vancouver General H o s p i t a l i n the summer and put into e f f e c t i n the f a l l , having then been approved by the c i t y voters q u a l i f i e d to vote on money by - l a w s . ^ The influence of ordinary c i t i z e n s on h o s p i t a l a f f a i r s was somewhat diminished by t h i s t r a n s f e r of au t h o r i t y to a corporation of subscribers (who made e i t h e r a $10 annual payment or a s i n g l e payment of $100). C l e a r l y aware of t h i s , the Vancouver Trades and Labor Council had communicated to the c i t y government t h e i r wish that the l a t t e r not "hand over the r i g h t s of the c i t i z e n s to a sel e c t few, according to t h e i r a b i l i t y to subscribe" and not introduce "Lady B o u n t i f u l s . . . dol i n g out g i f t s i n i n s u l t i n g and degrading c h a r i t y " into the h o s p i t a l ; they had proposed instead that the h o s p i t a l be governed l i k e the schools - by a popularly elected b o a r d . 1 7 * * * U n t i l i t moved from the old C.P.R. b u i l d i n g i n 1888, the C i t y H o s p i t a l served mainly as a boarding house for men who were i l l or injur e d and had no one to look a f t e r them. Medical attandance was 94 provided by the C i t y Medical Health O f f i c e r (whose duties included supervising the H o s p i t a l ) , but there was no resident doctor. Nor were there resident nurses: patients were tended by the h o s p i t a l steward (the only employee) or by convalescent patients i f the steward was away fetching supplies or a doctor. I f a patient needed constant a t t e n t i o n , f r i e n d s or workmates of h i s might take turns s i t t i n g with him through the night. Care i n the h o s p i t a l at t h i s stage of i t s development was not for the f a s t i d i o u s : rest was l i a b l e to be disturbed by drunken l a t e - n i g h t v i s i t o r s , by a d e l i r i o u s f e l l o w p a t i e n t , or by warning of an approaching c l e a r i n g - f i r e . * ^ Not s u r p r i s i n g l y , women were r a r e l y p a t i e n t s . 1 3 In c o n t r a s t , Vancouver General H o s p i t a l i n 1920 was a major reg i o n a l diagnosis, treatment, and t r a i n i n g center, capable of accomodating 1000 p a t i e n t s . 2 0 I t s fundamental services - medical attendance, nursing care, and surgery - were augmented by the work of a laboratory, a pharmacy, and x-ray, physiotherapy, electrocardiography, and anaesthsia departments. There were also services a v a i l a b l e only to the poor: medical attendance at an outpatient department and at s i c k -and well-baby c l i n i c s ; m a t e r i a l assistance and co u n s e l l i n g through a s o c i a l service department. T r a i n i n g was given to men and women i n medical, paramedical, t e c h n i c a l and c l e r i c a l types of h o s p i t a l work. The d e l i v e r y of fundamental services was s p e c i a l i z e d : there were separate maternity, surgery, and i s o l a t i o n wards, and there were further subdivisions - an eye, ear, nose and throat s u r g i c a l ward and a tub e r c u l o s i s i s o l a t i o n ward, for example. Two sections had ph y s i c a l f a c i l i t i e s away from the Fairview s i t e : an i n f a n t s ' h o s p i t a l on Haro 95 Street i n the West End and an annex for i n a c t i v e treatment cases i n Marpole. The s t a f f included 49 graduate nurses, over 200 student nurses, and the score of doctors who worked f u l l time i n the h o s p i t a l as i n t e r n s , a d m i n i s t r a t o r s , or s p e c i a l i s t s attached to h o s p i t a l departments. The Medical Board, who attended c h a r i t y p a t i e n t s ( i n a d d i t i o n to advising the D i r e c t o r s ) , comprised an honorary " c o n s u l t i n g " s t a f f ( a l l eminent doctors i n p r i v a t e p r a c t i c e i n the c i t y ) and a " v i s i t i n g " s t a f f of general p r a c t i t i o n e r s , medical s p e c i a l i s t s , and d e n t i s t s . A l l these workers were a v a i l a b l e * t o supplement the attendance of a patient's own doctor.21 The care given by Vancouver General H o s p i t a l was assessed i n 1919 by the Committee on H o s p i t a l Standardization of the American College of 99 Surgeons. ^ A f t e r i t s f i r s t v i s i t , t h i s committee assigned the h o s p i t a l a "Class A" r a t i n g , decided that t h e i r usual second v i s i t of i n s p e c t i o n was unnecessary, and indicated that "a patient [could] not get b e t t e r medical a t t e n t i o n anywhere on the continent".23 I t i s c l e a r that there was a great improvement i n the h o s p i t a l care a v a i l a b l e i n Vancouver over the period of t h i s study.24 Despite the improvement i n care, the cost per patient per day (as measured i n constant dollars25) decreased during t h i s period. In p a r t i c u l a r , t h i s r e a l expenditure held more or less steady through 1913, decreased s t e a d i l y throughout the war, and rose again from 1918 to 1920, but not to prewar l e v e l s . (See f i g u r e 1.) The marked decrease can i n some measure be a t t r i b u t e d to wartime a u s t e r i t y , but i t s beginning 96 Figure 1. Ho s p i t a l Operating Costs per Patient-Day 1903-1920 E'EEE: : E E E E ; : E J ; E | ; ^ ; - E : : • • ! • • • 1 - • - i -. . . j ! t j ) _ I n i . — _ EEjE:.: EEiEEiE:;EE ::: • - : E : E | : : E ; : - . " i EElEE EEiEE ,:::.:r:.:r: |. lii'ilfE -:::::.:! ;•:::: - — i • - • • ; E : E E . | E - E / : Y !—~—~—Ti EEjEE - i — : :rr:jrE: E E | E E ; E : | E E :r:..:riE::-: EEL: E \.::: E:.:i :- ;n- ' ,•• / E E - E : E | — i — EE|EE EEJrE EEjEE : : : : : r ! EEJ:::::: i : . : . : . L J : ~ • . : • " • : ! . - - : •. / • E :• y "'"ET-:: r J EEJEE EEJEE E E I E E : . : : : : j r . L : : ::-.::!:.:.-: :\r.:::.\ i-:-::t:r::: ' ••' / ' E E : | E E :E : !.:":::::" j :::::: :T."J : E | E : : | - E E E - : • • - ! / E ! / ! T E . ; E E ; E ! E E E E .EEJIEE" :.;.:.:.j:r::r E E ! 1 : : E " : E : : - - :'•:::::/::.: i i i : | : EEJEE I J . ; 'E ;E | :E -1EE i V-rr—^ ! E l : ! i • •! i EEJ-Er 7 : . X I .": - E : E - 1 M - v i ••:..!• .•!•:•: ; ;-;|..:.r: -! : EElEE E E E E E — i — : .-• . . 1. . . . . . . .] ; . . . i E : : j : E J : E E - - T " : : ; E : | 1 E E E E E "EEEE / A Y " :.:r:|:.r : !.• : EEj E: 7 : E | : T ! - f : ; ! . E : i E:±EE - - ""-•«. '• E H E " E E ! E E ! : E : ! E ; ! : E i : E ! E E I E E = r - i i t ' : : 'E — j . . v -• : . r : - | 1 • \ -:::.:! s„: : E : ; E E J . E . .::!:_::.: : — ; " Y - I • c EEjEE [• EELEE . . . , E E ! : E ! : : ^ ; E ! E i E n ! E - : n : ; i : ' ; E E i E :j-EE • • • • t ^ • / ! . . . : . : . t 1 |UU. : E ; : : ^ | E E E E .EElEE v . . /* ! ' " | • • • • • 1 .... , . , . , \! TEi-H-iElEEfe; D • : E - - r — - p : : . | \ * : | E E | : E : ; ! EEJEE : :E: : . . : . . ( . : | . I H 1300 d o l U n s t - - - - r j - • - - I -1' . 1 • •: 1 E.! ••• ; • : [ ' . ; :.\ I E O E E ' P IE.;:; JEEE VCDI ' I /• " r L i k ' l r 1 — ; ; • , i :EE j j . —r~ j ' 1 EEE:::. _ V J L- f 1 C K C L . . .: ri t - , 3 p \ • \ • • : E E [ E E EEEEIEEEE: - E $ E •:•:::.!:".: E E I I I E . . . . . . . j EEi: E : - i EElEE E E | E E ::EEEE E i J E : : ::E |."~' • : : . ; ' . . • I : : . : : • . J I ' /*) _ •:--|..V.-.T E " " j " ; . " ; : / ' E E | E E : " : : - j . : : : „ - :: !":E: : .:: E: IE : i • : : . : | - : : : : E : | : ; . : J E : : | : - E • • i E E J E E .: 1 : E ' I E E E E ' E %.— w » 1 /V3- ! /iP 1 1 l^/Y«J_ 1 i i • 1 1 i i IT' 1"? i 1 i i l l ' t ? H f t . : • . . j EE":!?-'.:! E~-: •::~™r~~ i ufe U f. ;.U:C L - : . : 4 : : : : J...! 1.. En j EE 1 i. 1 i • r r i i l b — 1 : : • : ! - " " - : 0. . • . E E :::L~ir:::::: : . L - : - j . : : : : : •_:.t7T.:; . E - H E E EEl-rE ^ E ! . E - : ! : E E E - f : | r.~-\ :~r :::::: rEr.::. 1 •:.:-|:r:_:. -TI::\: ::: • ••! EE! E : : I : " E ! E" "| -..:! E E | 97 coincided not with the beginning of the war, but with the appointment as General Superintendent of M.T. MacEachern, one of the outstanding North American medical administrators of h i s generation; the e f f i c i e n c i e s he introduced must be considered the major cause of the Ho s p i t a l ' s improved economic performance. In order to see what prompted new h o s p i t a l services o f f e r e d by C i t y H o s p i t a l and Vancouver General H o s p i t a l and how they developed when once e s t a b l i s h e d , we now examine the development of a number of s p e c i f i c h o s p i t a l s e r v i c e s . A women's ward was established at the urging of the Medical Board s h o r t l y a f t e r the r e l o c a t i o n of the C i t y H o s p i t a l to Pender and Cambie S t r e e t s . D A women s H o s p i t a l Committee asked i n 1890 for more extensive h o s p i t a l f a c i l i t i e s for women,27 and the Vancouver Medical A s s o c i a t i o n made a s i m i l a r request a few years l a t e r . 2 ^ The C i t y Council's Health Committee argued for C i t y funds for such f a c i l i t i e s , and the Council sought a grant from the p r o v i n c i a l government, 2^ but i t was 1898 before a new women's ward was f i n a l l y opened. 3 0 Although opening a maternity ward was apparently considered by the Health Committee i n 1890, 3* o b s t e t r i c a l care was not a p r a c t i c a l p o s s i b i l i t y u n t i l the new women's ward was opened i n 1898. I t was debated then whether o b s t e t r i c a l p a t i e n t s might be admitted to the h o s p i t a l , - the Medical Board ob j e c t i n g that the danger of c r o s s - i n f e c t i o n was too great to allow them to use the women's ward, the l o c a l chapter of the National Council of Women countering with the renewed suggestion that a separate maternity ward be added. The Health 98 Committee did not be l i e v e there was an urgent need for t h i s s ervice (the home being then the normal place for confinement) and determined that the C i t y should instead a s s i s t d e s t i t u t e women due to be confined by providing "a Doctor, a Nurse and Medical Comforts outside of the Hospital."32 Eight years l a t e r , when the issue was again r a i s e d , the Board of D i r e c t o r s of Vancouver General H o s p i t a l decided to admit o b s t e t r i c a l patients.33 The maternity service was popular: i t was d i f f i c u l t for the H o s p i t a l to provide enough maternity beds to meet public demand throughout the remaining years covered by t h i s study.34 The women's H o s p i t a l Committee mentioned above had suggested i n the e a r l y n i n e t i e s that the C i t y e s t a b l i s h a separate h o s p i t a l for women and c h i l d r e n , J and wards for in f a n t s and c h i l d r e n had been es t a b l i s h e d i n Vancouver General H o s p i t a l by 1909,36 but these expressions of concern pale i n comparison with the f a c i l i t i e s which m a t e r i a l i z e d i n the second decade of the twentieth century, when i n t e r e s t i n c h i l d r e n ' s health and welfare became widespread. The most important such f a c i l i t y was Infants' H o s p i t a l , opened i n 1917 at the request of the C i t y Council i n the West End b u i l d i n g which had housed the creche operated by the City.3? (The creche had l o s t much of i t s usefulness with the exodus of the wealthy from the West End to Point Grey and Shaughnessy, and the consequent reduction i n the number of domestic workers employed i n the West End and needing day care for t h e i r c h i l d r e n . ) O r i g i n a l l y , Infants' H o s p i t a l was used mostly for treatment of d i g e s t i v e distrubances (the most common cause of infant death) and of m a l n u t r i t i o n , but by the end of the period of t h i s study, the range of i t s work had been broadened by the ad d i t i o n of an operating 99 room and a se c t i o n for the care of premature babies. In a d d i t i o n , i t had been renovated to accomodate nearly 70 babies (more than double the o r i g i n a l number), and i n d i v i d u a l c u b i c l e s had been i n s t a l l e d to reduce the incidence of c r o s s - i n f e c t i o n . 3 ^ Infants' H o s p i t a l also served as a foundling home and centre of education for mothers. Some foundling babies had been cared for at the 39 creche,-" and with the opening of Infants' H o s p i t a l , the C i t y arranged for such babies to be cared for t h e r e . 4 0 This H o s p i t a l also accomodated the milk depot which had been opened by the H o s p i t a l A u x i l i a r y i n 1916 at the Fai r v i e w h o s p i t a l b u i l d i n g . The nurse i n charge of t h i s f a c i l i t y encouraged mothers to breast-feed t h e i r babies, taught them how to care for themselves so that they would be able to do so, and prepared correct formulas for babies of mothers who did not breast-feed. Babies were brought to the depot once a week for weighing, and when formula-fed babies were gaining weight w e l l , t h e i r mothers were taught how to prepare the formula themselves. There was a weekly charge of one d o l l a r for the formula provided, but t h i s was waived i f i t seemed l i k e l y to cause hardship. 4*- S i m i l a r l y , c l i n i c s which had operated at the main h o s p i t a l were relocated to Infants' H o s p i t a l and became part of the work supervised by the Health Department's D i v i s i o n of C h i l d Hygiene. At these c l i n i c s , babies under two years of age were given outpatient care, and mothers were advised on health matters. By 1920, the D i v i s i o n of Ch i l d Hygiene had incorporated the milk depot into t h e i r well-baby c l i n i c s ; formula was no longer a c t u a l l y prepared and d i s t r i b u t e d at these, i n s t r u c t i o n i n formula-making being offered instead, along with free t i c k e t s redeemable for m i l k . 4 2 100 As h o s p i t a l treatment became i n c r e a s i n g l y s c i e n t i f i c , C i t y H o s p i t a l and Vancouver General H o s p i t a l were i n c r e a s i n g l y r e l u c t a n t to accept incurable p a t i e n t s , ^ 3 since such patients u s u a l l y needed tending rather than treatment and often for long periods occupied a bed which could have been used for p a t i e n t s needing the h o s p i t a l ' s s p e c i a l f a c i l i t i e s . However, there was no appropriate f a c i l i t y f or such p a t i e n t s , and the h o s p i t a l got them by default-. The C i t y , having from i t s beginnings assumed r e s p o n s i b i l i t y to care for the s i c k poor, had permitted some paupers with incurable diseases to stay i n C i t y H o s p i t a l , providing them with c l o t h i n g and pocket money as w e l l as h o s p i t a l c a r e . ^ ( I t also paid t r a v e l expenses for others, so that they could go to family or f r i e n d s w i l l i n g to care for them.45) When the h o s p i t a l b u i l d i n g s were transfered from the C i t y to Vancouver General H o s p i t a l , the Board of D i r e c t o r s only r e l u c t a n t l y agreed to assume r e s p o n s i b i l i t y for the incurable patients then accomodated i n them,^ and t r i e d during the remainder of the period of t h i s study to get e i t h e r the c i t y or p r o v i n c i a l government to e s t a b l i s h other f a c i l i t i e s for i n c u r a b l e s . ^ 7 The number of p a t i e n t s i n wards set aside for the incurable contributed to a general overcrowding, and induced the H o s p i t a l to seek a separate f a c i l i t y for p a t i e n t s whose i l l h e a l t h was not acute.^8 E a r l y i n 1917, an annex for convalescent and inactive-treatment cases was opened i n a former h o t e l i n Marpole, with a s e c t i o n devoted to incurable c a s e s . ^ By 1919, the Marpole Annex was also nearly f i l l e d . ^ 0 During the F i r s t World War, Vancouver General H o s p i t a l was h e a v i l y involved i n the treatment of s i c k and wounded s o l d i e r s , having been asked by the M i l i t a r y H o s p i t a l Commission l a t e i n 1916 to provide such 101 treatment .-5-1 Although a ward for returned s o l d i e r s had been est a b l i s h e d i n the h o s p i t a l the preceding year,-'1 e x i s t i n g h o s p i t a l f a c i l i t i e s could not be stretched to care for the 200 s o l d i e r s envisioned by the Commission. In the p a t r i o t i c atmosphere of wartime Vancouver, funds for a M i l i t a r y Annex were q u i c k l y r a i s e d through g i f t s from i n d i v i d u a l s and from f r a t e r n a l and c h a r i t a b l e o r g a n i z a t i o n s . ^ 3 The p u b l i c continued to be involved with the M i l i t a r y Annex and i t s work: H o s p i t a l a u t h o r i t i e s consulted Annex subscribers about arrangements made with the M i l i t a r y H o s p i t a l Commission,^ and the s o l d i e r s were r e g u l a r l y provided with flowers and other comforts.^5 The h o s p i t a l ' s work with s o l d i e r s ( l i k e i t s emergency nursing service during the i n f l u e n z a epidemic at the end of the war) a t t r a c t e d public a t t e n t i o n to the h o s p i t a l and advertised i t s s o c i a l value. The t r a d i t i o n a l h o s p i t a l r o l e of caring for the poor was f u l f i l l e d by the free outpatient medical treatment given by C i t y H o s p i t a l and Vancouver General H o s p i t a l to d e s t i t u t e patients who were not i l l enough to require hospitalization.->6 With growth i n population and removal of the h o s p i t a l to suburban Fairview, p r o v i s i o n of such services by the h o s p i t a l apparently no longer met the needs of the c i t y ' s poor, and i t s f a c i l i t i e s were supplemented i n 1911 by a downtown free dispensary operated under the a u t h o r i t y of the Associated C h a r i t i e s (an o r g a n i z a t i o n subsequently incorporated into the c i t y ' s r e l i e f department) .-^ 7 This f a c i l i t y was closed i n 1915, when the H o s p i t a l opened i t s own new outpatient c l i n i c and added sixteen doctors to the Medical Board to attend i t s p a t i e n t s . ^ There were 525 outpatient consultations at Vancouver General H o s p i t a l i n 1905, when i t was s t i l l 102 operating at the downtown C i t y H o s p i t a l s i t e ; with the removal of the h o s p i t a l to Fairview, the number dropped, remaining under 200 i n most years u n t i l the depresssion of 1913 and 1914. There were 450 outpatient c o n s u l t a t i o n s i n 1914, 2400 i n 1915 (the f i r s t year of operation for the new c l i n i c ) , and the number remained between 2000 and 3000 for the r e s t of the period of t h i s study. The s o c i a l service department^ 0 f the h o s p i t a l was An outgrowth of the h o s p i t a l ' s c h a r i t y work. Members of the H o s p i t a l A u x i l i a r y had been accustomed to a s s i s t poor patients whom they encountered i n the course of t h e i r v i s i t s to the hospital,61 and the A u x i l i a r y asked i n 1912 i f i t could e s t a b l i s h a program of s o c i a l work i n the h o s p i t a l for needy pat i e n t s and t h e i r f a m i l i e s . H o s p i t a l a u t h o r i t i e s agreed to the proposal, and the A u x i l i a r y h i r e d a t r a i n e d nurse to be i n i n charge and provided her with volunteer assistance.62 As part of t h i s program, food was given to dependents of h o s p i t a l i z e d and convalescent breadwinners, and appropriate employment was found for p a t i e n t s upon t h e i r release from h o s p i t a l . I f such employment was out of town, the cost of t r a v e l to i t might also be paid. Homes were found for unwed mothers and t h e i r babies, and arrangements were made for adoption of babies who were not being kept by t h e i r mothers. Appeals were sometimes made i n the press on behalf of a p a t i e n t , and some cases were passed on to municipal r e l i e f o f f i c e r s or to r e l i g i o u s c h a r i t y organizations.63 This program received warm endorsement from the Medical Board.64 I t became l i n k e d a d m i n i s t r a t i v e l y with the outpatient department i n 1919, and student nurses were assigned to work i n i t beginning i n 1920;65 the H o s p i t a l did not, however, assume f i n a n c i a l r e s p o n s i b i l i t y for i t u n t i l 1926.66 103 The h o s p i t a l ' s b a c t e r i o l o g i c a l services expanded as the science of b a c t e r i o l o g y developed and as doctors perceived i t to be u s e f u l i n the p r a c t i c e of medicine. B a c t e r i o l o g i c a l diagnostic methods were l i t t l e used i n the h o s p i t a l u n t i l 1907, when the necessary expertise was made a v a i l a b l e by inc r e a s i n g the number of resident physicians from one to three. A pa t h o l o g i s t added to the Medical Board that year supervised the h o s p i t a l ' s laboratory work.67 As doctors became i n c r e a s i n g l y aware of the assistance l a b o r a t o r i e s could give them i n t h e i r p r i v a t e p r a c t i c e , the number of requests from doctors throughout the province for b a c t e r i o l o g i c a l work i n c r e a s e d ; ^ doctors working w i t h i n the h o s p i t a l also pressed for improvement of i t s laboratory.69 The r e s u l t i n g expansion i n f a c i l i t i e s and personnel i s r e f l e c t e d i n the increase i n laboratory work done by the h o s p i t a l . (This accelerated n o t i c e a b l y with the appointment of a f u l l - t i m e laboratory d i r e c t o r i n 1916. 7^) The number of laboratory examinations rose from 30,000 i n 1916 to 62,000 i n 1920, and there was p a r t i c u l a r l y r a p i d growth i n c e r t a i n types of work: 500 d i p h t h e r i a c u l t u r e s were made i n 1916, and 9,000 i n 1920; 300 Wasserman t e s t s were made i n 1916, and 800 i n 1917. 7 1 New types of work were undertaken - accurate weighing and c h a r t i n g of s p e c i a l d i e t s for patients with diabetes and kidney disease, blood-typing t e s t s for blood donors, and routine examination of t i s s u e from the operating rooms, f o r example 7^ -, and governmental agencies began to use the laboratory's s e r v i c e s . 7 3 By the end of the period of t h i s study, the laboratory operated twenty-four hours a day and was hard pressed to f i n d adequate space for i t s a c t i v i t i e s . 7 ^ 104 L i k e the laboratory s e r v i c e , the h o s p i t a l radiography s e r v i c e developed i n response to pressure from doctors and increased s t e a d i l y i n use from the time of World War I on. The f i r s t h o s p i t a l x-ray machine was purchased at the request of the Medical Board i n 1900, a time when such devices were s t i l l objects of wonder for the layman.?5 No one was put i n charge of t h i s machine, but with the g i f t i n 1906 of a new and presumably more s o p h i s t i c a t e d machine, such an assignment, although d i f f i c u l t to make because of the newness of radiography, became more urgent. An appointment was f i n a l l y made i n the spring of 1909 - to the r e t i r i n g superintendent of the h o s p i t a l , on the c o n d i t i o n that he undertake a s p e c i a l t r a i n i n g course. (He contintued as head of the radiography department u n t i l 1 9 3 0 . A l t h o u g h doctors were slower to take up the use of radiography than of the b a c t e r i o l o g i c a l laboratory, the number of x-ray plates made per year d i d increase i n the l a t t e r part of t h i s period, from 2115 i n 1915 to 9800 i n 1920. The increase was p a r t i c u l a r l y marked i n x-rays of the chest ( i n examinations for pulmonary t u b e r c u l o s i s ) and of the d i g e s t i v e t r a c t (made radio-opaque by the i n g e s t i o n of b i s m u t h ) . 7 7 T r a i n i n g nurses was a h o s p i t a l s e r v i c e of a d i f f e r e n t type: i t served pa t i e n t s only i n d i r e c t l y , and was i n fact e s t a b l i s h e d p r i m a r i l y as a means of keeping h o s p i t a l operating costs low. The program at Vancouver's p r i n c i p a l h o s p i t a l 7 * * s t a r t e d i n 1899 with eight student nurses and two supervising nurses, based on r u l e s and r e g u l a t i o n s drawn up a few weeks a f t e r the h o s p i t a l had spent a si z e a b l e amount to h i r e an a d d i t i o n a l temporary nurse. 7^ 105 Students graduated a f t e r a three-year course, i n which they received i n d i v i d u a l i n s t r u c t i o n i n the wards, a great deal of nursing p r a c t i c e , and weekly one-hour evening l e c t u r e s by doctors.^0 Although there was no maternity ward i n the h o s p i t a l , student nurses were able to obtain o b s t e t r i c a l experience: at f i r s t , they went to a New Westminster h o s p i t a l ; somewhat l a t e r , to a p r i v a t e h o s p i t a l operated i n Vancouver by a former C i t y H o s p i t a l n u r s e . ^ From 1900 to 1920, the h o s p i t a l enriched the basic nurses' t r a i n i n g program and added new courses for women wishing to t r a i n for s p e c i a l i z e d nursing p o s i t i o n s . In the basic program, t h e o r e t i c a l t r a i n i n g increased i n importance, and the range of p r a c t i c a l nursing experiences a v a i l a b l e to trainees increased as the h o s p i t a l undertook Q 9 new types of work.'' T r a i n i n g for graduate nurses who wished to s p e c i a l i z e was added - f i r s t i n o b s t e t r i c s and surgery, l a t e r i n p e d i a t r i c s and d i e t e t i c s as w e l l . ^ 3 Beginning i n 1919, women who combined study at the U n i v e r s i t y of B r i t i s h Columbia with nurses' t r a i n i n g at Vancouver General H o s p i t a l were able to q u a l i f y for a degree i n n u r s i n g ^ and thereby for teaching and a d m i n i s t r a t i v e p o s i t i o n s i n the f i e l d of nursing. Over the years, the o r i g i n a l casual methods of administering the nurses' t r a i n i n g program gave way to more formal ones. In 1912, the d i r e c t o r of the program introduced a system of i n d i v i d u a l record cards (modeled on one used i n New York) to record the progress of each s t u d e n t . ^ The h o s p i t a l d i r e c t o r s ' appointment of an education subcommittee i n 1916°° encouraged r a t i o n a l i t y and uni f o r m i t y i n the adm i n i s t r a t i o n of the program, since i t required the d i r e c t o r of the 106 t r a i n i n g program to e x p l a i n and j u s t i f y her decisions on such matters as admission and expulsion of student nurses. A f t e r the War, a formal channel for student complaints and suggestions was e s t a b l i s h e d i n the form of a Student Council which met r e g u l a r l y with the d i r e c t o r of the nursing program.^ 7 The foregoing summary of the development of h o s p i t a l services shows that the i n t e r e s t s represented i n the changes that took place were few i n number. Doctors and h o s p i t a l administrators pressed for good, modern f a c i l i t i e s which would enhance t h e i r reputations and f u r t h e r t h e i r careers. In crusading for improved conditons for women, c h i l d r e n , and the poor, l e i s u r e d middle-class women s a t i s f i e d c o n f l i c t i n g expectations which faced them - they acted independently of the a u t h o r i t y of men and s t i l l f u l f i l l e d woman's nur t u r i n g r o l e . The C i t y Health Department, wishing more and more to confine i t s medical work to preventive medicine and to expand i t s programs i n that f i e l d , was eager to have the h o s p i t a l assume c u r a t i v e services which had formerly belonged to the C i t y and to introduce new s e r v i c e s , such as a separate i n f a n t s ' h o s p i t a l , which lent themselves to a s s o c i a t i o n with p a r a l l e l preventive services i t could o f f e r . Services based on new technology were, implemented q u i c k l y -sometimes so q u i c k l y that the h o s p i t a l had to create a demand for t h e i r use. Services which were d i r e c t e d p r i m a r i l y to women, c h i l d r e n , or people of modest income were t y p i c a l l y implemented long a f t e r they were o r i g i n a l l y proposed - only when they had come in t o vogue among healt h and welfare workers or were demanded by the wealthy. Indeed, the i n t e r e s t s of doctors and the wealthy were the key to the s e l e c t i o n of 107 proposed h o s p i t a l services f or implementation: p r i o r i t i e s were assigned according to doctors' advice because of respect for t h e i r medical e x p e r t i s e ; i n h o s p i t a l matters as i n s o c i e t y as a whole, the wishes of the wealthy were heeded. The p r o v i s i o n of modestly luxurious h o s p i t a l services (such as p r i v a t e rooms) encouraged them to abandon the home as the usual place of medical care and to patronize the h o s p i t a l , but t h e i r patronage was not r e s t r i c t e d to luxury s e r v i c e s : t h e i r share of a l l h o s p i t a l costs was la r g e , and t h e i r i n t e r f e r e n c e with h o s p i t a l expansion minimal. As employers, they cannot have f a i l e d to see that services for workers and t h e i r f a m i l i e s made good business sense, minimizing absenteeism and i n s u r i n g a supply of strong workers. Both doctors and the wealthy spoke of "meeting the needs of the whole community", of "c r e a t i n g a strong new generation", and of "marching with s c i e n t i f i c and te c h n o l o g i c a l progress". * * * The h o s p i t a l was changing i t s p o s i t i o n i n s o c i e t y and becoming more a s c i e n t i f i c i n s t i t u t i o n run by experts, l e s s a c h a r i t a b l e refuge. Symptomatic of the tensions of t r a n s i t i o n , there was c o n f l i c t among those connected with h o s p i t a l a d m i n i s t r a t i o n . Two contests - one between experts and amateur volunteers for e f f e c t i v e a u t h o r i t y i n h o s p i t a l matters, and one for p o s i t i o n s as d i r e c t i n g experts among doctors connected with h o s p i t a l work - were at the center of the c o n f l i c t , but people associated with the h o s p i t a l i n the decade before World War I were working i n an a i r of tension which was general, not r e s t r i c t e d to well-defined c o n t e s t s . ^ 108 Amateurs on C i t y Council and the Board of D i r e c t o r s continued to be able to make sound decisions on purely business and f i n a n c i a l matters, but i n c r e a s i n g l y needed the advice of doctors as ( i n the i n c r e a s i n g l y s c i e n t i f i c h o s p i t a l ) more and more of t h e i r d e c isions had medical i m p l i c a t i o n s . Combined with the overabundance of d o c t o r s , ^ the opportunity doctors had to compete for influence on matters a f f e c t i n g t h e i r work tended to make them suspicious and r e s e n t f u l of each other: doctors who were not on the Medical Board appear to have been jealous of those who were;^ interns expressed d i s s a t i s f a c t i o n with the l i m i t e d l e a r n i n g opportunities provided them by the Medical Board;91 the Medical Board and the more i n c l u s i v e Vancouver Medical A s s o c i a t i o n frequently showed jealousy of each other's i n f l u e n c e ; ^ a n c j the Medical Board showed signs of fe a r i n g the power of the Superintendent. 9 3 The two well-defined contests mentioned were interwoven with the ev o l u t i o n of r e q u i s i t e q u a l i f i c a t i o n s for the h o s p i t a l ' s c h i e f o f f i c e r . On the one hand, the balance of power between amateurs and doctors s h i f t e d as t h i s o f f i c e came to require s p e c i a l i z e d and p r e s t i g i o u s medical q u a l i f i c a t i o n s ; and on the other, the inter n e c i n e medical struggle was superseded by the more f r u i t f u l work of adj u s t i n g to the sort of st r u c t u r e the employment of an a d m i n i s t r a t i v e s p e c i a l i s t would b r i n g . The o r i g i n a l c h i e f o f f i c e r at the C.P.R.-built h o s p i t a l was a man of a l l work; a London-trained nurse was placed i n charge when the h o s p i t a l moved into the b u i l d i n g at Pender Street i n 1888; 9 4 the f i n a l step i n t h i s progression - appointment of a resident p h y s i c i a n to supervise the h o s p i t a l - was attempted i n the C i t y Council Health 109 Committee i n 1896, but was blocked by the mass r e s i g n a t i o n of the Medical Board. I t was taken i n 1898, i n response to charges of insubordination among the n u r s e s . ^ (Perhaps the a u t h o r i t y given i n d i v i d u a l doctors by the h o s p i t a l supervisor's i n f e r i o r i t y of rank led to c o n f l i c t with respect to nurses' duties.) The growing status of the h o s p i t a l among the health services of the c i t y and the r e l a t e d b e l i e f that the i n s t i t u t i o n required a c h i e f o f f i c e r of more p r e s t i g e and higher medical q u a l i f i c a t i o n s than a nurse were affirmed. As the h o s p i t a l grew, the non-medical a d m i n i s t r a t i v e tasks -purchasing, accounting, b u i l d i n g maintenance, and laundry - also grew, and i n 1913, the Board of D i r e c t o r s of Vancouver General H o s p i t a l appointed the H o s p i t a l Secretary (who had a business background and considerable experience with the h o s p i t a l ) as Superintendent. This appointment seems to have been made i n response to an Alderman's charge that h o s p i t a l admission procedures were i n e f f i c i e n t , a charge that had led to the r e s i g n a t i o n of the incumbent Superintendent.96 The Medical Board was f i r m l y opposed to t h i s appointment, and convinced enough D i r e c t o r s of the imprudence of p l a c i n g the h o s p i t a l under the s u p e r v i s i o n of anyone but a doctor to have i t repealed.9? McEachern, the person appointed Superintendent f o l l o w i n g these d e l i b e r a t i o n s , was not only a doctor, but one committed to medical a d m i n i s t r a t i o n as a career. By formally recognizing the already present and increasing t e c h n i c a l s p e c i a l i z a t i o n of h o s p i t a l work, and by encouraging c o n s u l t a t i o n among s p e c i a l i s t s , he was able to replace the s p i r i t of jealousy and i n s e c u r i t y which pervaded the a d m i n i s t r a t i v e aspects of the h o s p i t a l ' s work by a s p i r i t of team endeavour.98 110 The D i r e c t o r s ' actions i n t h i s matter are at the crux of the h o s p i t a l ' s t r a n s i t i o n from c h a r i t a b l e refuge to s c i e n t i f i c i n s t i t u t i o n . Both t h e i r appointment of a business expert i n response to the charge of i n e f f i c i e n c y and t h e i r agreement to appoint a medical expert instead are symptomatic of the long-developing loss of e f f e c t i v e power by amateurs, and the v i c t o r y of medical expertise shows that the further devolution of power to a heirarchy organized along l i n e s of t e c h n i c a l s p e c i a l i z a t i o n was f u l l y under way. A f t e r these events, i t was c l e a r that the development of the h o s p i t a l would be guided by medical and s c i e n t i f i c values, not simply by those of business e f f i c i e n c y . The h o s p i t a l ' s e v o l u t i o n from c h a r i t a b l e refuge to s c i e n t i f i c i n s t i t u t i o n e n t a i l e d a widening of i t s constituency: i t ceased to be p r i m a r i l y a f a c i l i t y for the poor and extended i t s services to include comfortable p r i v a t e rooms for the well-to-do. 99 a.s those who could a f f o r d to pay came to be p a t i e n t s , the h o s p i t a l was no longer seen as a project to be financed p r i m a r i l y by government, but was expected to be i n c r e a s i n g l y s e l f - s u p p o r t i n g . This new perspective s u i t e d h o s p i t a l administrators' i n t e r e s t s w e l l (administrators gained greater autonomy of a c t i o n as the h o s p i t a l grew i n f i n a n c i a l independence), and h o s p i t a l income and expenditure became a primary a d m i n i s t r a t i v e concern. The t a n g i b l e sign the h o s p i t a l needed that the p u b l i c had accepted i t s new f i n a n c i a l basis was the p a t i e n t s ' payment of h o s p i t a l fees. This increased markedly over the period of t h i s study,^0 encouraged by a v a r i e t y of methods devised by h o s p i t a l a u t h o r i t i e s to supplement moral o b l i g a t i o n . I l l In the e a r l y years of the C i t y H o s p i t a l , c o l l e c t i o n of b i l l s was j u s t one of the many tasks assigned the h o s p i t a l steward. He was supposed to c o l l e c t from the C.P.R. once a month for charges incurred by t h e i r employees and from other paying p a t i e n t s as they l e f t the h o s p i t a l . Poor c o l l e c t i o n s from both the company and i n d i v i d u a l 102 p a t i e n t s led h o s p i t a l a u t h o r i t i e s to h i r e someone to act as bookkeeper and b i l l - c o l l e c t o r i n 1893, and l a t e r to increase the s t a f f of what had become the c o l l e c t i o n s department. 1*^ j j v 19H, the H o s p i t a l r o u t i n e l y determined whether patients were members of F r i e n d l y S o c i e t i e s or Lodges or were p a r t i c i p a n t s i n Sick Funds, and whether t h e i r employers were h o s p i t a l s u b s c r i b e r s , maintained s i c k funds of t h e i r own, or were otherwise prepared to help with the cost of i l l n e s s . 1 ^ S o c i a l pressure was also applied: f o r e i g n consuls were sometimes asked to help c o l l e c t from t h e i r n a t i o n a l s , r e s i d e n t s of adjacent m u n i c i p a l i t i e s were h i r e d to c o l l e c t from t h e i r neighbours, and members of some a s i a t i c ethnic groups were appointed to c o l l e c t among t h e i r fellows.106. However, the h o s p i t a l ' s t r a d i t i o n a l function as refuge (and modern t r a n s l a t i o n s of i t - O r i e n t a l s were being received by 1907!07) remained fundamental, and low-income p a t i e n t s continued to be served. To maximize income from fees w i t h i n these terms of reference, the h o s p i t a l used two d i f f e r e n t fee schedules - one set low enough that few p a t i e n t s could j u s t i f i a b l y assume the status of c h a r i t y cases. Thus, although charges for p r i v a t e and semi-private r o o m s 1 ^ a n < j other h o s p i t a l f a c i l i t i e s 1 ^ w e r e r a i s e d from time to time, as were charges to such bodies as the Workmen's Compensation Board and the Department of Indian A f f a i r s , which paid a f l a t rate per person treated,HO the long-standing 112 charge of $1.00 per day for p u b l i c wards was not increased u n t i l 1918, when i t was r a i s e d to $1.50'. 1 1 1 In 1900 d o l l a r s , the r i s e i n 1918 was from $0.39 to $0.58 for accomodation which had cost $0.97 i n 1 8 9 0. 1 1 2 Strenuous e f f o r t s were made to c l a s s i f y p a t i e n t s c o r r e c t l y according to t h e i r a b i l i t y to pay and to force them to act according to t h i s c l a s s i f i c a t i o n . The c o l l e c t i o n s t a f f were to check the address and reference given by a patient at the time of admission and a s c e r t a i n whether the patient had any income (beyond that needed to support h i s or her family) from which the h o s p i t a l could be p a i d . 1 1 3 C h a r i t y and paying pa t i e n t s i n p u b l i c wards were to be segregated, so that the former would not encourage the l a t t e r to non-payment of h o s p i t a l b i l l s . 1 1 4 Payment for p r i v a t e and semi-private rooms was e i t h e r to be made upon admission or guaranteed by some responsible p e r s o n , 1 1 ^ and patients i n these rooms were to be moved in t o p u b l i c wards i f they were tardy with t h e i r payments. Fortunately for the H o s p i t a l ' s a s p i r a t i o n s for independence, i t was as w e l l placed with respect to the problem of expenses as i t was awkwardly placed with respect to the problem of income. I t kept the cost of labour very low by e s t a b l i s h i n g t r a i n i n g programs and using trainees for h o s p i t a l work. (Student nurses were paid between $6 and $10 per month when even Aldermen thought they should be paid $ 2 0 . 1 1 7 ) By the end of the period of t h i s study, Vancouver General H o s p i t a l had e s t a b l i s h e d basic t r a i n i n g courses for nursery maids, medical records c l e r k s , laboratory t e c h n i c i a n s , o r d e r l i e s , and nurses, as w e l l as post-graduate t r a i n i n g for nurses and a residency program for newly 1 1 Q t r a i n e d doctors. Although there were always more applicants for the 113 Vancouver General H o s p i t a l nurses' t r a i n i n g program than could be a c c e p t e d , 1 1 9 the l i m i t s placed on t h i s economy by the a v a i l a b i l i t y of men and women w i l l i n g to be trainees on the terms offe r e d were r e a l - i n the years immediately a f t e r the War, there was a general shortage of applicants for nurses' t r a i n i n g schools, and Vancouver h o s p i t a l a u t h o r i t i e s f e l t the threat to t h i s important supply of labour sharply enough to allow some expense for the improvement of nurses' working c o n d i t i o n s : an eight-hour working day for student nurses was introduced, and the twenty-four-hour duty s h i f t i n i n f e c t i o u s wards was phased o u t . 1 2 0 The success of the Ho s p i t a l ' s quest for independence of government financ i n g appears c l e a r l y i n fi g u r e 2, which shows the sources of operating income for Vancouver General H o s p i t a l i n the years of t h i s study, along with i t s annual operating d e f i c i t . 1 2 1 The f r a c t i o n of operating income made up by government grants f e l l from about 70% i n 1904 to less than 35% i n 1920. By accepting the s i z a b l e d e f i c i t s i n i t i a t e d by the H o s p i t a l i t s e l f i n the l a s t few years, c r e d i t o r s c l e a r l y recognized i t s autonomy. For the H o s p i t a l as for government bureaus and p r i v a t e f i r m s , expansion was the surest way to autonomy. The H o s p i t a l ' s expansion was gen e r a l l y believed to be appropriate, l i n k e d as i t was to the growth of population and technology, and i t was stron g l y supported. In 1920, Vancouver General H o s p i t a l had c a p i t a l assets which had cost $1,384,970, 1 2 2 and i t s f a c i l i t i e s had expanded to provide 330,000 patient-days of treatment i n 1920, as compared with 19,000 i n 1 9 0 3 . 1 2 3 20% of the c a p i t a l for t h i s expansion was provided as grants from the 114 Figure 2. Vancouver General H o s p i t a l Operating Income by Sources (and Operating D e f i c i t ) 1904-1920 •I 1 - -r::;tr-::|=:r|_::7r.:l::-r7rTE -m-V2& BB: — 3 3 0 --8-oef-loo--46-PZZL - 6 © o — \ j ::!:!•:•.: - S o © -fco--206--Zoo— •feo- 4ot n n Q U U U U U I ? -CL 63 10 12 131 5 * IS y(> , 1 ? J8| ±3-— i— j — ! " ' I P u b l i c So Writ "0v\^ -cTeV^itT ~ 115 province, and 6% was p r i v a t e l y d o n a t e d . 1 2 4 In a d d i t i o n to t h i s generous downpayment, the H o s p i t a l was given considerable a u t h o r i t y i n the management of i t s own c a p i t a l i z a t i o n by means of the power to issue bonds and debentures. 1 2^ These were to be endorsed by the C i t y of Vancouver through i t s usual money by-law mechanism, and the required approval of c i t y voters was g e n e r a l l y g i v e n . 1 2 ^ ( R e a l i z i n g how important a favourable p u b l i c view of the h o s p i t a l was, administrators obtained extensive press coverage and p e r i o d i c a l l y i n v i t e d the p u b l i c to tour the h o s p i t a l . 1 2 7 ) As a p r a c t i c a l matter, the H o s p i t a l ' s c a p i t a l i z a t i o n was l i m i t e d by the f i n a n c i a l resources of the c i t y . The C i t y government sometimes refused, on the grounds that i t s c r e d i t would not extend so f a r , to cooperate i n p u t t i n g a h o s p i t a l money by-law before the v o t e r s , and the voters themselves once defeated such a measure. 1 2^ For whatever reason, the H o s p i t a l ' s decisions on c a p i t a l i z a t i o n were conservative: even i n the boom-time of the second decade of the twentieth century when voters r e a d i l y approved by-laws, h o s p i t a l f a c i l i t i e s lagged behind need. Incorporation was a u s e f u l v e h i c l e for autonomy, since i t put enough distance between day-to-day h o s p i t a l operation and p o l i t i c a l c o n t r o l to allow comparatively unfettered development of h o s p i t a l s e r v i c e s . Proponents saw i t as a sign' of Vancouver's progress beyond the f r o n t i e r stage of development i n which government had had to undertake what were upper-class o b l i g a t i o n s i n e s t a b l i s h e d urban centers, and framed t h e i r arguments to show inc o r p o r a t i o n i n that l i g h t . That t h e i r r h e t o r i c ignored the a d m i n i s t r a t i v e advantages inherent i n the scheme denies neither the r e a l i t y of these advantages 116 nor the proponents' awareness of them. S p e c i f i c a l l y , arguments for inc o r p o r a t i o n included ;the suggestion that the voluntary donations i t would encourage would s i g n i f i c a n t l y d i minish the Ho s p i t a l ' s need for government support. The annual tag days sponsored by the Women's A u x i l i a r y d i d e l i c i t p u b l i c support, as did various h o s p i t a l b u i l d i n g fund d r i v e s , and a spectacular new-style whirlwind campaign i n 1919 rai s e d $200,000 (enough to wipe out the accumulated d e f i c i t of seventeen years of h o s p i t a l o p e r a t i o n ) . 1 3 ^ Given the scale of the Ho s p i t a l ' s operations at that time, these means of support were completely inadequate: i n 1920, the Hospital, 1 s operating d e f i c i t (9% of expenses i n that year of i n f l a t i o n ) was more than $100,000. 1 3 1 In 1912, the i n q u i r y of a p r o v i n c i a l commission i n t o the management of the h o s p i t a l had already exposed the v a n i t y of the hope that c i t y government underwriting of h o s p i t a l expenses could be sharply l i m i t e d . The i n v e s t i g a t i o n was held at the request of the Board of Di r e c t o r s a f t e r charges of h o s p i t a l mismanagement had been made at a C i t y Council meeting. The commissioner exonerated those responsible for the h o s p i t a l from any f a u l t more serious than reluctance to spend money they did not have. He suggested a one-third increase i n nurses and a one-half increase i n o r d e r l i e s . 1 3 3 S h o r t l y before the commission report was made p u b l i c , the Board of D i r e c t o r s o f f e r e d to turn management of the h o s p i t a l back to the C i t y . 1 3 4 The s p e c i a l grant of $15,000 to defray the h o s p i t a l d e f i c i t authorized a few days l a t e r by the C i t y C o u n c i l 1 3 ^ shows c l e a r l y t h a t , when faced with t h i s a l t e r n a t i v e , the Aldermen preferred the C i t y to accept i t s r o l e as 117 f i n a n c i a l guarantor of the h o s p i t a l . * * * Over the years covered by t h i s study, Vancouver's p r i n c i p a l h o s p i t a l developed many of the c h a r a c t e r i s t i c s of a t y p i c a l modern corporation: i t s services and a d m i n i s t r a t i v e s t r u c t u r e became more d i v e r s i f i e d and s p e c i a l i z e d ; i t s Board of D i r e c t o r s became an approving body, with experts the a c t u a l d e c i s i o n makers; team s p i r i t and committee decision-making became more t y p i c a l of a d m i n i s t r a t i v e s t y l e than competitive i n d i v i d u a l i s m ; and p u b l i c - r e l a t i o n s methods were employed to " s e l l " consumers (who were general l y also taxpayers and therefore h o s p i t a l f i n a n c i a l backers) on the q u a l i t y of the h o s p i t a l product. During the l a s t decade of the nineteenth century and the f i r s t two of the twentieth, " s c i e n t i f i c management" became the creed of enlightened i n d u s t r i a l corporations. The time-and-motion studies of F r e d e r i c k W. Taylor and Frank and L i l l i a n G i l b r e t h were symptomatic of widespread e f f o r t s by corporation administrators to economize, standardize, and s p e c i a l i z e . 1 3 7 C e n t r a l i z a t i o n of c h a r i t a b l e work (as i n the C h a r i t y Organization S o c i e t i e s ) and the i n c r e a s i n g employment of C i t y Managers i n d i c a t e that t h i s creed was also adopted by c h a r i t a b l e organizations and governments. Adoption of s c i e n t i f i c management d i d not insure the development of a modern corporate st r u c t u r e (as the frequently c i t e d example of the Ford Motor Company proves), but i t d i d provide a powerful push i n that d i r e c t i o n : i t encouraged s p e c i a l i z a t i o n , and t h i s i n turn encouraged r e a l decision-making to migrate from the top of the corporate pyramid to teams of experts w i t h i n 118 i t s middle l a y e r s . M.T. MacEachern may w e l l have been consciously applying current ideas about corporate management when he i n i t i a t e d and encouraged changes which c r y s t a l i z e d the a d m i n i s t r a t i v e s t r u c t u r e of Vancouver General H o s p i t a l . However, foundations f or that s t r u c t u r e had already been l a i d by Vancouver doctors: they encouraged h o s p i t a l growth and s p e c i a l i z a t i o n along l i n e s developing w i t h i n the f i e l d of medicine and r e g u l a r l y exercised t h e i r influence c o l l e c t i v e l y through committees; most important, they comprised a body of experts working w i t h i n the h o s p i t a l ' s a d m i n i s t r a t i o n . These doctors do not appear to have been i n s p i r e d by theories of corporate management; rat h e r , t h e i r own s e l f - i n t e r e s t led them to seek power over h o s p i t a l a f f a i r s , e s p e c i a l l y when pati e n t s who could a f f o r d any type of medical care began to chose h o s p i t a l care, and when h o s p i t a l s began to provide medical equipment and lear n i n g opportunities unavailable elsewhere. Indeed, despite the undoubted impetus given by MacEachern's leadership and by the p r o t e c t i o n from government in t e r f e r e n c e inherent i n i n c o r p o r a t i o n , a s u f f i c i e n t explanation for the d i r e c t i o n of the ev o l u t i o n of Vancouver General H o s p i t a l l i e s with the s c i e n t i f i c basis of i t s work, and t h i s was est a b l i s h e d as medicine i t s e l f became more s c i e n t i f i c . Once the h o s p i t a l ' s primary task - care of the s i c k - was f e l t to require expert knowledge, those who possessed expert knowledge were bound to p r e v a i l i n a contest for power with those who did not. NOTES ON CHAPTER 3 Abbreviations: C i t y C l e r k ( i n ) V.C.A., Vancouver, C i t y Clerk's Correspondence (inward). D.N.-A. The D a i l y News-Advertiser. Health Comm. V.C.A., Vancouver, C i t y Council Health Committee. Minutes. M.H.O. Vancouver, Health Department. Medical Healt O f f i c e r ' s Annual Report. Province The Vancouver D a i l y Province. Sun The Vancouver D a i l y Sun. V.C.A. Vancouver C i t y Archives. V.G.H. V.C.A., Vancouver General H o s p i t a l Papers (Add. Mss. 320). V.G.H.Ann.Rep. Vancouver General H o s p i t a l . Annual Report. V.G.H.,B.D. V.G.H., series A, Minutes of Board of D i r e c t o r s . V.G.H.,M.B. V.G.H., series C, Medical S t a f f Minutes. [These include the minutes of the C i t y H o s p i t a l and Vancouver General H o s p i t a l Medical Boards.] 1. D.N.-A., 29 February 1888, p.4; "Counting the Years unto the Year of J u b i l e e " , Commemorating the F i f t i e t h Anniversary of St. Paul's  H o s p i t a l , 1894-1944 ([Vancouver, 1944;] a copy may be found i n the pamphlet c o l l e c t i o n , S p e c i a l C o l l e c t i o n s , U n i v e r s i t y of B r i t i s h Columbia L i b r a r y ) , p.25. 2. See en t r i e s l i s t e d i n c l a s s i f i e d pages of c i t y d i r e c t o r i e s under " H o s p i t a l s " . The services of one pr i v a t e h o s p i t a l included " S u r g i c a l , Gynaecological and E l e c t r i c a l treatment, i n c l u d i n g . . . X-Ray Radiography and Radiotherapy, with superior accommodation for L y i n g - i n cases[, and] . . . Turkish, Russian and E l e c t r i c Light Baths i n the Basement, under the management of a graduate of B a t t l e Creek Sanitarium, Michigan." (Henderson's Vancouver D i r e c t o r y , 1904, foll o w i n g p. 662.) 119 120 3. The Vancouver News, 26 J u l y 1886, 14 September 1886; Health Comm., 11 September 1886; V.C.A., Add. Mss. 54, v.13, f i l e L 29,interview of H.E. Langis by J.S. Matthews, 2 March 1936. (The exact l o c a t i o n of the C.P.R. h o s p i t a l i s a subject of dispute. See V.C.A., Add. Mss. 54, f i l e " H o s p i t a l s , C.P.R., f i r s t i n Vancouver".) 4. For examples of the high hopes held by Vancouver c i t i z e n s for t h e i r c i t y ' s future, see: V.C.A., Vancouver, C i t y Council Minutes, 23 May 1887; D.N.-A., 27 August 1887, p.4. 5. V.C.A., Vancouver, C i t y Council Minutes, 8 February 1887, 21 February 1887. For expresssions of the b e l i e f that the e x i s t i n g h o s p i t a l was a disgrace, see the report of a C i t y Council meeting i n D.N.-A., 25 October 1887, p.4. 6. The h o s p i t a l accomodated nine p a t i e n t s . There were eleven newspaper references to the number of patients i n the h o s p i t a l during i t s f i r s t t h i r t e e n months of operation by the C i t y , and the h o s p i t a l was only reported f u l l twice: The Vancouver News, 22 September 1886 (one p a t i e n t ) , 30 September 1886 ( f i v e p a t i e n t s ) , 5 November 1886 ( f u l l ) , 20 March 1887 (empty for twenty-four hours), 24 March 1887 (three p a t i e n t s ) ; The Vancouver News and D a i l y A d v e r t i s e r , 1 A p r i l 1887 ( f i v e p a t i e n t s ) , 5 A p r i l 1887 ( s i x p a t i e n t s ) , 30 A p r i l 1887 (two p a t i e n t s ) ; D.N.-A., 5 August 1887 ( f i v e p a t i e n t s ) , 3 September 1887 (seven p a t i e n t s ) , 12 October 1887 ( f u l l ) . In the l a s t s i x months of 1887, t h i r t y patients were treated i n the h o s p i t a l . (D.N.-A., 29 December 1887, p . l . ) Also see D.N.-A., 1 December 1887, p.2. 7. D.N.-A., 16 October 1887, p.2; 8 November 1887, pp.2, 4. 8. D.N.-A., 23 September 1888, p.8. For a more d e t a i l concerning d e l i b e r a t i o n s leading to the con s t r u c t i o n of t h i s h o s p i t a l , see my unpublised paper "Boosterism and Makeshift Government: Vancouver P u b l i c Health Services, 1886-1888" (V.C.A. has a copy), pp.13-20. 9. Vancouver D a i l y World, 13 December 1901, p.6; 7 January 1902, p.4; 4 February 1902, p.2; V.G.H..M.B., 1 February 1901; C i t y C l e r k ( i n ) , v.17 (1901), pp.13232-13233 ( l e t t e r from 0. Weld to the Mayor and Cou n c i l , 4 February 1901); pp. 13734-13735 ( l e t t e r from Mrs. M.E. Finch to the Mayor, 2 A p r i l 1901); Health Comm., 3 J u l y 1901. 10. C i t y C l e r k ( i n ) , v.17 (1901), p.13579 ( L e t t e r from R. Marpole to the C i t y Clerk, 14 October 1901); Vancouver. By-law #401, B r i t i s h Columbia Gazette, 16 January 1902, p.97; Vancouver D a i l y World, 10 January 1902, p . l ; Health Comm., 16 October 1901. 11. V.G.H.,B.D. 11 January 1906. 12. Health Comm., 7 June 1899, 19 June 1901. 13. V.G.H..M.B., 24 December 1898. 121 14. The h o s p i t a l by-laws p r o h i b i t e d clergymen and women from becoming D i r e c t o r s . The p r o h i b i t i o n against women was rescinded i n 1918, a f t e r the p r o v i c i a l government had included a woman among i t s three appointees for that year. ( A r t i c l e 11(b), By-laws of the  Corporation of the Vancouver General H o s p i t a l , passed 10 October 1902 [a copy i s insert e d f o l l o w i n g p.5 of the f i r s t volume of V.G.H.,B.D.]); V.G.H..B.D., 28 March 1918, 14 February 1919. 15. Vancouver D a i l y World, 6 December 1901, p.5; 13 December 1901, p.6. 16. B r i t i s h Columbia, Statutes, 1902, c.69, "An Act to Incorporate Vancouver General H o s p i t a l " ; B r i t i s h Columbia Gazette, 25 September 1902, p.1701. ^ 17. C i t y C l e r k ( i n ) , v.18 (1902), pp. 14888-14893 ( L e t t e r s from the Trades and Labor Council to the Mayor and Cou n c i l , 24 February 1902 and 10 March 1902). 18. D.N.-A., 3 June 1887, p.4; 26 J u l y 1887, p . l ; 5 October 1887, p.4; 12 October 1887, p.4; 29 December 1887, p . l ; 22 January 1888, p.4. Regulations governing patient behaviour i n the new h o s p i t a l b u i l d i n g i n d i c a t e conditions i n the old one. They forbade patients to swear, s p i t on the f l o o r , gamble, deface the w a l l s , or l i e i n bed with boots on. (Health Comm., 15 December 1888.) 19. I know of only one woman patient i n C i t y H o s p i t a l while i t was housed i n i t s o r i g i n a l b u i l d i n g . (The Vancouver News, 10 February 1887.) 20. This paragraph and the two foll o w i n g are based on V.G.H.Ann.Rep., 1920, pp.5-7, 20-21, 35-36, 44-46, 61, 64-66, 105. 21. Vancouver General H o s p i t a l was an "open" h o s p i t a l : any doctor l i c e n s e d to p r a c t i c e i n the province could attend h i s or her pati e n t s there. 22. For the objectives and c r i t e r i a of the Standardization Program, see: "Report of Ho s p i t a l Conference Held at Chicago, October 22-23, 1923 and Survey of Ho s p i t a l s of F i f t y Beds and Over for the Year 1923", B u l l e t i n of the American College of Surgeons, v.8, no.l (January 1924); American College of Surgeons, A Point Rating System for Use i n  the Survey of Ho s p i t a l s Under the Program of Standardization, (n.p., n.d. [1923?]). 23. V.G.H.,Ann.Rep., 1920, pp.30-31; Province, A p r i l 22, 1919, p.3; V.G.H., se r i e s C, v.20, f i l e 222, p.33 ( u n i d e n t i f i e d newspaper c l i p p i n g ) ; Sun, 22 A p r i l 1919, p.3. The quotation i s from the l a s t source c i t e d . 24. H o s p i t a l administrators often use h o s p i t a l death rates as a measure of h o s p i t a l care. The death rate i n C i t y h o s p t i a l i n 1888 was 11.1%, and that i n Vancouver General H o s p i t a l i n 1920 was 4.6%. (V.G.H.Ann.Rep., 1920, p.105; David Oppenheimer, Province of B r i t i s h 122 Columbia, Vancouver C i t y , i t s Peoples and I n d u s t r i e s , with P r a c t i c a l  Hints for C a p i t a l i s t s and Intending S e t t l e r s [Vancouver, 1889], p.34.) 25. According to the wholesale p r i c e index reported i n M.C. Urquhart and K.A.H. Buckley (eds.), H i s t o r i c a l S t a t i s t i c s of Canada (Toronto, 1965), p.291. This index, rather than the conceivably more appropriate r e t a i l p r i c e index of the Dominion Bureau of S t a t i s t i c s ( P r i c e s and P r i c e Indexes, 1913-1936, [Ottawa, 1938], p.103), has been used because i t i s a v a i l a b l e for the e n t i r e period of t h i s study. The c o e f f i c i e n t of c o r r e l a t i o n between these two indices for the years 1913-1920 i s .95. 26 V.G.H..M.B. 7 November 1888; Health Comm., 15 December 1888. 27. Health Comm., 9 September 1890, 27 January 1891, 25 March 1891, 17 A p r i l 1891. 28. Health Comm., 7 August 1895. 29. Health Comm., 17 A p r i l 1891, 13 February 1894, 27 March 1894, 5 February 1896, 6 January 1897. 30. Health Comm., 6 A p r i l 1898. 31. Health Comm., 22 A p r i l 1890. 32. Health Comm., 2 February 1898, 16 February 1898. 33. V.G.H.,B.D. 8 March 1906; V.G.H.Ann.Rep., 1906, p.14; 1920, p.105. 34. Maternity cases were often turned away. (V.G.H.Ann.Rep., 1913, p.19; V.G.H., ser i e s C, v.20, f i l e 222, pp.63-64 [ u n i d e n t i f i e d newspaper c l i p p i n g ] . ) A new, well-equipped maternity department was opened i n 1916, but i t too had become inadequate by 1919. A money by-law for maternity accomodation and other f a c i l i t i e s was defeated i n the summer of 1920. (Vancouver General H o s p i t a l , Annual Report, 1920, pp.31-32.) 35. Health Comm., 27 January 1891, 25 March 1891, 17 A p r i l 1891. 36. V.G.H.Ann.Rep., 1909, p.9; V.G.H.,B.D. 15 A p r i l 1905. 37. V.G.H.,B.D., 23 November 1916; V.G.H.Ann.Rep., 1916, p.12; V.G.H., ser i e s A, v.20, Creche Committee Minutes, 30 November 1916. 38. V.G.H.Ann.Rep., 1917, p.41; 1918, p.53; 1920, pp.23,46, 39. M.H.O., 1916, n.p.; V.C.A., Add. Mss. 124, v.1-4 (Vancouver, Health Department, Creche Daybooks, 1912-1913). 40. V.G.H.Ann.Rep., 1919, p.92. 123 p.17. 41. V.G.H.Ann.Rep., 1916, pp.19,21-22; 1917, p.17; 1920, p.23. 42. V.G.H.Ann.Rep., 1914, p.11; 1917, pp.41, 113; M.H.O., 1920, 43. By-laws of the Corporation of the Vancouver General H o s p i t a l , passed 10 October 1902, l o c . c i t . ; Health Comm., 26 May 1891, 24 November 1891, 15 December 1888; V.G.H.,B.D. 8 March 1906. 44. For example: Health Comm., 7 September 1898. 45. For example: Health Comm., 18 August 1897, 18 September 1895. 46. Health Comm., 21 January 1903; V.G.H.,B.D. 8 January 1903, 12 February 1903, 23 December 1905. 47. V.G.H..B.D., 8 November 1906, 26 February 1914, 22 November 1917, 22 May 1919, 9 March 1920; V.G.H.Ann.Rep., 1913, p.8; 1915, p.11. 48. V.G.H.,B.D. 23 March 1916, 27 J u l y 1916, 23 November 1916. 49. V.G.H.Ann.Rep., 1917, p.10. 50. V.G.H.Ann.Rep., 1919, p.89. 51. V.G.H.,B.D. 11 December 1916; V.G.H., s e r i e s A, v.20, Executive Committee Minutes, 9 December 1916. 52. V.G.H.Ann.Rep., 1915, p.13. 53. V.G.H.Ann.Rep., 1917, pp.29-30; Sun, 12 January 1917, p.3. 54. Sun, 6 October 1917, p.8; V.G.H., s e r i e s A, v.20, C i t i z e n ' s Committee Minutes, 9 December 1916. 55. V.G.H.Ann.Rep., 1917, p.26; 1918, p.28. 56. Oppenheimer, p.34; C i t y C l e r k ( i n ) , v.3 (1890), p.2488 ( l e t t e r from A.M. Robertson to the Mayor and Cou n c i l , 16 January 1890); V.C.A., pamphlet 1907-25 (By-laws of Vancouver General H o s p i t a l , approved by the Board of D i r e c t o r s , 11 January 1907), By—law #93. This by—law s p e c i f i e d that outpatients could be recommended by any Governor, member of the Medical Board, m i n i s t e r or magistrate, or by the Mayor. Outpatients were to be i n "poor circumstances". 57. M.H.O., 1911, p.13; [George A. Ki d d ] , " H i s t o r y of the Vancouver Medical A s s o c i a t i o n (Continued), General Progress of the A s s o c i a t i o n " , Vancouver Medical A s s o c i a t i o n B u l l e t i n , v.23 (1947), p.265-266; V.G.H.,B.D. 23 February 1911, 22 February 1912. 58. V.G.H..B.D., 19 November 1914, 17 December 1914; V.C.A. Vancouver, C i t y Council Minutes, 14 December 1914, 28. December 1914; V.G.H.Ann.Rep., 1914, pp.30, 10-11; 1915, p.29. The C i t y was 124 responsible for c e r t i f y i n g those e l i g i b l e for outpatient care. (Idem.) 59. V.G.H.Ann.Rep., 1906, p.13; 1920, p.105. 60. The best account of the ea r l y work of t h i s department i s : Irene Rogers, " E a r l y H i s t o r y of S o c i a l Service at Vancouver General H o s p i t a l " , Address given at the Golden J u b i l e e of the S o c i a l Service Department, 23 February 1962 (V.C.A., Add. Mss. 320, Series C, V o l . IX, f i l e 49.) 61. V.G.H.Ann.Rep., 1910, p.11. 62. Sun, 23 February 1912, p.12; V.G.H.,B.D. 22 February 1912. 63. V.G.H.Ann.Rep., 1913, p.9; 1914, pp.20-21; 1915, pp.21-24; 1916, p.21; 1917, pp. 20-21; Province, 3 June 1915, p.8. 64. V.G.H.,B.D. 16 December 1915. 65. V.G.H.Ann.Rep., 1919, p.24; 1920, pp.20,41; Rogers, pp.12-13 (a copy of the Vancouver General H o s p i t a l Women's A u x i l i a r y Minutes of 1 June 1920). 66. Rogers, p.3. 67. V.G.H.,B.D. 15 August 1907; V.G.H.Ann.Rep., 1906, p.4; 1907, pp.11, 4. 68. Vancouver D a i l y World, 24 A p r i l 1914, pp.8-9. 69. V.G.H.,M.B., 4 November 1908, 20 A p r i l 1909, 4 May 1909, 9 December 1913. 70. V.G.H.,M.B., 21 March 1916; V.G.H.,B.D. 23 March 1916; Vancouver D a i l y World, 24 March 1916, p.2. The f i r s t two men to hold the p o s i t i o n were experienced p a t h o l o g i s t s from the United States. (V.G.H.,B.D., 25 May 1916, 23 August 1917.) 71. V.G.H.Ann.Rep., 1917, p.47; 1920, pp.76-77. 72. V.G.H.Ann.Rep., 1916, p.37; 1919, p.123; 1920, p.76. 73. V.G.H.Ann.Rep., 1916, pp. 36-37; B r i t i s h Columbia, Board of Health, Annual Report, 1919-1920, p.A7.. 74. V.G.H.Ann.Rep., 1920, p.76; M.T. MacEachern, "Progress and A p p l i c a t i o n of H o s p i t a l Standardizaion i n the Vancouver General H o s p i t a l i n B r i t i s h Columbia and other Western Provinces", T y p e s c r i p t [ , 1919?] (V.C.A., Add. Mss. 320, Series C, v.9, f i l e 47), p.6. 75. Health Comm., 6 June 1900, 20 June 1900, 1 August 1900; V.G.H..M.B., 6 June 1900; Province, 29 December 1900, p.3. 125 76. V.G.H..B.D. 20 May 1909, 16 September 1909; V.G.H.,M.B., 24 September 1906, 5 November 1907, 7 February 1909, 2 March 1909; V.G.H., se r i e s C, v.14, f i l e 164 ("A B r i e f O utline of the H i s t o r y of the X-Ray Department of the Vancouver General H o s p i t a l [and the Vancouver C i t y H o s p i t a l ] " ) . 77. V.G.H.,M.B., 21 March 1916; V.G.H.Ann.Rep., 1915, p.77; 1917, p.48; 1918, pp.50-51; 1919, p.126; 1920, p.78. 78. For the h i s t o r y of the Vancouver General H o s p i t a l School of Nursing, see: Anne S. Cavers, Our School of Nursing, 1899-1949 ([Vancouver,] n.d.); Nora K e l l y , Quest for a Pr o f e s s i o n - the H i s t o r y of  the Vancouver General H o s p i t a l School of Nursing (Vancouver, 1973). 79. Health Comm., 9 October 1899. A t r a i n i n g program had been suggested i n 1888, but no ac t i o n was taken; i n A p r i l 1899, the h o s p i t a l paid over $80 for an extra nurse, and a set of rule s and regulations for a t r a i n i n g school were prepared the fo l l o w i n g month. (Health Comm., 26 October 1888, 5 A p r i l 1899, 17 May 1899.) The p r i n c i p l e that nurses' t r a i n i n g programs were important p r i m a r i l y for t h e i r e f f e c t on h o s p i t a l finances was widely held around the turn of the century. (Mary M. Roberts, American Nursing: H i s t o r y and I n t e r p r e t a t i o n (New York, 1954), p.56; Richard H. Shryock The H i s t o r y of Nursing, an I n t e r p r e t a t i o n of  the S o c i a l and Medical Factors Involved ( P h i l a d e l p h i a , 1959), p.300.) 80. Cavers, pp.15,18. 81. Cavers, p.14; Health Comm., 6 December 1899. 82. For the content of the nursing course, see: V.G.H., s e r i e s A, v.20, Minutes of the Education Committee, 7 September 1916, 2 September 1920. 83. V.G.H.Ann.Rep., 1913, p.19; 1920, p.40. 84. U n i v e r s i t y of B r i t i s h Columbia Archives, Papers of the U n i v e r s i t y of B r i t i s h Columbia School of Nursing, "Memorandum concerning the development of the combined course i n Nursing given by the U n i v e r s i t y of B r i t i s h Columbia, Vancouver, Canada i n conjunction with the Vancouver General H o s p i t a l T r a i n i n g School for Nurses". 85. Cavers, p.24. 86. V.G.H.,B.D. 25 May 1916, 29 June 1916. 87. V.G.H.Ann.Rep., 1920, p.40. 88. For example: Province, September 6, 1913, p.17; V.G.H.,B.D. 10 May 1906, 14 June 1906, 24 J u l y 1913. 89. See Chapter 2. 126 90. V.G.H.,B.D. 8 February 1906. 91. V.G.H...M.B. , 19 November 1912, 9 February 1915. 92. V.G.H.,M.B., 7 February 1907, 4 A p r i l 1907; V.G.H.,B.D. 17 December 1906, 10 January 1907. 93. V.G.H.,M.B., 14 A p r i l 1896, 23 June 1903, 20 A p r i l 1909. 94. D.N.-A., 23 September 1888, p.8. 95. Health Comm., 15 A p r i l 1896, 14 J u l y 1898, 20 J u l y 1898, 3 August 1898; V.G.H.,M.B., 14 A p r i l 1896. 96. D.N.-A., 12 A p r i l 1913, p.2; Vancouver D a i l y World, 11 A p r i l 1913, p.15; V.G.H.,B.D. 24 A p r i l 1913, 1 May 1913, 8 May 1913. 97. V.G.H.,B.D., 22 May 1913, 28 May 1913; D.N.-A., 23 May 1913, p.6; Province, 29 May 1913, p.2. 98. For example: V.G.H.Ann.Rep., 1919, pp.34-35; MacEachern, p.5; V.G.H.,M.B., 10 June 1918, 11 February 1919, 11 March 1919, Minutes of the Executive Committee of the Medical Board, 18 February 1919. 99. V.G.H.Ann.Rep., 1913, p.19; 1916, pp.26,29. 100. V.G.H.,B.D., 27 March 1919; C i t y C l e r k C i n ) , v.3 (1890), pp.2465-2469. 101. Health Comm., 31 August 1888. 102. For example: Health Comm., 25 September 1891, 10 May 1892. 103. Health Comm., 10 January 1893, 20 March 1895; V.G.H.,B.D., 14 November 1907. 104. V.G.H.,B.D., 20 A p r i l 1911. 105. V.G.H.,B.D., 10 November 1904; Health Comm., 18 September 1895. 106. V.G.H..B.D., 22 May 1919. 107. V.G.H.,B.D., 18 J u l y 1907; V.G.H.Ann.Rep., 1908, p.8; 1916, p.27. 108. For example: Health Comm., 28 December 1888; V.G.H.,B.D., 13 January 1906, 18 December 1913. 109. For example: V.G.H.,B.D., 2 August 1917, 27 September 1917, Report of a Committee of the Medical S t a f f i n s e r t e d f o l l o w i n g minutes for 6 J u l y 1909. 127 110. V.G.H.,B.D., 19 August 1915, 19 A p r i l 1917, 24 A p r i l 1919, 27 May 1920, 22 J u l y 1920. 111. V.G.H..B.D., 27 December 1917, 25 J u l y 1918. 112. Currency values determined as stated i n note 25; C i t y C l e r k ( i n ) , v.3 (1890), pp.2465-2469. 113. V.G.H.,B.D. , 20 A p r i l 1911. 114. V.G.H.,B.D. , 18 June 1917. 115. V.G.H.,B.D. , 9 March 1905, 16 January 1908. 116. V.G.H.,B.D. , 28 December 1916. 117. D.N.-A., 25 February 1911, p . l . 118. V.G.H.,B.D. , 22 October 1914; V.G.H.Ann.Rep., 1913, p.19; 1919, pp.123-124; 1920, p.41; MacEachern" p.9. 119. For example, there were 106 applicants i n 1905; 24 were admitted on probation, and 9 of these were accepted as student nurses. (V.G.H.Ann.Rep., 1905, p.13.) There were 356 applicants i n 1920; 108 were admitted on probation, and 93 were accepted as student nurses. (V.G.H.Ann.Rep., 1920, p.36.) The admission standards were high: the minimum age for students varied between 20 and 21, and the maximum was 35; i n 1906, a grammar-school education was required, and i n 1919, students also needed three years of high school. (V.C.A., Add. Mss. 190, Rules and Regulations of the Vancouver General H o s p i t a l , [Approved by the Board of D i r e c t o r s 8 November 1906], p.39; V.C.A., pamphlet 1919-34 [Nursing as £ Vocation for Young Women: T r a i n i n g i n the  Vancouver General H o s p i t a l ] , pp.6-7.) 120. V.G.H.Ann.Rep., 1919, pp.35,40; 1920, p.40. I r o n i c a l l y , when the C i t y Council and the Trades and Labor Council had t r i e d to get the H o s p i t a l to introduce the eight-hour s h i f t and higher rates of pay for student nurses i n 1911, the nurses at Vancouver General H o s p i t a l protested against the proposed changes. (V.G.H.,B.D., 15 February 1911, 16 March 1911; V.C.A., Vancouver, C i t y Council Minutes, 13 February 1911, 27 February 1911; D.N.-A., 25 February 1911, p . l . ) 121. Income and expenditure figures f or the C i t y H o s p i t a l period are incomplete. The C i t y contributed whatever was required above the income accruing from fees and the p r o v i n c i a l government grant. My guess i s that one t h i r d of the h o s p i t a l income came from each of these sources i n an average year. P r o v i n c i a l grants were $5,000 per year from 1893 to 1899, and about $9,500 from 1900 to 1902. H o s p i t a l fees brought i n amounts varying from $1,000 to $5,000 per year from 1893 to 1902. The C i t y c o n t r i b u t i o n to the h o s p i t a l during these years i s not recorded, but c a l c u l a t i o n s based on relevant figures which are a v a i l a b l e i n d i c a t e that i t ranged from $1,300 to $9,600 per year. (Vancouver, Annual  Report, 1893, pp.13-14; 1894, pp.13-14; 1895, pp.15-16; 1896, pp.13-14; 1897, pp.13-14; 1898, pp.13-14; 1899, pp.13-14; 1900, pp.13-14; 1901, 128 pp.15-16; 1902, pp.15-16.) 122. V.G.H.Ann.Rep., 1920, p.102. 123. V.G.H.Ann.Rep., 1919, p.152; 1920, p.105. 124. V.G.H.Ann.Rep., 1920, p.102. 125. B r i t i s h Columbia, Statutes, 1906, c.44, "An Act further to amend the 'Vancouver General H o s p i t a l Act, 1902'". 126. Vancouver D a i l y World, 1 May 1913, p.22. 127. For example: V.G.H.Ann.Rep., 1912, p.15; V.G.H., s e r i e s C, v.20, f i l e 222 ( u n i d e n t i f i e d newspaper c l i p p i n g [December 1913]); Province, 2 January 1915, p.20. 128. V.G.H.Ann.Rep., 1920, pp.31-32; V.G.H.,B.D., 21 June 1912, 18 December 1913. 129. For example: Vancouver D a i l y World, 11 December 1901, p.2; 12 December 1901, p.2; 13 December 1901, p.6; 7 January 1902. 130. V.G.H.Ann.Rep., 1905, p.10; 1906, p.12; 1907, p.8; 1916, p.19; 1917, p.17; 1918, p.19; 1919, pp.16,20; 1920, pp.17,102. 131. V.G.H.Ann.Rep., 1920, pp.99-101. 132. V.G.H.,B.D., 18 March 1912; D.N.-A., 19 March 1912, p.15. 133. Province, 18 September 1912, p.15. The commissioner found most of the complaints petty. Since the Trades and Labor Council stated that they found no f a u l t with the way the H o s p i t a l was run (Sun, 5 A p r i l 1912, p . l ) , the petty complaints may w e l l represent the overniceness of those who had only r e c e n t l y achieved middle-class status during Vancouver's boom years. 134. Sun, 6 September 1912, pp.1-2. 135. D.N.-A., 7 September 1912, p.7; V.G.H.Ann.Rep., 1912, p.58. 136. John Kenneth G a l b r a i t h , The New I n d u s t r i a l State (2nd ed., rev.; New York, 1971), i n p a r t i c u l a r chaps. 6 and 7; James Burnham, The  Managerial Revolution (Bloomington, Ind., 1941); Paul A. Samuelson and Anthony Scott, Economics (4th Canadian ed.; Toronto, 1975), chap. 6. 137. Daniel A. Wren, The E v o l u t i o n of Management Thought (New York, 1972), ch.6-10; Claude S. George, J r . , The H i s t o r y of Management  Thought (Englewood C l i f f s , N.J., 1968), ch.5-8. 138. Charles Richmond Henderson, "World Currents i n Ch a r i t y , Theory and P r a c t i c e " , Annals of the American Academy of P o l i t i c a l and  S o c i a l Science, v.21 (1903), pp.363-378; Paul Rutherford, "Tomorrow's Metropol i s : The Urban Reform Movement i n Canada, 1880-1920", i n Canadian 129 H i s t o r i c a l A s s o c i a t i o n , H i s t o r i c a l Papers, 1971, pp.203-224; Robert H. Wiebe, The Search for Order, 1877-1920 (New York, 1967). NOTES ON FIGURES, CHAPTER 3 Key to abbreviations may be found on page 119. Sources for Figure 1: V.G.H.Ann.Rep., 1920, p.105; 1919, p.152; M.C. Urquhart and K.A.H. Buckley (eds.) / H i s t o r i c a l S t a t i s t i c s of  Canada (Toronto 1965), p.291, p.49. Note on Figure 2: From 1913 through 1920, "other" includes grants (amounting to between 1% and 4% of the annual operating income) from nearby m u n i c i p a l i t i e s to defray the cost of care for t h e i r c i t i z e n s . Sources for Figure 2: V.G.H.Ann.Rep., 1904, p.21; 1905, p.23; 1906, pp.28-29; 1907, pp.26-27; 1908, pp.28-29; 1909, pp.32-33; 1910, pp.56-57; 1912, pp.58-59; 1913, pp.64-65; 1914, pp.82-83; 1915, pp.88-89; 1916, pp.112-113; 1917, pp.137-139; 1918, pp.141-143; 1919, pp.147-149; 1920, pp.99-101. 130 CHAPTER 4 VISITING NURSING Although government i s c h i e f l y responsible today for medical care and poor r e l i e f , much of t h i s work was done at the turn of the century by voluntary a s s o c i a t i o n s . This chapter examines the process whereby medical services were brought to Vancouver residents during the years 1898 to 1920 by one such o r g a n i z a t i o n , the V i c t o r i a n Order of Nurses for Canada. 1 During the period of t h i s study, the V.O.N., at f i r s t c l e a r l y a benevolent so c i e t y i n the nineteenth-century mold, became recognizably s i m i l a r to the c h a r i t a b l e a s s o c i a t i o n s of our own day: the making of decisions which determined the nature and e f f e c t of the organization's work s h i f t e d from volunteers to h i r e d experts, and from p e r i p h e r a l to c e n t r a l o f f i c e s of the o r g a n i z a t i o n . Thus, t h i s examination w i l l provide i n s i g h t not only i n t o p u b l i c h e a l t h work i n an e a r l i e r s o c i e t y , but also into the process whereby modern a d m i n i s t r a t i v e s t r u c t u r e s evolved. E a r l y i n 1897, Lord and Lady Aberdeen, then the v i c e r e g a l couple i n Canada, proposed the establishment of a n a t i o n a l order of v i s i t i n g n urses 2 i n commemoration of Queen V i c t o r i a ' s Diamond J u b i l e e . I t was to be patterned on the Queen's J u b i l e e Nurses of Great B r i t a i n (a product of the e a r l i e r Golden J u b i l e e c e l e b r a t i o n ) , and was to r e l i e v e the d i s t r e s s i s o l a t e d parts of the country suffered through lack of any kind of t r a i n e d medical attendance. Despite considerable opposition from 131 132 physicans (who saw v i s i t i n g nurses as p o t e n t i a l competitors), the orga n i z a t i o n was f i r m l y e s t a b l i s h e d under a r o y a l charter before t h e i r E x c e l l e n c i e s ended t h e i r Canadian tour of duty l a t e i n 1898, with V.O.N, nurses already serving as far a f i e l d as the Klondike. The formation of the Vancouver A s s o c i a t i o n of the V.O.N, was authorized i n October 1898 by the n a t i o n a l Executive Council of the Order. 3 That a l o c a l a s s o c i a t i o n (under the V.O.N. Charter, a body responsible for ad m i n i s t r a t i o n of the work of the Order i n a s p e c i f i c c i t y , town, or r u r a l area 4) was esta b l i s h e d i n Vancouver i s not s u r p r i s i n g , since Vancouver residents had p a r t i c i p a t e d i n the founding of the Order: two Vancouver women had brought the medical needs of p r a i r i e women to the a t t e n t i o n of Lady Aberdeen, and had also communicated t h e i r concern to the National Council of Women, an orga n i z a t i o n which was instrumental i n e s t a b l i s h i n g the V.O.N.; furthermore, a committee of Vancouver residents had s o l i c i t e d donations of more than $1000 for an endowment fund for the Order p r i o r to i t s formal establishment.-' Over the period of t h i s study, the geographical area served by the Vancouver A s s o c i a t i o n expanded, as nursing services were extended to the suburbs, but also contracted, as separate V.O.N, ass o c i a t i o n s responsible for nursing services i n some of these areas were formed.^ * * * I f the Vancouver A s s o c i a t i o n of the V.O.N, was to be e f f e c t i v e i n providing health services to the community, three sets of r e l a t i o n s h i p s i n t e r n a l to i t had to be harmonious: those between people a f f i l i a t e d 133 with the V.O.N, i n Vancouver and o f f i c i a l s of the n a t i o n a l V.O.N, org a n i z a t i o n , those between Vancouver nurses and Vancouver A s s o c i a t i o n members, and those among groups with d i f f e r i n g motivations for working w i t h i n the A s s o c i a t i o n . The V.O.N, nurses employed by the Vancouver A s s o c i a t i o n had contact with the n a t i o n a l V.O.N, or g a n i z a t i o n through the nurses on the na t i o n a l s t a f f - the Chief Superintendent, A s s i s t a n t Superintendent, and Inspector. In p a r t i c u l a r , the Chief Superintendent was responsible f or approval of q u a l i f i c a t i o n s of nurses seeking admission to the Order, recommendation of nurses to l o c a l a s s o c i a t i o n s for appointment, i n s p e c t i o n of work done by V.O.N, nurses, and reports on these inspections to the appropriate l o c a l a s s o c i a t i o n s . 7 Thus, although employees of the l o c a l A s s o c i a t i o n , Vancouver V.O.N, nurses were under the supervision of n a t i o n a l s t a f f members. The Chief Superintendents were women of fin e i n t e l l e c t and strong o r g a n i z a t i o n a l a b i l i l t y , and were devoted to the humanitarian purpose of the Order and i n touch with recent developments i n the f i e l d of nursing:** they were able to give guidance, ass i s t a n c e , and i n s p i r a t i o n to the members of the Order scattered across Canada, who often had to work i n a s e t t i n g of h o s t i l i t y or i n d i f f e r e n c e toward the new health procedures they were t r y i n g to implement. Vancouver nurses turned to the Chief Superintendents f or support, and viewed them as p o t e n t i a l advocates i n case of disagreement between themselves and the Vancouver A s s o c i a t i o n . q The Vancouver A s s o c i a t i o n corresponded frequently with the na t i o n a l Board of Governors and with the Chief Superintendent, and the l a t t e r also v i s i t e d Vancouver r e g u l a r l y . * 0 From time to time, 134 A s s o c i a t i o n members tr a v e l e d to Ottawa to attend annual meetings or to confer with the n a t i o n a l Executive C o u n c i l . 1 1 This frequent contact, combined with the d i s p a r i t y of perspective which grew from the d i f f e r e n t scale of t h e i r a d m i n i s t r a t i v e a c t i v i t i e s , could w e l l have led to c o n f l i c t between l o c a l and c e n t r a l bodies, but c o n f l i c t r a r e l y occurred. Instead, the A s s o c i a t i o n deferred to the wishes of the n a t i o n a l o f f i c i a l s and frequently turned to them for f i n a n c i a l support and adm i n i s t r a t i v e advice. The harmony i n t h i s r e l a t i o n s h i p was due i n part to the diplomatic s k i l l s of successive Chief Superintendents and the tolerence e x h i b i t e d by the Board of Govenors for l o c a l v a r i a t i o n . 1 2 In a d d i t i o n , the l o c a l A s s o c i a t i o n may have deferred r e a d i l y to the wishes of the Board of Governors because of the d i s t i n g u i s h e d and a r i s t o c r a t i c character of the Board Members. 1 3 The f i r s t attempt of the Vancouver A s s o c i a t i o n to work with V.O.N, nurses was a dismal f a i l u r e . In 1899, two nurses sent from Ottawa at the request of the Vancouver A s s o c i a t i o n were promptly sent back "on account of t h e i r a t t i t u d e . " 1 4 The disagreement between A s s o c i a t i o n members and nurses was based on d i f f e r i n g conceptions of the functi o n of a nurse, and i n p a r t i c u l a r of a V.O.N, nurse. Trained nurses were s t i l l a f a i r l y new phenomenon,1^ and i t i s not s u r p r i s i n g that many A s s o c i a t i o n members d i d not d i s t i n g u i s h nurses t r a i n e d i n h o s p i t a l schools, as the V.O.N, nurses were, from s e l f - t r a i n e d p r a c t i c a l nurses, who were often domestic servants with a f l a i r f or nursing. The V.O.N. Charter i n d i c a t e d that nurses h i r e d by V.O.N, asso c i a t i o n s were to do " d i s t r i c t nursing" 1*' (nursing on a v i s i t i n g rather than a continuous b a s i s ) , but since t h i s type of nursing was j u s t being introduced into 135 Canada by the V.O.N., i t i s even less s u r p r i s i n g that many A s s o c i a t i o n members d i d not understand i t s character. The A s s o c i a t i o n expected the nurses to do housework i n p a t i e n t s ' homes as w e l l as to nurse the p a t i e n t s , and expected them to undertake continuous nursing when asked. The nurses refused to undertake what they considered inappropriate work, on the grounds that the a u t h o r i t y over them was not the l o c a l A s s o c i a t i o n , but rather Ottawa and the " C o n s t i t u t i o n " of the O r d e r . 1 7 Following t h i s episode, the Vancouver A s s o c i a t i o n lapsed into i n a c t i v i t y for nearly three y e a r s . ^ Nursing was s u c c e s s f u l l y undertaken by the Vancouver A s s o c i a t i o n i n 1902, but a c o l l e g i a l r e l a t i o n s h i p between members of the A s s o c i a t i o n and V.O.N, nurses was slow to develop. The minutes of the A s s o c i a t i o n meetings for the succeeding few years report lengthy and c r i t i c a l , even susp i c i o u s , discussions of nurses' p r o f e s s i o n a l judgement and of t h e i r requests for s a l a r y increases and improved working c o n d i t i o n s . ^ In 1911, the A s s o c i a t i o n began to view nurses d i f f e r e n t l y - to see them as expert advisors rather than h i r e d servants. In p a r t i c u l a r , there was a noticeable change i n the r e l a t i o n s h i p between the A s s o c i a t i o n and the head nurse: she was encouraged to p a r t i c i p a t e i n the making of p o l i c y f o r nursing matters, to attend subcommittee and general meetings as an advisor, and to be i n contact with other organizations on behalf of the A s s o c i a t i o n . 2 0 Over the remaining years covered by t h i s study, t h i s c o l l e g i a l r e l a t i o n s h i p continued and grew: the head nurse came to i n i t i a t e plans of a c t i o n , to make f i n a l decisions regarding nursing matters, and to represent the A s s o c i a t i o n at meetings with p r o v i n c i a l o f f i c i a l s . 136 This new r e l a t i o n s h i p was a natural r e s u l t of an increase in the scale of V.O.N, operations i n Vancouver and in the complexity of the f i e l d of public health nursing. Since the autumn of 1910, the Vancouver A s s o c i a t i o n had provided nursing services to suburban areas. This required that a d d i t i o n a l nurses be employed and that some reside away from the c e n t r a l Nurses' Home,22 and so brought the A s s o c i a t i o n to depend on the head nurse for knowledge of the nurses and t h e i r work. Furthermore, as public health nursing came to demand knowledge of such s p e c i a l t i e s as tuberculosis and c h i l d welfare nursing, and of the network of government and other community agencies whose services could encourage good health by improving l i v i n g conditions, A s s o c i a t i o n members turned to the head nurse for her advice as an expert i n t h i s f i e l d . 2 3 Ina M.K. Cole, head nurse from 1917 to 1920, made conscious e f f o r t s to help A s s o c i a t i o n members understand developments i n the f i e l d of public health nursing generally and see t h e i r a p p l i c a b i l i t y i n Vancouver. 2 4 In 1920, the Association's Advisory Committee (discussed more f u l l y on page 139) established a subcommittee, comprising four doctors knowledgeable i n public health work, to serve as "a medical advisory committee . . . to a s s i s t Miss C o l e " 2 ^ and thereby provided a means of monitoring her work. These two circumstances suggest that by the end of the period of t h i s study, both members of the A s s o c i a t i o n and the head nurse were aware that the r e l a t i o n s h i p between the A s s o c i a t i o n and the nurses was not the usual one between employer and employee, p a r t i c u l a r l y i n that the A s s o c i a t i o n was often unable e i t h e r to s p e c i f y the nurses' work or to evaluate t h e i r performance. It also seems that 137 a l l p a r t i e s were endeavouring to adjust to l i f e i n the age of the s p e c i a l i s t . The nature of the r e l a t i o n s h i p between A s s o c i a t i o n members and nurses changed s i g n i f i c a n t l y over the period of t h i s study, but t h e i r conceptions of t h e i r respective r o l e s were at a l l times ( a f t e r . the i n i t i a l f i a s c o ) s u f f i c i e n t l y consonant to allow the he a l t h work of the Order to proceed without d i s r u p t i o n . Although the Vancouver A s s o c i a t i o n of the V.O.N., composed p r i m a r i l y of suc c e s s f u l members of the middle c l a s s , 2 ^ w a s s o c i a l l y homogeneous, three d i s t i n c t subgroups can be discerned w i t h i n i t : one comprises people, mostly men, who had s p e c i a l s k i l l s they wished to make a v a i l a b l e without undue expense of time; a second comprises people, mostly women, who found s a t i s f a c t i o n not only i n helping provide a needed community service but also i n the s o c i a l intercourse connected with that s e r v i c e ; and a t h i r d comprises young women s t i l l l e a r n i n g adult r o l e s . Harmonious r e l a t i o n s h i p s w i t h i n the A s s o c i a t i o n could have been achieved by discouraging p a r t i c i p a t i o n of a l l but one of these divergent subgroups. However, the A s s o c i a t i o n needed the f i r s t two for current strength, and the t h i r d for i t s future, so had to insure instead that a l l three could f i n d s a t i s f a c t i o n . This task was f a i r l y e a s i l y accomplished for the t h i r d subgroup, young women who had f i n i s h e d t h e i r schooling but had not yet s e t t l e d i n t o matrimony. A u x i l i a r i e s were established i n which they could enjoy l e a r n i n g the s k i l l s of a volunteer worker without the i n h i b i t i n g presence of large numbers of women of t h e i r mother's g e n e r a t i o n . 2 7 138 I t was more d i f f i c u l t to insure s a t i s f a c t i o n f or both the f i r s t two subgroups, since each wanted to f e e l that i t had a u t h o r i t y w i t h i n the o r g a n i z a t i o n . Although women could determine who would hold o f f i c e (they made up about ninety percent of the membership2**), s o c i a l assumptions about the sex of o f f i c e r s i n an or g a n i z a t i o n comprising both sexes led them to choose men for many o f f i c e s . The d i f f e r e n c e s between these two groups were not confined to issues of a u t h o r i t y : men and women were i n t e r e s t e d i n d i f f e r e n t aspects of the Ass o c i a t i o n ' s work and were therefore not a t t r a c t e d to the same types of meeting - men gene r a l l y enjoyed d i s c u s s i o n of l e g a l and f i n a n c i a l matters and women more sociable a c t i v i t i e s . With the wisdom of h i n d s i g h t , we can see that i t was necessary for formal a u t h o r i t y to be vested i n women, and at the same time for each sex to exercise e f f e c t i v e power i n i t s areas of s p e c i a l e x p e r t i s e . However, the A s s o c i a t i o n learned t h i s only through experimentation. In the e a r l y years, when the President and Treasurer of the A s s o c i a t i o n were men and the Secretary and Vice-Presidents women, women created an all - f e m a l e "Working Committee", which had i t s own o f f i c e r s and subcommittees, and which organized f u n d - r a i s i n g projects and r e l i e f work and supervised the management of the Nurses' Home. The Working Committee was abolished i n 1906, 2^ apparently because the extent of i t s a c t i v i t i e s and d e l i b e r a t i o n s had led to an unworkable d i s p e r s i o n of au t h o r i t y . Subsequently, A s s o c i a t i o n meetings became i n c r e a s i n g l y dominated by women; formal a u t h o r i t y for the Ass o c i a t i o n ' s work was c l e a r l y placed i n t h e i r hands by the d e c i s i o n i n 1912 to have only female o f f i c e r s . 3 0 However, a f t e r experimenting with female treasurers 139 and an al l - f e m a l e Finance Committee, ^ the women chose (presumably because they f e l t themselves inadequately prepared to handle the Asso c i a t i o n ' s f i n a n c i a l a f f a i r s ) to give t h i s work back to men: an all-m a l e Finance Committee was es t a b l i s h e d i n 1919, 3 2 and a male trea s u r e r was elected i n 1920. 3 3 As women began to c o n t r o l A s s o c i a t i o n a f f a i r s i n general, a separate niche was created for men: an all-male Adivsory Committee was esta b l i s h e d i n 1907^ 4 and was t h e r e a f t e r o f t e n consulted on l e g a l and f i n a n c i a l matters. The task of achieving harmony i n a l l three sets of i n t e r n a l r e l a t i o n s h i p s was undoubtedly s i m p l i f i e d by the common committment of nurses and laymen throughout the V.O.N, to i t s benevolent purpose. There were instances of pettyness and c o n f l i c t , but they d i d not s e r i o u s l y d i s r u p t the organization's nursing and educational work. * * * As stated above, the function of a l o c a l V.O.N, a s s o c i a t i o n was adm i n i s t r a t i o n of c e r t a i n p u b l i c h e a l t h services i n i t s own l o c a l i t y . During the period of t h i s study, the Vancouver A s s o c i a t i o n managed a "cottage h o s p i t a l " f or co a s t a l loggers, provided various types of nursing care for residents of the Vancouver area, provided r e l i e f s e r v i c es for the s i c k poor, and educated graduates of h o s p i t a l t r a i n i n g schools i n pub l i c h e a l t h nursing. In a d d i t i o n , i t r a i s e d the money which paid for these s e r v i c e s . In t h i s s e c t i o n , each of these aspects of i t s work w i l l be examined i n turn. 140 i During the f i r s t two decades of the twentieth century, the V.O.N, set up a number of small f r o n t i e r h o s p i t a l s known as cottage h o s p i t a l s . A t y p i c a l cottage h o s p i t a l had from s i x to ten beds and two nurses who provided both outpatient treatment and h o s p i t a l care for s e t t l e r s who were remote from other medical s e r v i c e s . By the end of World War I , over f o r t y cottage h o s p i t a l s had been established by the V.O.N, i n Canada, i n c l u d i n g twelve i n B r i t i s h Columbia. 3^ In the summer of 1903, the Vancouver A s s o c i a t i o n of the V.O.N, proposed to e s t a b l i s h a cottage h o s p i t a l i n some c o a s t a l logging a r e a . 3 ^ This undertaking u l t i m a t e l y led the A s s o c i a t i o n to l i m i t i t s f i e l d of serv i c e to the c i t y and immediate environs, and i t s h i s t o r y i l l u s t r a t e s the use both of A s s o c i a t i o n members' contacts and influence and of the funds and expertise of the n a t i o n a l V.O.N. - important resources throughout the period of t h i s study. Men i n logging camps had long come to Vancouver i n case of accident or i l l n e s s , so i t was nat u r a l for the A s s o c i a t i o n to consider t h e i r medical needs when i t determined to fo l l o w the current V.O.N, trend and e s t a b l i s h a cottage h o s p i t a l . Members of the A s s o c i a t i o n discussed the proposal with managers of various timber companies and with the Secretary of the loggers' u n i o n , 3 7 but d i d not press ahead with plans because the necessary campaign for publ i c donations would be u n l i k e l y to have much success, there being already an a c t i v e campaign for a new b u i l d i n g for the Vancouver General H o s p i t a l . 141 When i n t e r e s t i n the cottage h o s p i t a l for loggers was r e k i n d l e d a year l a t e r by an i n q u i r y a f t e r i t s progress from the Honorary President of the n a t i o n a l V.O.N., Lady M i n t o , 3 9 there was s t i l l concern that the cost of a cottage h o s p i t a l might prevent i t s establishment. The Vancouver A s s o c i a t i o n had a s l i g h t d e f i c i t at the end of 1904, 4 0 and i t was estimated t h a t , i n a d d i t i o n to the cost of b u i l d i n g and equipping the h o s p i t a l , i t s operation would require $125 a month, an amount roughly equal to that already required each month for the nursing work i n Vancouver. 4 1 The A s s o c i a t i o n found the necessary money by turning to the n a t i o n a l V.O.N, and by e n l i s t i n g help from groups w i t h i n Vancouver. The n a t i o n a l body gave $500, the cost of f u r n i s h i n g and equipping a cottage h o s p i t a l ; 4 2 the B r i t i s h Columbia M i l l s , Timber and Trading Company, a logging company operating i n the area selected for the h o s p i t a l s i t e , agreed to put up the h o s p i t a l b u i l d i n g ; 4 3 and the Columbia Coast Mi s s i o n of the Anglican Church took up f i n a n c i a l management of the h o s p i t a l . According to an agreement made between the Mission and the A s s o c i a t i o n , the M i s s i o n was to c o l l e c t money from loggers for both the V.O.N, cottage h o s p i t a l and the d o c t o r - s t a f f e d Mission boat. The M i s s i o n was to pay h o s p i t a l expenses, i n c l u d i n g s a l a r i e s , from t h i s sum, but the V.O.N, was to have f u l l c o n t r o l over the running of the h o s p i t a l . 4 4 The personal contacts and influence of A s s o c i a t i o n members undoubtedly helped e n l i s t the assistance of the Mission and the logging company. Archdeacon Pentreath, an Anglican clergyman who worked c l o s e l y with the M i s s i o n , 4 ^ was a member of the V.O.N, committee which di d p r e l i m i n a r y work on the h o s p i t a l p r o j e c t . 4 ^ Mrs. R.H. Alexander, wife 142 of the Secretary of the B r i t i s h Columbia M i l l s , Timber and Trading Company, was an a c t i v e member of the V.O.N, and was subsequently to be Honorary President of the A s s o c i a t i o n for a number of years. However, cooperation with the A s s o c i a t i o n held advantages from the point of view of both the Mission and the logging company. A h o s p i t a l i n the c o a s t a l area would provide s k i l l e d i n t e r i m care for pat i e n t s u n t i l the a r r i v a l of the Mission-boat doctor. I t would also enlarge the p o t e n t i a l labour pool of the logging company, since some loggers were u n w i l l i n g to work i n areas which were a number of days d i s t a n t from medical c a r e . 4 7 Once f i n a n c i a l arrangements were made, plans for the h o s p i t a l progressed smoothly. The ten-bed h o s p i t a l was to be b u i l t at Rock Bay, 200 kilometers from Vancouver on the east coast of Vancouver I s l a n d , i n the midst of a logging area i n which between three and four thousand loggers worked.4** Plans for the b u i l d i n g were drawn up, 4 9 a nurse was appointed from the Ottawa h e a d q u a r t e r s a n d an o r d e r l y and a housekeeper were hi r e d i n Vancouver.-'1 The secretary of the Vancouver A s s o c i a t i o n was one of a small group - A s s o c i a t i o n members and h o s p i t a l s t a f f - who t r a v e l l e d to Rock Bay e a r l y i n J u l y 1905 on the "Ca s s i a r " to open the h o s p i t a l . She described the t r i p i n the Minute Book: . . . l e f t . . . to open up the H o s p i t a l - a r r i v i n g about 9 PM Tuesday the 3rd. . . . the f u r n i t u r e etc had been conveyed to the H o s p i t a l - We immediately set to work to get the rooms i n order, and the next morning, the f i f t e e n months o l d c h i l d of the Locomotive Engineer John Shortreed was brought i n to be operated on - The Rev. J . Antle and Doctor Hutton of the Mi s s i o n boat "Columbia" was at the warf [ s i c ] awaiting us. Doctor Hutton s u c c e s s f u l l y operated on the c h i l d , and four other cases came i n the same day -The Committee v i s i t e d the various camps i n the 143 v i c i n i t y of Rock Bay and were everwhere received with great c o r d i a l i t y and respect, the Loggers expressing t h e i r pleasure at the advent of the H o s p i t a l and promising support - the secy, c o l l e c t e d $91.50 for a cow from the Loggers for the use of the H o s p i t a l . On Sunday J u l y 9th Ven. Archdeacon Pentreath conducted morning service when the H o s p i t a l was set apart with a serv i c e of dedi c a t i o n - The ser v i c e was attended by about f i f t y Loggers - some having come a long distance The foreman Mr. James Shortreed brought a s p e c i a l engine down A f t e r the s e r v i c e , the Loggers went a l l through the H o s p i t a l . . .52 The d i r e c t contact of V.O.N, members with the Rock Bay community added a personal dimension to the cottage h o s p i t a l p r o j e c t , which had p r e v i o u s l y been a matter of fu n d - r a i s i n g and a d m i n i s t r a t i v e d e t a i l . The two hampers of turkeys, pluin puddings, g i f t s , and h o l l y sent to Rock Bay i n December for the h o s p i t a l p a t i e n t s ^ 3 were a fu r t h e r expression of continuing personal i n t e r e s t on the part of the Vancouver V.O.N. As s o c i a t i o n . There was s i g n i f i c a n t expansion of h o s p i t a l f a c i l i t i e s over the next two years: a second nurse joined the h o s p i t a l s t a f f i n November 1905, 5 4 a physic ian was added to the resident s t a f f i n 1906,55 a n c j t n e h o s p i t a l b u i l d i n g was doubled i n s i z e i n 1907.56 These f a c i l i t i e s were used by approximately 140 h o s p i t a l p a t i e n t s and several hundred outpatients each year.57 Some of the cost of t h i s expansion had to be borne by the Vancouver V.O.N. Assocation, and proved to be f i n a n c i a l burden enough to threaten the Assoc i a t i o n ' s support of nursing work i n Vancouver.58 xhe A s s o c i a t i o n gave p r i o r i t y to the l a t t e r , and was eager to withdraw from the h o s p i t a l e n t e r p r i s e , i t s motives presumably i n c l u d i n g the desire to encourage donations by keeping i t s work i n sight of the Vancouver 144 p u b l i c . The Mission was w i l l i n g to assume the f i n a n c i a l r e s p o n s i b i l i t y which belonged to the A s s o c i a t i o n , but the timber company i n s i s t e d that the V.O.N, remain i t s tenant. The complex l e g a l arrangements that ensued were so u n s a t i s f a c t o r y to the Mission t h a t , i n the f a l l of 1908, the Bishop of Columbia (whose diocese was responsible for the M i s s i o n ) , accompanied by Archdeacon Pentreath and the p r i e s t i n charge of the Mis s i o n , appeared before the V.O.N. Executive Council i n Ottawa to ask for i t s i n t e r v e n t i o n . As a r e s u l t , the n a t i o n a l o r g a n i z a t i o n assumed r e s p o n s i b i l i t y for the h o s p i t a l i n January 1909.^9 When the h o s p i t a l burned down the f o l l o w i n g year, the n a t i o n a l body also ceased to p a r t i c i p a t e i n the Rock Bay work, and the Mission assumed e n t i r e r e s p o n s i b i l i t y for the management of the h o s p i t a l when i t was r e b u i l t . ^ 0 i i At the turn of the century, most nurses were e i t h e r h o s p i t a l nurses or private-duty nurses ( h i r e d to tend an i n d i v i d u a l patient on a f u l l - t i m e b a s i s , u s u a l l y i n the patient's own home). V.O.N, nurses were of a new type, the o r i g i n a l type of pub l i c h e a l t h nurse, known as " d i s t r i c t " or " v i s i t i n g " nurse.^1 L i k e p r i v a t e - d u t y nurses, v i s i t i n g nurses tended pat i e n t s i n the p a t i e n t s ' own homes, but on a part-time b a s i s , making perhaps s i x or more v i s i t s i n a s i n g l e working day.^2 Their work included assistance at operations and confinements, as w e l l as the nursing of chronic i n v a l i d s , newborn babies, and people s u f f e r i n g from serious but not h i g h l y contagious d i s e a s e s . ^ 3 V.O.N, nurses were governed by attending physicans' d i r e c t i o n s regarding care of p a t i e n t s , but exercised t h e i r own i n i a t i v e when they i n s t r u c t e d p a t i e n t s ' f a m i l i e s i n sound nursing procedures and good health h a b i t s . 145 Although the fees charged were too small to cover the cost of V.O.N, s e r v i c e s , many could not pay them: commonly, between 40 and 50 percent of V.O.N, patie n t s i n Vancouver were tended free of charge.64-Before the establishment of V.O.N, v i s i t i n g nursing i n 1901, many working-class people i n Vancouver had, when taken i l l , only the choice between c h a r i t y nursing i n a h o s p i t a l and no s k i l l e d nursing at a l l . The i n s t i t u t i o n of v i s i t i n g nursing gave them the a d d i t i o n a l option of remaining at home and r e c e i v i n g p r o f e s s i o n a l care, u n t i l then the prerogative of the more a f f l u e n t . Thus, while providing needed nursing care to the poorer members of Vancouver s o c i e t y , the V.O.N, was, however unconsciously, l e v e l l i n g s o c i a l d i s t i n c t i o n s by o f f e r i n g t h i s care i n a middle-class form. (That the a f f l u e n t were, during the same years, turning i n c r e a s i n g l y to h o s p i t a l s for nursing care i s u n l i k e l y to have detracted from the p r a c t i c a l and psychological value t h i s opportunity for home nursing had for working-class f a m i l i e s . ) Although v i s i t i n g nursing remained the heart of V.O.N, services i n Vancouver, the A s s o c i a t i o n , f o l l o w i n g a current trend i n the f i e l d of publ i c h e a l t h nursing, developed a preventive health-care program which placed ^ p a r t i c u l a r emphasis on pre-natal and c h i l d welfare nursing. Around 1913, Vancouver V.O.N, nurses began to take a keen i n t e r e s t i n these two types of nursing,65 which, i n contrast to t h e i r bedside nursing, had to be done free of charge i n order to reach t h e i r c l i e n t e l e . T h e c h i e f object was to reduce i n f a n t m o r t a l i t y and improve the health of c h i l d r e n ; the c h i e f means were: advice to expectant mothers on the importance of c l e a n l i n e s s , proper food, and adequate rest for themsleves and t h e i r babies; i n s t r u c t i o n of new 146 mothers i n proper methods of c h i l d care; and frequent inspections of the babies' progress.6? At f i r s t , the V.O.N, nurses d i d t h i s work only through home v i s i t s and between-visit c o n s u l t a t i o n s i n the o f f i c e of the V.O.N. Nurses' Home,68 and only for f a m i l i e s who asked for help or whose names were given to the Order. In 1917, the c i t y made i t e a s i e r for the V.O.N, to a s s i s t appropriate f a m i l i e s by granting i t permission to inspect the c i t y records of new births.69 i n 1919 s a fur t h e r means of contact with new babies of the c i t y was provided by the a d d i t i o n of the V.O.N. C h i l d Welfare Nurse (a s p e c i a l i z e d p o s i t i o n created two years e a r l i e r ) to the s t a f f of the c i t y well-baby c l i n i c s . 7 0 The V.O.N, welcomed c l i n i c work as an adjunct to home v i s i t i n g and shared with the c i t y the cost of equipping a new c l i n i c i n the working-class East End of the c i t y . 7 1 In 1920, the establishment of a D i v i s i o n of C h i l d Hygiene under the c i t y Health Department led to the withdrawal of the V.O.N, from c h i l d welfare nursing. The new D i v i s i o n , l i k e i t s famous prototype i n New York C i t y , coordinated a l l city-funded health services f or pregnant women, i n f a n t s , and c h i l d r e n . 7 2 I n i t i a l l y , i t h i r e d the V.O.N, to provide nurses to do c h i l d welfare nursing i n connection with the c i t y c l i n i c s , but l a t e i n the year made these nurses regular employees of the Health Department. Although the V.O.N, continued c h i l d welfare nursing i n the surrounding m u n i c i p a l i t i e s , i t l e f t t h i s nursing f i e l d to the Health Department w i t h i n the c i t y boundaries, and undertook instead an expanded program of prenatal nursing as i t s major c o n t r i b u t i o n to infant 73 he a l t h i n Vancouver. 147 The use of V.O.N, nurses by the D i v i s i o n of C h i l d Hygiene i l l u s t r a t e s an important aspect of the V.O.N. nursing s e r v i c e - the p r o v i s i o n of tr a i n e d public health nurses to other health and welfare agencies. Because the V.O.N, t r a i n i n g centers o f f e r e d almost the only p u b l i c h e a l t h nursing courses a v a i l a b l e i n Canada u n t i l 1920, 7 4 V.O.N, nurses were eagerly sought a f t e r f or s o c i a l welfare and p u b l i c h e a l t h work. 7^ The e a r l i e s t formal arrangement for such s e r v i c e was made i n 1906 between the V.O.N. and the F r i e n d l y Help Society, a voluntary a s s o c i a t i o n aided by municipal funds, which c a r r i e d the major r e s p o n s i b i l i t y f or r e l i e f of the poor w i t h i n the c i t y . 7 ^ The Society paid the Order to have a V.O.N, nurse spend part of her time i n v e s t i g a t i n g and r e l i e v i n g the poverty and sickness of those who applied for r e l i e f , a number of whom were already c l i e n t s of the V.O.N.77 A V.O.N, nurse was employed f u l l time a f t e r the Society incorporated as The Associated C h a r i t i e s of Vancouver i n 1909. 7^ The working r e l a t i o n s h i p between the V.O.N, nurse and the c i t y Medical Health O f f i c e r (who was o f f i c i a l l y or otherwise concerned with poor r e l i e f throughout the period of t h i s study) was very c l o s e , and she was refered to as the " c i t y nurse" long before the c i t y took over management of the Associated C h a r i t i e s i n January 1913. A f t e r that event, i t was the C i t y that paid the l o c a l V.O.N, a s s o c i a t i o n for her s e r v i c e s . 7 9 The Metropolitan L i f e Insurance Company also made extensive use of the Vancouver V.O.N, nursing s e r v i c e . In September 1912, V.O.N, nurses began to provide nursing care to Metropolitan i n d u s t r i a l l i f e insurance p o l i c y holders. The Metropolitan Company had, since 1909, contracted 148 with nursing organizations to provide (at a f i x e d rate) nursing care for p o l i c y holders during i l l n e s s or confinement. 8 1 The contract with the Vancouver A s s o c i a t i o n normally allowed as many as twenty-five v i s i t s by a nurse for an i l l n e s s and eight for a confinement. 8 2 The Metropolitan Company paid the V.O.N, le s s than the actual cost of a nursing v i s i t , 8 3 but since many of the i n d u s t r i a l p o l i c y holders were poor and would normally be v i s i t e d without charge by V.O.N, nurses, t h i s arrangement nevertheless benefited the V.O.N, f i n a n c i a l l y . 8 4 In 1920, the l a s t year studied here, the Metropolitan work accounted f or 28% of the fees received, 23% of the patie n t s tended, and 16% of the v i s i t s made for the Greater Vancouver A s s o c i a t i o n of the V.O.N.85 In. the period of t h i s study, the f i e l d of p u b l i c health nursing was maturing and sub d i v i d i n g , i n c r e a s i n g l y emphasizing preventive work. The extent of t h i s development i n Vancouver can be measured by the d i v e r s i f i c a t i o n of V.O.N, services o f f e r e d , and can be seen from the s t a t i s t i c a l report of the Greater Vancouver A s s o c i a t i o n f or 1920. During that year, about 20,000 v i s i t s were made by V.O.N, nurses. The greatest number of these (13,000) were home nursing v i s i t s , the only type reported at the beginning of the period of t h i s study; the new types comprised 4500 c h i l d welfare v i s i t s , 600 prenatal v i s i t s , 600 " s o c i a l s e r v i c e " v i s i t s ( s o c i a l work done by n u r s e s 8 6 ) s atid 1000 v i s i t s to tubercular p a t i e n t s who attended the Rotary C l i n i c for Chest D i s e a s e s . 8 7 The standards of the V.O.N, guaranteed a high l e v e l of t r a i n i n g i n the nurses supplied through the Vancouver A s s o c i a t i o n ; the scale of operation of the n a t i o n a l V.O.N, or g a n i z a t i o n provided a si z e a b l e labour 149 pool; and the Ass o c i a t i o n ' s p o l i c y of w i l l i n g n e s s to provide agencies with nurses on even an occasional basis**** a n a i t s maintenance of the V.O.N. Nurses' Home as a residence allowed agencies concerned with public health the greatest p o s s i b l e f l e x i b i l i t y i n the employment of V.O.N, nurses for t h e i r own work. i i i Recovery from i l l n e s s often requires warmth and proper food as w e l l as nursing care. P o v e r t y - s t r i c k e n V.O.N, patie n t s had no way of providing these f or themselves, so women of the A s s o c i a t i o n undertook the p r o v i s i o n of r e l i e f for d e s t i t u t e patients and, i n e v i t a b l y , f or t h e i r f a m i l i e s as w e l l . In the e a r l y years, an ad hoc committee or a ro t a of i n d i v i d u a l s was responsible for r e l i e f . In 1914, under the influence of widespread economic d i s t r e s s i n the c i t y , a r e l i e f committee was esta b l i s h e d which subsequently became a standing committee and supervised eleemosynary work of the A s s o c i a t i o n during the remaining years covered by t h i s study.** 9 Some examples w i l l best show the nature of A s s o c i a t i o n r e l i e f work: a family burned out of i t s home i n the summer of 1919 by a f i r e which had inju r e d the husband was given accommodation; 9^ the newborn c h i l d of a man l e f t a widower by the 1918 i n f l u e n z a epidemic was cared for by an A s s o c i a t i o n member for s i x months; 9 1 at Christmas i n 1905, poor c h i l d r e n were given t o y s . 9 2 Food, c l o t h i n g , and bed l i n e n were r e g u l a r l y given to patie n t s i n need of them. Of most fundamental importance, e f f o r t s were made to break_ the c i r c l e of unemployment, poverty, and i l l n e s s by f i n d i n g s u i t a b l e employment for patients (when 150 they were able to work) and for members of t h e i r f a m i l i e s . 9 3 A major task f or A s s o c i a t i o n r e l i e f workers was the accumulation of r e l i e f s u p p l i e s . They d i s t r i b u t e d g i f t s of food, used l i n e n and c l o t h i n g , and new garments made by women of other l o c a l organizations or by A s s o c i a t i o n members i n t h e i r sewing s e s s i o n s . 9 4 During the d i s t r e s s of 1914, the A s s o c i a t i o n increased the scale of t h i s work by arranging for the use of an empty G r a n v i l l e Street store as sewing room and c o l l e c t i o n depot. Two days a week, A s s o c i a t i o n members went there to receive donations and to supervise women who came to remake and mend old garments and to cut and sew new ones. 9^ V.O.N, r e l i e f workers undoubtedly c a r r i e d t h e i r middle-class moral values with them in t o the homes of the poor, and may w e l l have appeared to those they served to be p a t r o n i z i n g or preoccupied with the d i s t i n c t i o n between the deserving and the undeserving. However, these women received nothing for t h e i r work but personal s a t i s f a c t i o n . This f a c t , together with t h e i r evident desire to be h e l p f u l , must have embued V.O.N, r e l i e f work with a q u a l i t y of caring which i s ge n e r a l l y l a c k i n g from governmental r e l i e f s e r v i c e s . i v Since the V.O.N, required i t s nurses to have t r a i n i n g i n " d i s t r i c t " and other forms of pub l i c health n u r s i n g , 9 ^ and since no other i n s t i t u t i o n i n Canada offered a sustained t r a i n i n g program i n any such form of nursing u n t i l 1920, 9 7 the Order had to undertake such a program i t s e l f . T r a i n i n g centers authorized by the Order were esta b l i s h e d i n several eastern c i t i e s before 1900, and i t was these 151 centers which supplied many of the V.O.N, nurses sent to Vancouver and other western communities by the Order. 9** i n a d d i t i o n , the Order permitted associations which did not operate t r a i n i n g centers to accept graduate nurses on probation and t r a i n them on the j o b . 9 9 The preference of the Vancouver A s s o c i a t i o n f or l o c a l nurses, along with the Chief Superintendents' preference for the assured q u a l i t y of nurses with diplomas from a V.O.N. t r a i n i n g center, led the As s o c i a t i o n to e s t a b l i s h a t r a i n i n g center i n Vancouver.^0 This center, e s t a b l i s h e d i n 1911, s a t i s f i e d important l o c a l needs: graduates of h o s p i t a l t r a i n i n g schools w i t h i n the province who desired t r a i n i n g i n publ i c health nursing were no longer put to the expense and inconvenience of t r a v e l i n g to eastern Canada or the United States, and publi c and p r i v a t e agencies w i t h i n the Province were given a l o c a l pool of t r a i n e d p u b l i c h e a l t h nurses to draw upon when f i l l i n g the numerous new p o s i t i o n s r e q u i r i n g such t r a i n i n g . ^ 1 The t r a i n i n g given i n the Vancouver center, l i k e that given i n h o s p i t a l t r a i n i n g schools of the day, was h i g h l y p r a c t i c a l . The course, c o n s i s t i n g p r i m a r i l y of apprenticeship experience, extended over at lea s t four months. Students l i v e d i n the V.O.N. Nurses' Home and worked i n p a t i e n t s ' homes under the supervision of a V.O.N, nurse, r e c e i v i n g a small s a l a r y for the work they performed. ^ 2 They were also given the opportunity to observe p u b l i c health nursing work done by other agencies i n the c i t y , and to attend l e c t u r e s given i n the Nurses' Home by doctors, s a n i t a r y engineers, and other p u b l i c health s p e c i a l i s t s . ^ 4 There was close supervision of the standards and p r a c t i c e s of the Vancouver t r a i n i n g center by the n a t i o n a l headquarters of the Order: 152 a p p l i c a t i o n s f or admission to the course had to be sent there for approval, and the Chief Superintendent was i n s i s t e n t that students at the t r a i n i n g center be given s u f f i c e n t time o f f from t h e i r p r a c t i c a l work for attendance at lec t u r e s and for study. 1 Q5 gy complying with her desire f or the i n c l u s i o n of t h e o r e t i c a l study of p u b l i c h e a l t h n u r s i n g , t h e A s s o c i a t i o n created a remarkably broad t r a i n i n g course which enjoyed a reputati o n for high q u a l i l t y both w i t h i n the V.O.N, and e l s e w h e r e . 1 0 7 The Chief Superintendent's emphasis on the i n c l u s i o n of t h e o r e t i c a l work i n V.O.N, t r a i n i n g courses was i n d i c a t i v e of new currents i n the pedagogy of pub l i c h e a l t h nursing which would bri n g an end to the Vancouver t r a i n i n g center. When pub l i c h e a l t h nursing was simply a matter of bedside nursing on a v i s i t i n g b a s i s , the apprenticeship method of i n s t r u c t i o n was s a t i s f a c t o r y , but as the f i e l d came to include p r e n a t a l , c h i l d welfare, t u b e r c u l o s i s , school, i n d u s t r i a l , and s o c i a l - s e r v i c e nursing, the t r a i n i n g of pu b l i c h e a l t h nurses had to include not only o p p o r t u n i t i e s for observation and p r a c t i c e , but also explanation of the medical r a t i o n a l e behind recommended nursing p r a c t i c e s ( p a r t i c u l a r l y those of a preventive nature), and of the r e l i e f and other s o c i a l services a v a i l a b l e to t h e i r p a t i e n t s . Local V.O.N. Asso c i a t i o n s which wished to adjust t h e i r t r a i n i n g programs to meet the expanding nature of pub l i c h e a l t h nursing faced two d i f f i c u l t i e s : o btaining the services of l e c t u r e r s able to present a s u f f i c e n t l y extensive and rigorous survey of pu b l i c health work, and bearing the cost of a t r a i n i n g scheme which y i e l d e d fewer hours of student-performed nursing work than that to which they were 153 accustomed. i U 0 In 1920, these d i f f i c u l t i e s led the Vancouver A s s o c i a t i o n to discontinue the diploma course at i t s t r a i n i n g center. The sequence o f events which led to t h i s d e c i s i o n began i n the f a l l of 1919. Trained p u b l i c health nurses were needed for the r u r a l h e a l t h centers the p r o v i n c i a l Board of Health proposed to e s t a b l i s h , and Henry Esson Young, the Secretary of the Board, suggested that they be tra i n e d i n a new way. Under h i s proposal, graduate nurses who wished t r a i n i n g i n pub l i c health work would e n r o l l i n an extension course at the U n i v e r s i t y of B r i t i s h Columbia. The U n i v e r s i t y ' s newly opened School of Nursing would provide the t h e o r e t i c a l part of the course, and the Vancouver V.O.N, the p r a c t i c a l part. In order to give students experience i n r u r a l p u b l i c h e a l t h nursing, the l a t t e r would arrange to have students spend part of t h e i r period of p r a c t i c a l t r a i n i n g at the V.O.N, healt h center i n Saanich on Vancouver I s l a n d . The B r i t i s h Columbia Red Cross would subsidize the cost of the t r a i n i n g course as part of i t s peacetime p u b l i c health program. This proposal was agreeable to the various p a r t i c i p a t i n g agencies, and the f i r s t course was scheduled to be offered e a r l y i n 1920. ^ 9 In the event, the Vancouver t r a i n i n g center assumed r e s p o n s i b i l i t y for both the t h e o r e t i c a l and p r a c t i c a l aspects of t h i s course. This was necessary because, at the l a s t minute, and despite students having been r e c r u i t e d 1 1 ^ a n ( j l e c t u r e r s engaged, 1 1 1 the u n i v e r s i t y course was postponed u n t i l autumn. 1 1 2 The t r a i n i n g center could not arrange a lec t u r e s e r i e s on such short n o t i c e , so arranged instead for the students to attend weekly l e c t u r e s given by school doctors for school 113 nurses. At. the end of the summer, the t r a i n i n g center gave diplomas 154 to twenty nurses, 1 f a r more than u s u a l l y p a r t i c i p a t e d i n a s i n g l e t r a i n i n g - c e n t e r c o u r s e . 1 1 ^ The s t r a i n s produced by the large enrollment and improvised nature of t h i s course led the Vancouver A s s o c i a t i o n to reassess i t s r o l e i n the t r a i n i n g of pub l i c health nurses. The A s s o c i a t i o n saw that i t was unable to provide a strong t h e o r e t i c a l component i n a t r a i n i n g course and that the p a r t i c i p a t i o n of the u n i v e r s i t y , which could do so, was de s i r a b l e . H 6 I t recognized the value of p r a c t i c a l t r a i n i n g given by the V.O.N., but decided that i t could not bear unaided the cost of t r a i n i n g i n which, on balance, students received rather than gave s e r v i c e s . 1 1 7 In November, the Vancouver A s s o c i a t i o n provided supervision for the p r a c t i c a l work of a l l twenty-five students e n r o l l e d i n the U n i v e r s i t y of B r i t i s h Columbia pu b l i c h e a l t h nursing course, and boarded at t h e i r Nurses' Home the eight who belonged to the Order ( i n return f or s u b s t a n t i a l payments from the V.O.N. Board of Govenors and the p r o v i n c i a l Red C r o s s ) . 1 1 8 Outwardly, these a c t i v i t i e s resembled those p r e v i o u s l y undertaken by the t r a i n i n g center. There was, however, a fundamental d i f f e r e n c e - r e s p o n s i b i l i t y for the t r a i n i n g course had passed i n t o the hands of the U n i v e r s i t y , which thus became the i n s t i t u t i o n i n B r i t i s h Columbia granting diplomas i n pu b l i c h e a l t h nursing. The Vancouver Asso c i a t i o n ' s withdrawal from r e s p o n s i b i l i t y for education of pu b l i c health nurses a n t i c i p a t e d a s i m i l a r withdrawal by the n a t i o n a l V.O.N. In 1921, the V.O.N. Board of Governors decided to leave education of public health nurses to the u n i v e r s i t i e s and to a s s i s t women who sought such education by means of scholarships for 155 u n i v e r s i t y c o u r s e s . 1 1 9 Trying to keep abreast of rapi d growth i n medical knowledge and techniques, h o s p i t a l nursing schools also faced the obsolesence of o l d methods and the need for new ones. Unlike the V.O.N., which r e a d i l y gave up i t s t r a i n i n g a c t i v i t i e s when i t r e a l i z e d i t could no longer do them w e l l and that more capable agencies had developed, many small h o s p i t a l s held on to t h e i r t r a i n i n g programs for years a f t e r t h e i r l i m i t e d f a c i l i t i e s had become inadequate to provide more than minimal t r a i n i n g for nurses.^0 The d i f f e r e n c e between the V.O.N, and such small h o s p i t a l s was one of purpose: the former was committed to cr e a t i n g w e l l q u a l i f i e d p u b l i c health nurses; the l a t t e r to r e t a i n i n g a cheap labour supply. v Apart from fees c o l l e c t e d from i n d i v i d u a l s and agencies using V.O.N, s e r v i c e s , the Vancouver A s s o c i a t i o n of the V.O.N, had two sustained sources of income over the period of t h i s study: g i f t s from the p u b l i c and government grants. During the war years, fees, g i f t s , and grants were approximately equal as sources of income; during the rest of the period, g i f t s were general l y dominant (see f i g u r e ) . S o l i c i t i n g f i n a n c i a l support from the community was c o n s i s t e n t l y a major a c t i v i t y of A s s o c i a t i o n members. A s s o c i a t i o n members were a s s i s t e d i n t h i s task by a network of charitably-minded i n d i v i d u a l s w i t h i n the c i t y who devoted large parts of t h e i r l i v e s over many years to c h a r i t a b l e work, and who knew the c a p a b i l i t i e s and needs of various c i t y c h a r i t i e s . They were part of an 156 Figure. Vancouver V.O.N. A s s o c i a t i o n Income by Source 1902-1920 (Exclusive of i n t e r e s t , rent, and proceeds from sales of property) lEE --—-1----: : : :E : :r: rr.Er.:: EElEE :pr: f ^ E E l E E ^ ; : _ :.:.. :.i:r... r r j r rjEErjr E t" • • r:: lEEJ :E : :r. :E |_.E frr: !::::.: EEEEE .EEIEE EEEjrE: i • lEE'lEEfiEErE'E s.v—• I:::: rrrlrr: f EElEE: . : : :E.rr — J • - -I i ....... I • IEEE . r r : r.r E E = 4 = 1 EE E E J E E - :::::!::::.: 1 • • ; | E E EEEEEE ::::.:j.:::. : r r p : 1 E E E . ' [ E . E E : E E E E E E EE: :::r: E E E E E :EE EEEEE E ^ | E E :::::):::• E E E J E . E E • — 3 0 — EE ( E E E E E E E E E E E E EE : E E EEEEE . I . E . : . : E E I E E \ : :::} E E : E ! Err E E • EEE 1 -: E E E E E E E : E E E E E :E EE EEE|::EE. .[rr_ .::.:.:|::::: rrrpr: ~ : : E :ETEEE E E E | E E EE-EE EEJEE E E | E E - I -=r.|—:r - r: r:.i::::: :.:::::l:::..:: ::..: j . . . : : : i l:=r: EEEEE E E E E EEEEE ::.:.::!:.::: :: :::j..::::. ::::.:!•:::' : r : ! ::::. : .EEjEE .::::: r : - r r EEEEE : E E ! E E T - — i . . . . .::::::. i.r:: | . _ : : : . | : : . : • : : E E..1 : : E . : .. . . 2 & ~ |EE l» c EE -•::r.!r ::::::! : r r .:-_.:[.::: 1 E E E E • V i rrrjrrr :rrir:::: m rrrlrr: E_E-I.EE i ::;:.(:.::: ::::::!::::.:. '.. 1 i E E . _ . _ . . .... | E : : : : : • E E E E J E E . E E ::::::.!'::::: : . : : : ) : : : : : 1 . . . . I E E E E " I [ E E E E E E prr E :::E: -- - f— prr:: • • i 1 — :EEE|EE .:r:::j.:::r. - • 1 r r:ir::r EEifE: EELEE EEJEEE ; ; ; ; -p no t r.o S :rrrr: I • • ; E | ; - : : : ; E E \:^S: EElEE [ : ' .. I" i ' . E J ; ; : - ; : 1 h&— > i • • • • JEEE r::::j:r:r • — ( . j r:r:r:..:r: E E I E E . i r:~ 1 • • EEEIEE. EritiEE ::. . : ; r r | : : r : | E E f EEEEEE 1 _ E E E E E EEJEEE E E E E E ! i j : EE ........ -Ir t • |~ ••• • ! — ... E E : E E | E E | . : : •'. | s • ' • • I : i-EE 3 • - EE r : ~ > : i — • _ 1 i EEE 2 -—_.— EE E E E • -! EE — — i E E 1 - P=l W f i i : • - . - 1 .... . E E E E E J q 03 0 * c a* Or? 03 1 •> 11 12 11 \+ ) T n 13 la E E E E rr: /./ EEJEE E E I E E .:.: E r r : E E E E rr:: E E _r.r jr:r EEJEEE :::rj..:::r :::::::. hrr: :r:E[E::: EEE "EE EE:JEE. E E I E E : EEEl-EE. :::::. E:r: ::: rr::::.:. rr:jr.:.r :::: rt:.:::: : . : : : : l . : : : :::::[.:::: E E : i : : : : E : r . : l EE- E E - , ... I E | WD; i EEEiEE: T—— E E I E E -I n t A O lEE EEE E E : EElEE: rr::|.:r:: r r j:::r: E : E E E £k-_jAlf_rt EE: E E :r:r: 1 :.:::: I:::::. 1 EEtErE EE:j EE-lEEEEE EE EEJEE E E :r.r:j.:::.: r.r.irr: :::rir:r E E : E : ] E E : E - E E j : :.r . r:r: :::r:t::::::: r r t:rr:. — i EEEhE E : ' : E ! : E E E E E E E | E E ! ::r: r : : : J : : : : : : — I- rr :.::::: ::::: .:::: E EI - E ^ : ' EEiEEiEE! • • • -1 - J 157 overlapping membership which provided a channel through which donations from other organizations made t h e i r way to the V.O.N., and through which V.O.N. appeals f or p a r t i c u l a r types of assistance reached other o r g a n i z a t i o n s . The scope of t h i s network i s suggested by a l i s t of organizations which helped canvass i n a V.O.N, fu n d - r a i s i n g campaign i n 1920: St. Paul's H o s p i t a l A u x i l i a r y , the Imperial Order of the Daughters of the Empire, various King's Daughters groups, the Ladies of the Maccabees, the New Era League, the Vancouver Council of Women, the Women's C h r i s t i a n Temperance Union, and women's groups of various c h u r c h e s . 1 2 1 The o r g a n i z a t i o n of s o c i a l events for the be n e f i t of the V.O.N. was a form of fund - r a i s i n g a c t i v i t y popular with A s s o c i a t i o n members. In the e a r l y years of the Ass o c i a t i o n ' s h i s t o r y , they gave an annual Easter Week B a l l ; 1 2 2 l a t e r , they organized a c h i l d r e n ' s fancy-dress b a l l 1 i i each Christmas, and throughout the period of t h i s study, they arranged for teas, garden f e t e s , dances and be n e f i t performances. 1 2 4 The reputation of the V.O.N, as a " p r i v a t e Organization with c e r t a i n a r i s t o c r a t i c t e n d e n c i e s " 1 2 ^ l i k e l y gave a c e r t a i n cachet to these s o c i a l a f f a i r s . Money was s o l i c i t e d d i r e c t l y by means of d i s t r i c t canvasses, and by means of l e t t e r s of appeal sent to and c i r c u l a t e d among selected i n d i v i d u a l s . 1 2 * * In a d d i t i o n , there were annual city-wide appeals. In the f i r s t decade of the century, the M i n i s t e r i a l A s s o c i a t i o n arranged for a c o l l e c t i o n of funds for the V.O.N, i n the churches of the c i t y on a designated Sunday each y e a r . 1 2 7 Commencing i n 1911, the annual appeals were made on the st r e e t s i n the form of a tag day, which came to 158 be known as "Rose Day". 1^8 Well i n advance of the designated day, thousands of paper roses were made by V.O.N, members and t h e i r f r i e n d s , and by patie n t s at Vancouver General H o s p i t a l . 1 2 9 Qn "Rose Day" i t s e l f , "hundreds of young l a d i e s , c l a d i n white, with baskets of roses, spent the day s e l l i n g f or the be n e f i t of the Order."130 Many i n d i v i d u a l s and groups gave without being asked. Some deeded r e a l estate to the Order, or l e f t i t si z e a b l e sums of money i n t h e i r w i l l s . 1 3 1 Others sent money when the Order was i n p a r t i c u l a r n e e d . 1 3 2 For wintertime r e l i e f of the d e s t i t u t e V.O.N, p a t i e n t s , the Hastings Saw M i l l Co. sent loads of firewood; Wallace F i s h e r i e s sent kegs of h e r r i n g ; and a Maple Ridge farmer sent bushels of f r u i t and v e g e t a b l e s . 1 3 3 A number of companies gave discounts on items purchased by the V.O.N., or simply donated the required a r t i c l e s or s e r v i c e s . 1 3 4 Some organizers of sporting events donated part of t h e i r gate r e c e i p t s , 1 3 ^ and many organizations undertook money-making proj e c t s on behalf of the V.O.N. J O I t was p r i m a r i l y the female members of the Vancouver A s s o c i a t i o n of the V.O.N, who organized the b a l l s and teas, sold roses on the s t r e e t , acknowledged donations, and d i s t r i b u t e d c o l l e c t i o n boxes to churches. Middle-class women of the day were t r a i n e d i n such f u n d - r a i s i n g a c t i v i t i e s while s t i l l young (the V.O.N, g i r l s ' a u x i l i a r y p a r t i c i p a t e d i n t h i s t r a i n i n g ) , and they enjoyed e x e r c i s i n g t h e i r s k i l l s . However, by the end of the second decade of the century, men came to p a r t i c i p a t e a c t i v e l y i n A s s o c i a t i o n fund r a i s i n g . During that decade, with the advent of the whirlwind campaign, the nature of North American p h i l a n t h r o p i c fund r a i s i n g changed s i g n i f i c a n t l y . 1 3 7 Women i n the Vancouver A s s o c i a t i o n , apparently l a c k i n g confidence i n t h e i r 159 a b i l i l t y to organize the new type of campaign, which required the s k i l l f u l use of p u b l i c i t y , and of competitive techinques borrowed from the world of business, turned to the men i n the A s s o c i a t i o n . In 1920, a committee of w e l l known businessmen handled a V.O.N, campaign of the new t y p e . 1 3 8 The success of V.O.N, fu n d - r a i s i n g e f f o r t s was contingent upon the pu b l i c ' s viewing V.O.N, nursing as a worthy object for c h a r i t y . R e l i e f of the s i c k and s u f f e r i n g had long been a f a m i l i a r type of c h a r i t y , and V.O.N, bedside nursing was therefore e a s i l y seen as an appropriate object for c h a r i t a b l e g i v i n g . However, when the incr e a s i n g emphasis on preventive work prevalent i n the f i e l d of pub l i c h e a l t h nursing began to be t r a n s l a t e d i n t o new V.O.N, s e r v i c e s , money given to the V.O.N, was no longer d i r e c t e d only to those who were s u f f e r i n g , but also to those who were not. To ensure undiminished f i n a n c i a l support from the p u b l i c , V.O.N. fund - r a i s i n g p u b l i c i t y emphasized the value of preventive 139 work. 7 I t was, i n c i d e n t a l l y , thereby instrumental i n spreading the new p u b l i c h e a l t h perspective. During i t s e a r l y years, the Vancouver A s s o c i a t i o n received no government grants. This appears not to have been because the A s s o c i a t i o n was averse to such grants: the n a t i o n a l V.O.N, o r g a n i z a t i o n had, from i t s founding, considered support from various l e v e l s of government appropriate and d e s i r a b l e . 1 4 0 The Vancouver A s s o c i a t i o n may have applied for a municipal grant as e a r l y as 1903, 1 4 1 but i t was 1906 before i t a c t u a l l y received one (of $ 3 0 0 ) . 1 4 2 Subsequently, municipal grants ,were given annually to the A s s o c i a t i o n , i n c r e a s i n g i n amount from time to time u n t i l 1913, when $2000 was given, and then remaining 160 stable. 1 4 3 i n 1916, the m u n i c i p a l i t y of Point Grey gave a grant for $150. 1 4 4 In 1920, i n addition to the grant from the c i t y of Vancouver, the Greater Vancouver A s s o c i a t i o n of the V.O.N, received a grant of $500 from the m u n i c i p a l i l t y of Burnaby and one of $750 from the m u n i c i p a l i t y of South Vancouver. 1 4-' The Vancouver A s s o c i a t i o n f i r s t received a grant from the p r o v i n c i a l government i n 1916. The amount of t h i s grant was $250, and the A s s o c i a t i o n continued to receive grants i n t h i s amount through the remaining years of t h i s study. These grants were large enough to encourage the A s s o c i a t i o n to expand the scale of i t s operations, but not so large as to destroy i t s autonomy. However, since grants of public money for health services had at least the p o t e n t i a l for encouraging the public i n the b e l i e f that those who needed such services should have them by r i g h t , they did prepare the way for eventual t r a n s f e r of V.O.N, nursing services to government agencies. * * * During the years of t h i s study, the V.O.N, i n Vancouver took new ideas and practices from the f i e l d of public health nursing, introduced them into the c i t y , and fostered t h e i r growth there. The new services which i t undertook were examples of up-to-date public health nursing, and the ideas for these services u s u a l l y came from the nat i o n a l organization of the V.O.N., usu a l l y through a suggestion of the Chief Superindentent or the example of a l o c a l a s s o c i a t i o n elsewhere i n the country.-^ 4 7 Once established, these services proved t h e i r worth by reducing s u f f e r i n g , saving l i v e s , and creating good health; and t h e i r 161 success helped k i n d l e i n t e r e s t i n preventive p u b l i c h e a l t h work. Other public health services i n the c i t y had a s i m i l a r e f f e c t , and pub l i c health agencies, often of a s p e c i a l i z e d nature, p r o l i f e r a t e d i n t h i s new environment. Some of the services which the V.O.N, had introduced remained under i t s sponsorship, but, as agencies b e t t e r s u i t e d than the V.O.N, to p a r t i c u l a r tasks emerged, some services were operated j o i n t l y or were given over to the more competent body. Government was i n c r e a s i n g l y taking over heal t h s e r v i c e s , and the i n t e r a c t i o n i n Vancouver between the V.O.N, and government i l l u s t r a t e s a pattern of takeover which has become f a m i l i a r : a se r v i c e e s t a b l i s h e d by a voluntary agency i s s u f f i c i e n t l y b e n e f i c i a l to convince members of the p u b l i c , relevant bureaucrats, and p o l i t i c i a n s that i t should be a v a i l a b l e to a l l who need i t ; at some point the force of t h i s opinion i s s u f f i c i e n t l y strong to r e s u l t i n tax support for the s e r v i c e ; at f i r s t t h i s support i s minimal, but i n time the service becomes wholly tax supported and i t s a d m i n i s t r a t i o n goes into government hands. Although there was a s i g n i f i c a n t growth i n government ad m i n i s t r a t i o n of health services during the period of t h i s study, these two decades were w i t h i n the heyday of the voluntary a s s o c i a t i o n : those who concerned themselves with the f i e l d s of healt h and welfare s t i l l b e l ieved that p r i v a t e - agencies, voluntary f i n a n c i a l support, and programs which preserved working-class s e l f - r e s p e c t were e s s e n t i a l . 1 4 * * The V.O.N., with i t s corps of tr a i n e d s p e c i a l i s t s , i t s n a t i o n a l o r g a n i z a t i o n , and i t s deep committment to human betterment, d i d perform many e s s e n t i a l p u b l i c health functions. In p a r t i c u l a r , i t s experimental and educational work exerted a b e n e f i c i a l influence on public health i n 162 Vancouver which extended far beyond i t s act u a l nursing s e r v i c e s . NOTES ON CHAPTER 4 Abbreviations: Ann.Rep. V i c t o r i a n Order of Nurses for Canada. Annual Report. (There i s a complete set of these reports at the Order's n a t i o n a l o f f i c e i n Ottawa.) Nursing School U n i v e r s i t y of B r i t i s h Columbia Archives, U n i v e r s i t y of B r i t i s h Columbia School of Nursing Papers. Province The Vancouver D a i l y Province. V.A.VON V i c t o r i a n Order of Nurses for Canada, Vancouver A s s o c i a t i o n . Minutes. VON Pu b l i c Archives of Canada, V i c t o r i a n Order of Nurses for Canada Papers, Executive Council Minutes (MG28, 1-171, v.3-4). 1. For general information on the V.O.N., see: C h r i s t i n e M. L i v i n g s t o n , "The H i s t o r y , Aims and Programme of the V i c t o r i a n Order of Nurses for Canada", I n t e r n a t i o n a l Nursing Review, n.s., v.3, no.2 (October, 1956), pp.42-47; John Murray Gibbon, The V i c t o r i a n Order of  Nurses for Canada 1897-1947 (Montreal, 1947); M. Adelaide Nutting and L a v i n i a L. Dock, A H i s t o r y of Nursing, v.4 (New York, 1912), pp.151-155; Florence H.M. Emory, P u b l i c Health Nursing i n Canada, P r i n c i p l e s and  P r a c t i c e s (Toronto, 1945), pp.29-33; John Murray Gibbon and Mary S. Mathewson, Three Centuries of Canadian Nursing (Toronto, 1947), ch.28-29; P u b l i c Archives of Canada, MG28, 1-171, v.7, "A Synopsis of the H i s t o r y & A c t i v i t i e s of the V i c t o r i a n Order of Nurses for Canada", t y p e s c r i p t , [1935]. 2. For the establishment of the V.O.N., see: Gibbon, pp.1-37; John Campbell Gordon and Ishbel M.M. Gordon, Marquis and Marchioness of Aberdeen and Temair, "We Twa", Reminiscences of Lord and Lady Aberdeen (London, 1925), v.2, ch.10. A sense of the dynamic leadership given by Lady Aberdeen i s given by her address at the fourth Annual Meeting of the N a t i o n a l Council of Women which i s quoted i n B.F. Au s t i n (ed.), Woman: Maiden, Wife and Mother, study of Woman's Worth and Work i n A l l Departments of Her Manifold L i f e , Education, Business, Society,  Housekeeping, Health, P h y s i c a l C u l t u r e , Marriage and Kindred Matters, (Prepared for the Canadian Council of Women and the V i c t o r i a n Order of Nurses; Toronto, 1898), pp.500-504. 163 164 3. VON, 8 October 1898. 4. V i c t o r i a n Order of Nurses for Canada (pub.), The Royal Charter  and Regulations of the V i c t o r i a n Order of Nurses for Canada (n.p., 1920), sections 6 and 7 of the Charter. 5. Gibbon, p . l , 4; V.A.VON, 27 J u l y 1898; P u b l i c Archives of Canada, MG28, 1-171, v.2, V i c t o r i a n Order of Nurses for Canada P r o v i s i o n a l Committee Minutes, 7 A p r i l 1897. 6. V.A.VON, 14 October 1910, [? November] 1910, [?] December 1910, 8 December 1911, 28 June 1912; Ann.Rep., 1920, pp.143-144. 7. "By-laws and Regulations of the V i c t o r i a n Order of Nurses for Canada", Ann.Rep., 1911, regulations 21(b-d) and 26(b) (pp. 136-137). .8. This assessment i s based p r i m a r i l y on the annual reports of the Chief Superintendents (which are pri n t e d i n the annual reports of the Order), and on the p i c t u r e of t h e i r work that emerges from the Minutes of the Executive C o u n c i l . For evidence of the Chief Superintendents' contact with nursing developments, see: Ann.Rep., 1901, pp.40-42; VON, 2 May 1918. 9. Ann.Rep., 1920, p.34; V.A.VON, 6 October 1899; Nursing School, l e t t e r from H.E. Young to R.H. M u l l i n , 6 October 1920. 10. Ann.Rep., 1916, p.62 r e f e r s to her v i s i t s as "annual". 11. V.A.VON, 20 February 1914, 11 January 1918; VON, 1 October 1908. 12. Ann.Rep., 1905, p.6. 13. This conjecture i s based on the importance the v i c e r e g a l connection of the Honorary President of the n a t i o n a l V.O.N, obviously had for members of the Vancouver A s s o c i a t i o n . (Ann.Rep, 1919, p.148; V.A.VON, 2 October 1919, 6 February 1913; Province, 17 May 1920, p.8.) 14. V.A.VON, 7 January 1899, 8 February 1899, 10 March 1899. 15. Richard H. Shryock, The H i s t o r y of Nursing, An I n t e r p r e t a t i o n  of the S o c i a l and Medical Factors Involved ( P h i l a d e l p h i a , 1959), pp.267-268; Isabel Hampton Robb,Educational Standards for Nurses and  Other Addresses on Nursing Subjects (CleveTand, 1907), pp.33-34. 16. Royal Charter . . ., se c t i o n 5(b). 17. V.A.VON, 6 October 1899; VON, 2 March 1899. 18. Except for one meeting with the Chief Superintendent of the Order to discuss the f i a s c o , there were no meetings recorded i n the Minute Books between March 10 March 1899 and 22 November 1901. 165 19. V.A.VON, 9 September 1903, 29 November 1904, 16 March 1906. 20. V.A.VON, 6 February 1911, 7 A p r i l 1911, 22 August 1911, 7 September 1911. 21. V.A.VON, 14 March 1913, 13 June 1913, 13 September 1918, 12 September 1919, 17 February 1920, 12 March 1920, 20 February 1920. 22. V.A.VON, [?] December 1910, 7 A p r i l 1911, 8 December 1911, 28 June 1912; Ann.Rep., 1920, pp.143-144. 23. Ann.Rep., 1920, pp.39-40, 145. 24. Ann.Rep., 1920, p.39. 25. V.A.VON, 27 February 1920. The doctors were: Malcolm MacEachern, superintendent of Vancouver General H o s p i t a l ; Charles H. Vrooman, head of the Rotary C l i n i c for Chest Diseases; F.T. U n d e r b i l l , C i t y Medical Health O f f i c e r ; and W.D. Brydone-Jack, a long-time School Trustee and supporter of school hygiene work. 26. I have based my assessment of the c l a s s of A s s o c i a t i o n members on the occupations of A s s o c i a t i o n o f f i c e r s or t h e i r husbands for 1906 and 1920, and on the fact that a number of A s s o c i a t i o n members belonged to the f a m i l i e s of Vancouver business leaders. In 1906, the o f f i c e r s were: Mrs. R.H. Alexander, whose husband was both the manager of Hastings Sawmill and secretary of the B r i t i s h Columbia M i l l , Timber and Trading Company (Honorary P r e s i d e n t ) ; Anglican Archdeacon E.S.W. Pentreath ( P r e s i d e n t ) ; Mr. W.F. Salsbury, l o c a l t reasurer of the Canadian P a c i f i c R a i l r o a d (Treasurer); Mrs. H.J. Newton, wife of an o f f i c i a l of the Hastings Sawmill (Secretary); Mrs. James Macaulay, wife of a partner i n a wholesale confectionary and importing company (1st Vice P r e s i d e n t ) ; Mrs. H.G. Ross, wife of an insurance adjuster (2nd Vice P r e s i d e n t ) ; Mrs. W.D. Brydone-Jack, wife of the doctor (3rd Vice P r e s i d e n t ) . In 1920, the o f f i c e r s were: Mrs. James Macaulay (Honorary P r e s i d e n t ) ; Mrs. W.D. Brydone-Jack (Honorary Vice P r e s i d e n t ) ; Mrs. M.A. MacLean, whose husband was Vancouver's f i r s t mayor and subsequently a magistrate (Honorary Vice P r e s i d e n t ) ; Mrs. A.P. Judge, wife of a conveyancer (Honorary Vice P r e s i d e n t ) ; Mrs. W.M. Rose, widow of a druggist ( P r e s i d e n t ) ; Mrs. W.A. Clark, whose husband had been i n the r e a l estate business (Vice P r e s i d e n t ) ; Mrs. J.W. Weart, wife of a b a r r i s t e r (Vice P r e s i d e n t ) ; Mrs. F.E. Burke, wife of the general manager of Wallace F i s h e r i e s L t d . (Secretary); Mrs. F.W. Brydone-Jack, wife of the doctor ( A s s i s t a n t Secretary); Mr. C.G. Pennock, manager of the Bank of Ottawa (Treasurer); Mrs. S.P. Judge, wife of a high school teacher ( A s s i s t a n t Treasurer). The f o l l o w i n g members of the A s s o c i a t i o n are l i s t e d as business leaders by Robert A.J. MacDonald i n h i s unpublished Ph.D. t h e s i s , "Business Leaders i n E a r l y Vancouver, 1886-1914" ( U n i v e r s i t y of B r i t i s h Columbia, 1977, Appendices A and B), or were members of the f a m i l i e s of men so l i s t e d : Mrs. E.J. McFeely, Mrs. E. Rand, Mr. and Mrs. Ewing Buchan and Miss Buchan, Mrs. John Dewar, Mrs. S.F. Faulkner, Mr. Charles 166 G. Pennock, Mrs. Peter Wallace, Mrs. John Hendry, and Dr. and Mrs. W.D. Brydone-Jack and Mrs. F.W. Brydone-Jack, t h e i r daughter-in-law. 27. V.A.VON, 8 May 1903, [?] October 1911, 21 February 1906, 6 February 1913. 28. Membership l i s t s f or the years 1905 through 1912 are at the back of the Minute Book which covers the years 1905-1912, and at the back of the one which covers the years 1912-1915. 29. For i n s i g h t into the nature of the Working Committee, see V.A.VON, 4 January 1902, 22 January 1902, 30 January 1903. For i t s a b o l i t i o n , see V.A.VON, 21 February 1906. 30. V.A.VON, 17 January 1912. 31. Province, 22 January 1915, p.3. 32. V.A.VON, 14 February 1919, 25 February 1919, 11 A p r i l 1919. 33. V.A.VON, 29 January 1920. 34. V.A.VON, 7 February 1907. 35. Gibbon, pp.58-63, 243, 269, 276. The V.O.N. cottage h o s p i t a l s i n B r i t i s h Columbia were located at Arrowhead, As h c r o f t , B a r k e r v i l l e , Chase, Fe r n i e , Ganges, Invermere, Kaslo, Quesnel, Revelstoke, Rock Bay, and Vernon. 36. V.A.VON, 8 August 1903. 37. V.A.VON, 7 October 1903. 38. Ann.Rep., 1903, p.79. 39. V.A.VON, 1 November 1904. 40. V.A.VON, 21 March 1905. 41. V.A.VON, 17 January 1905; note between the e n t r i e s for 10 November 1905 and 21 February 1906. 42. V.A.VON, 20 February 1905, 21 March 1905. 43. V.A.VON, 13 January 1905. 44. V.A.VON, 21 March 1905, 27 March 1905, 3 J u l y 1905. 45. Richard John Lonsdale, "A H i s t o r y of the Columbia Coast M i s s i o n " (unpublished M.A. t h e s i s , U n i v e r s i t y of V i c t o r i a , 1973), pp.9-10. 167 46. V.A.VON, 27 November 1904. 47. M. A l l e r d a l e Grainger, Woodsmen of the West (1908; r p t . Toronto, 1964), p.101. 48. "The V i c t o r i a n Order of Nurses i n 1904", The Canadian Nurse, v . l (1905), p.31; "In Memoriam", The Canadian Nurse, v.2 (1906), p.28; Ann.Rep., 1905, pp.32-33. 49. V.A.VON, 13 January 1905, 17 January 1905. 50. V.A.VON, 21 March 1905. 51. V.A.VON, 16 May 1905, 3 J u l y 1905. 52. V.A.VON, 3 J u l y 1905. 53. Ann.Rep., 1905, p.71. 54. V.A.VON, note between the e n t r i e s for 10 November 1905 and 21 February 1906. 55. "The V i c t o r i a n Order of Nurses", The Canadian Nurse, v.3 (1907) , p.255; Ann.Rep., 1906, p.10. 56. Lonsdale, p.11; V.A.VON, 6 August 1907. 57. Ann.Rep., p.23; 1907, p.26; 1908, p.41; 1909, p.75. 58. V.A.VON, 20 September 1907. 59. V.A.VON, 13 November 1908, 6 January 1909; VON, 1 October 1908, 10 October 1908, l e t t e r from Charles Morse to J.R. Dalton, 22 October 1908 (i n s e r t e d i n the minute book f o l l o w i n g the entry for the 10 October 1908 meeting). 60. Ann.Rep., 1910, p.16; Lonsdale, p.15. 61. For d e s c r i p t i o n s of v i s i t i n g nursing by women who did i t , see: Georgie H. C o l l e y , " D i s t r i c t Nursing", The Canadian Nurse, v . l (1905), pp.16-17; A.E.B., " V i s i t i n g Nursing", The Canadian Nurse, v.4 (1908) , pp.105-109. For a b r i e f d e s c r i p t i o n of v i s i t i n g nursing and i t s r e l a t i o n s h i p to the whole f i e l d of nursing, see: Emory, pp. 23-53. 62. Gibbon, p.85. 63. V.A.VON, 6 February 1913, 5 February 1914; Ann.Rep., pp.61-62. 64. Records showing fees c o l l e c t e d from patients are incomplete for many years during t h i s period. Records appear to be complete for 1902-1903, when 18% of the patients were tended free of charge, and for 1908-1913, when the percentage of free p a t i e n t s ranged from 37% to 51%. (Ann.Rep., 1902, p.38; 1903, p.49; 1908, p.44; 1909, p.78; 1910, p.76; 168 1911, p.71; 1912, p.81; 1913, p.117.) 65. Ann.Rep., 1913, pp.15, 80. 66. I t i s c l e a r that by the end of the decade t h i s work was free. (Ann.Rep., 1920, p.25; 1919, p.148.) I am not c e r t a i n whether i t was o r i g i n a l l y . 67. Ann.Rep., 1920, p.144; Vancouver, Health Department, Medical  Health O f f i c e r ' s Annual Report, 1920, p. 17; Mary Sewall Gardner, P u b l i c  Health Nursing (New York, 1919), pt.3, ch.2. 68. Ann.Rep., 1913, p.80. 69. Ann.Rep., 1917, p.71. Ann.Rep., 1917, p.71; 1919, pp.148-149; V.A.VON, 14 February 70 1919, 71. Ann.Rep., 1919, pp.148-149; Province, 22 March 1919, p.16. 72. Vancouver, Health Department, Medical Health O f f i c e r ' s Annual  Report, 1920, pp.17-18. 73. Ann.Rep., 1920, pp.142-144; V.A.VON, 30 March 1920, 23 J u l y 1920, 12 November 1920; V i c t o r i a n Order of Nurses for Canada, Vancouver A s s o c i a t i o n , Papers, [Ethel Brown?], "A Report to the Local Committee, 10 December 1920". 74. Nursing School, l e t t e r from J . Charlotte Hanington to H.E. Young, 27 September 1919; "The S i x t h Annual Convention of the Canadian Nati o n a l A s s o c i a t i o n of Trained Nurses . . . June 14th and 15th, 1917", The Canadian Nurse, v.13 (1917), pp.422-423. 75. They were i n fact used by such bodies as the p r o v i n c i a l and c i t y health departments, the c i t y p o l i c e department, and the Rotary C l i n i c f or Chest Diseases. (V.A.VON, 28 June 1912, 20 January 1920, March 30, 1920; Ann.Rep.. 1920, p.144; 1912, p.12.) 76. Vancouver, Annual Report, 1906, p.14; 1907, p.14; 1908, p. 17. The annual reports of the C i t y do not itemize the municipal grants i n 1906 and 1907; i n 1908 the F r i e n d l y Help Society received $1500 from the c i t y . I t i s reasonable to assume that funds were being given i n the two previous years as w e l l . 77. V.A.VON, 21 November 1906; "The V i c t o r i a n Order of Nurses", The Canadian Nurse, v.3 (1907), p.65. 78. V.A.VON, 4 February 1909, [? December] 1909. 79. V.A.VON, 18 October 1907, [? December] 1909; Vancouver C i t y Archives, Vancouver, C i t y Council Minutes, 27 January 1913; Associated C h a r i t i e s [Committee] Minutes, 6 February 1913; Ann.Rep., 1913, p.200; 1914, p.227. 169 80. Holders of i n d u s t r i a l l i f e insurance p o l i c i e s paid t h e i r premiums i n small weekly i n s t a l l m e n t s (under f i f t y cents) to an agent who c a l l e d at t h e i r homes to c o l l e c t . They were u s u a l l y working-class people who bought these small-benefit ( t y p i c a l l y $150) p o l i c i e s to cover the cost of f i n a l i l l n e s s and b u r i a l for members of t h e i r f a m i l i e s . (J.D. Buchanan, " I n d u s t r i a l L i f e Insurance" and the d i s c u s s i o n which f o l l o w s , Transactions of the A c t u a r i a l Society of America, v.22 (1921), no.65, pp.36-74; Louis I. Dublin and A l f r e d J . Lotka, Twenty-five Years  of Health Progress ^ a_ Study of the M o r t a l i t y Experience among the  I n d u s t r i a l P o l i c y Holders of the Metropolitan L i f e Insurance Company  1911 to 1935 (New York, 1937), pp.6-7; L a v i n i a L. Dock, "The H i s t o r y of Pu b l i c Health Nursing" i n Mazyck P. Ravenel (ed.), A Half Century of  P u b l i c Health (New York, 1921), p.442. 81. The Metropolitan Company was i n the vanguard i n implementing a new l i f e insurance p r i n c i p l e : save money through preventing death of p o l i c y holders. See "Insurance - Saving Lives for P r o f i t " , World's  Work, v.21 (1911), pp.13963-13965. 82. Ann.Rep., 1913, pp.80-81. 83. V.A.VON, 11 March 1919. 84. Ann.Rep., 1913, p.81. 85. Ann.Rep., 1920, pp.61-62. 86. For a d e s c r i p t i o n of t h i s type of nursing, see Gardner, pt.3, ch.6. 87. Ann.Rep., 1920, pp.61-62. 88. V.A.VON, 13 August 1920. 89. V.A.VON, 16 December 1903, 21 February 1906, 6 February 1913, 10 September 1914. The evidence of r e l i e f work done by the Vancouver A s s o c i a t i o n i s fragmentary and provides l i t t l e i n s i g h t i n t o the nature of the i n t e r a c t i o n between pati e n t s and A s s o c i a t i o n members. (An exception i s found i n Ann.Rep., 1915, p.80.) A report of the R e l i e f Committee of the Montreal V.O.N. A s s o c i a t i o n i s h i g h l y informative i n t h i s regard, and the i n t e r a c t i o n s i t describes may be s i m i l a r to those which occurred i n Vancouver. (Ann.Rep., 1900, pp.48-51.) 90. V.A.VON, 13 June 1919. 91. Ann.Rep., 1918, p.156. 92. V.A.VON, note between the e n t r i e s for 10 November 1905 and 21 February 1906. 93. Ann.Rep., 1907, pp.9-10. 170 94. V.A.VON, 8 May 1903, 2 March 1906, 17 May 1907, 11 June 1909, 11 May 1911, 6 February 1913, 8 May 1914, 29 J u l y 1914, 18 September 1914, 9 October 1914, 13 November 1914, 14 November 1919; Ann.Rep., 1914, pp.80-81; 1918, p.156. 95. Ann.Rep., 1914, pp.80. 96. Gibbon, p.38, pp.24-25. 97. Nursing School, l e t t e r from J . Charlotte Hanington to H.E. Young, 27 September 1919. 98. Gibbon, pp.38-39, pp.42-43. 99. V i c t o r i a n Order of Nurses for Canada (pub.), The Royal  Charter and Regulations of the V i c t o r i a n Order of Nurses for Canada (n.p., 1920), regulations 49 and 50; V.A.VON, 8 August 1903 and note between the en t r i e s for 10 November 1905 and 21 February 1906. 100. V.A.VON, 17 J u l y 1907, 7 A p r i l 1911, 11 August 1911, 9 November 1911, 8 December 1911. 101. U n i v e r s i t y of B r i t i s h Columbia L i b r a r y , S p e c i a l C o l l e c t i o n s , E t h e l Johns Papers, box 1, f i l e 39, l e t t e r from Eth e l Johns to Dr. Uprichard, 16 September 1965, p.2. A f t e r approximately one year of operation, the Vancouver t r a i n i n g center had t r a i n e d nurses who had been placed i n V i c t o r i a , South Vancouver, North Burnaby, Kaslo, and Steveston. (V.A.VON, 9 May 1913.) 102. The s a l a r y scale for student nurses was about h a l f that of regular s t a f f nurses. (V.A.VON, 17 March 1919.) 103. Ann.Rep., 1915, p.23; Vancouver Board of School Trustees, Annual Report, 1913, p.41. 104. I b i d . , 1913, pp.81-82; 1915, p.23. 105. I b i d . , 1913, p.21. 106. I b i d . , 1913, pp.81-82; V.A.VON, 25 October 1912, 28 October 1913, 9 October 1914, 13 November 1914, 11 January 1918, 17 January 1919. 107. V i c t o r i a n Order of Nurses for Canada, Vancouver A s s o c i a t i o n , Papers, Minutes of the Committee Appointed to Consider the Question of the Reconstruction of the Tr a i n i n g Centers, 31 March 1920 [meeting i n Ottawa]; Ann.Rep., 1914, p.13; 1915, p.23. In 1919, the U n i v e r s i t y of Washington requested that i t s nursing students be allowed to do f i e l d work at the (Vancouver V.O.N, t r a i n i n g center. V.A.VON, 12 September 1919; Nursing School, l e t t e r from J . Charlotte Hanington to H.E. Young, 27 September 1919; VON, 11 September 1919.) 171 108. VON, 11 December 1919, 7 October 1920; Ann.Rep., 1913, p.12; 1914, pp.22-23. 109. VON, 2 October 1919, 13 November 1919; B r i t i s h Columbia, Board of Health, Annual Report, 1918-1919, pp.B7-B8; 1919-1920, pp.A5-A6; P r o v i n c i a l Archives of B r i t i s h Columbia, P r o v i n c i a l Secretary's Papers, Board of Health, f i l e : Health Center and Pu b l i c Health, memo from H.E. Young to the P r o v i n c i a l Secretary, 12 J u l y 1920; V.A.VON, 16 September 1919; Nursing School, l e t t e r from J . Charlotte Hanington to H.E. Young, 27 September 1919; l e t t e r from L.S. K l i n c k to H.E. Young, January 22, 1920; Outline for Short Course i n Pu b l i c Health Nursing; p o r t i o n of the 29 September 1920 Minutes of the Saanich A s s o c i a t i o n of the V.O.N., attached to a l e t t e r from H.E. Young to R.H. M u l l i n , 7 October 1920; l e t t e r from E t h e l Johns to Dr. Uprichard, 16 September 1965, pp.2, 5. 110. The type of woman applying may be i n f e r r e d from c h a r a c t e r i s t i c s of the students recommended by the V.O.N.: They were mature, having graduated from h o s p i t a l t r a i n i n g schools between 1908 and 1917, and geographically mobile, having graduated from schools i n Montreal, Brandon, Hamilton, Prince A l b e r t , Ottawa, Toronto, Edmonton, and Omaha. Two of them had served as army nurses. (Nursing School, memo: Students from the V i c t o r i a n Order of Nurses, 16 February 1920.) 111. Nursing School, l e t t e r from J . Charlotte Hanington to E t h e l Johns, 25 February 1920; l e t t e r from H.E. Young to E t h e l Johns, 9 February 1920; l e t t e r from E t h e l Johns to H.E. Young, 11 February 1920; Outline of Short Course i n P u b l i c Health Nursing. 112. Margaret M. S t r e e t , Watch-fires on the Mountains - The L i f e  and Writings of E t h e l Johns (Toronto, 1973), p.128; V.A.VON, 12 March 1920. I t seems l i k e l y that E t h e l Johns, D i r e c t o r of the School of Nursing, made the d e c i s i o n . She was under a great deal of pressure, holding the p o s i t i o n of D i r e c t o r of the School of Nursing Service and Education at Vancouver General H o s p i t a l i n a d d i t i o n to her u n i v e r s i t y p o s i t i o n . The postponement of the pub l i c health course may have been prompted by the serious problems at the H o s p i t a l which r e s u l t e d from a recurrence of the i n f l u e n z a epidemic i n February and March. ( S t r e e t , pp.120-121, 126-131.) 113. Vancouver Board of School Trustees, Annual Report, 1920, p. 37. 114. V.A.VON, 10 September 1920. 115. For example, there were s i x graduates i n January 1920. (V.A.VON, 29 January 1920.) 116. Ann.Rep., 1920, p.146. 117. V.A.VON, 16 June 1920, 23 J u l y 1920, 15 October 1920. 172 118. Ann.Rep., 1920, p.146; VQN, 6 January 1921. 119. Ann.Rep., 1920, pp.15-16; Gibbon, p.78. 120. Robb, ch.4; M.T. MacEachern, A Survey of the Nursing  Question, with S p e c i a l Consideration of the Problems A r i s i n g Therefrom  and Their A p p l i c a t i o n i n the Vancouver General H o s p i t a l (Vancouver, 1919), p.9; Shryock, pp.266-267, 301, 304; Isabel Maitland Stewart, The Education £f Nurses, H i s t o r i c a l Foundations and Modern Trends (New York, 1953), ch.4-5. 121. Province, 17 May 1920, p.8. 122. V.A.VON, 11 February 1902, 12 March 1902, 24 March 1902, 9 A p r i l 1902, 27 February 1903, 8 May 1903, 29 February 1904, 20 A p r i l 1904, 27 March 1905; Ann.Rep., 1902, p.52; 1904, p.70. 123. V.A.VON, 22 November 1907, 13 November 1908, [? December] 1909, 14 November 1919. 124. V.A.VON, 11 June 1902, 14 Auguat 1903, 3 J u l y 1907, 21 February 1908, 12 June 1908, [? December] 1909, 5 February 1914, 10 December 1920; Ann.Rep., 1914, p.81. 125. "[V.O.N.] Chief Superintendent's Annual Report, 1916", The  Canadian Nurse, v.13 (1917), p.760. 126. V.A.VON, 24 November 1902, 29 November 1904, 15 November 1907, 6 December 1907, 12 December 1908, 12 May 1909, 13 January 1911, 6 February 1911, 10 January 1913, 10 September 1920, 12 November 1920. 127. V.A.VON, 28 January 1902, 6 December 1907, 6 January 1909, 12 November 1909, 14 October 1910, [? November] 1911. 128. V.A.VON, 7 September 1911, 4 October 1911, 8 J u l y 1912, 9 J u l y 1918, 27 June 1919; Ann.Rep., 1916, p.62; 1917, p.71. 129. Ann.Rep., 1914, pp.78-79; 1913, p.81. 130. Ann.Rep., 1913, p.81. 131. V.A.VON, 11 August 1911, 6 February 1913, 14 March 1913. 132. V.A.VON, 9 January 1920; Ann.Rep., 1905, p.71. 133. V.A.VON, 18 September 1914, 13 November 1914, 5 December 1919. 134. V.A.VON, [? November] 1910, 22 August 1911, 14 March 1913, 5 J u l y 1914, 27 June 1919. 135. V.A.VON, 11 October 1912; Ann.Rep., 1910, p.55 173 136. V.A.VON, 11 February 1902, 11 June 1902, 18 May 1906, 5 December 1919. 137. A i l e e n D. Ross, "Organized Philanthropy i n an Urban Community," Canadian Journal of Economics and P o l i t i c a l Science, v.18 (1952), pp.474-486. In contrast to the c h a r i t a b l e agencies of " W e l l s v i l l e " , the Vancouver V.O.N. A s s o c i a t i o n had developed i n at least rudimentary form, even i n i t s pre-whirlwind campaigns, some of the c h a r a c t e r i s t i c s Ross sees as developing i n " W e l l s v i l l e " with adoption of the whirlwind campaign. These included acceptance of fund r a i s i n g as an appropriate a c t i v i t y for women of the l e i s u r e d c l a s s , adoption of the t r a i n i n g of young women for t h i s a c t i v i t y as customary, corporate g i v i n g to c h a r i t a b l e agencies, and the s e c u l a r i z a t i o n of fund r a i s i n g . 138. Ann.Rep., 1920, p.142; V.A.VON, 27 February 1920, 12 March 1920, 30 March 1920, 1 A p r i l 1920, 9 A p r i l 1920, 21 A p r i l 1920, 28 A p r i l 1920, 5 May 1920, 11 June 1920, 14 June 1920; Province, 17 May 1920, p.8. 139. For example, Province, 20 May 1920, p.15; 22 March 1919, p.16. 140. VON, 7 May 1897; Ann Rep., 1903, p.15; 1908, p.5; 1909, p.5; 1910, p.19; 1914, pp.169-170; 1912, p.10. 141. V.A.VON, 16 December 1903. 142. V.A.VON, 2 March 1906; Ann.Rep., 1906, p.61. 143. The annual municipal grants were: 1906, $300; 1907-1910, $600; 1911, $1000; 1912, $1800; 1913, $2000. Ann.Rep., 1906, p.61; Vancouver, Annual Report, 1908, p.17; 1909, p.18; 1910, p.19; 1911, p.21; 1912, p.21; 1913, p.22; 1914, p.22; 1915, p.21; 1916, p.23; 1917, p.22; 1918, p.21; 1919, p.22; 1920, p.22; V.A.VON, 19 A p r i l 1907. 144. Ann.Rep., 1916, p.168. 145. Ann.Rep., 1920, p.95. 146. Ann.Rep., 1916, p.168; 1917, pp.146-147; 1918, p.99; 1919, p.83; 1920, p.95. 147. For example, " . . . much has been done i n . . . g i v i n g up-to-date information as to c u r a t i v e and preventive methods. During the past twelve months, more and more of that knowledge has been d i f f u s e d , the Order, being, as i t were, a large bureau of information on a l l matters p e r t a i n i n g to h e a l t h . Much has been done, and may s t i l l be done, by means of correspondence, but i t i s the personal touch which counts for most i n the V i c t o r i a n Order system." (Ann.Rep., 1912, p. 17 [Report of the Chief Superintendent, Mary Ard. Mackenzie].) 148. For example, Jamison B. Hurry, D i s t r i c t Nursing on a Provident Basis (London, 1898); Charles Richmond Henderson, "World Currents i n C h a r i t y : Theory and P r a c t i c e , " Annals of the American 174 Academy of P o l i t i c a l and S o c i a l Science, v.21 (1903), pp.363-378; B r i t i s h Columbia, Board of Health, Annual Report, 1919-1920, pp.A5-A7; Vancouver, Annual Report, 1906, p.14. NOTES ON FIGURE, CHAPTER 4 Key to abbreviations may be found on page 163. Note on Figure: "Fees for s e r v i c e s " include $2500 paid i n 1919 by the n a t i o n a l V.O.N, "re Tr a i n i n g Nurses" and $3183 paid i n 1920 by the Canadian Red Cross Society as "Tra i n i n g fees" and for s u p p l i e s . Sources for Figure: Ann.Rep., 1902, p.24; 1903, p.34; 1904, p.28; 1905, p.26; 1906, p.61; 1907, p.75; 1908, p.87; 1909, p.127; 1910, p.129; 1911, p.123; 1912, p.159; 1913, p.200; 1914, p.227; 1915, p.215; 1916, p.168; 1917, pp.146-147; 1918, p.99; 1919, p.83; 1920, p. 95. 175 CHAPTER 5 SCHOOL MEDICAL SERVICES This chapter examines the school hygiene program i n Vancouver between 1907 and 1920 and the forces which brought i t in t o being and shaped i t s development. School hygiene programs, which aroused considerable i n t e r e s t i n many B r i t i s h and North American c i t i e s during the f i r s t two decades of the twentieth century, comprise preventive and educational work done i n the schools by medical and dental s p e c i a l i s t s or with t h e i r guidance. The objectives of such programs made them an expression of the widespread contemporary commitment to moral and s o c i a l reform, and t h e i r methods a l l i e d them with science, which, i n at l e a s t some i n f l u e n t i a l c i r c l e s , had come to be seen as a panacea. Thus, i n a d d i t i o n to being of i n t r i n s i c i n t e r e s t , school hygiene programs are worth studying as exemplars of the pervasive c u l t u r a l tendencies j u s t mentioned. These programs were the r e s u l t of a new public h e a l t h o b j e c t i v e which developed i n the l a s t two decades of the nineteenth century. At that time, the use of vaccines and e f f e c t i v e s a n i t a t i o n having brought some of contagious diseases under c o n t r o l , p u b l i c health a u t h o r i t i e s were able to extend t h e i r concern beyond the saving of l i v e s to the cr e a t i o n of good h e a l t h . C h i l d r e n were often the object of t h e i r e f f o r t s , and such child-centered services as prenatal and well-baby c l i n i c s , centers for d i s t r i b u t i n g pure milk, and school hygiene programs 176 177 appeared i n a number of B r i t i s h , French, German, and North American communities i n the l a t e nineteenth century and the f i r s t decade of the t w e n t i e t h . 1 The health of Vancouver school c h i l d r e n i n the f i r s t two decades of the twentieth century was poor by present-day standards. 2 I t seems l i k e l y that 90 percent of the c h i l d r e n examined i n schools had decayed teeth, and that a quarter were s i g n i f i c a n t l y underweight and therefore undernourished. Skin i n f e c t i o n s , enlarged t o n s i l s , enlarged t h y r o i d or other glands, and uncorrected poor eyesight were common complaints. C h i l d r e n who l i v e d i n the overcrowded tenements and shacks of the c i t y came to school d i r t y , i n f e s t e d with l i c e , and i n c i p i e n t l y t u b e r c u l a r . Measles, s c a r l e t fever, whooping cough, mumps, and chicken pox swept through the schools p e r i o d i c a l l y . There were also cases of typhoid, d i p h t h e r i a , and i n f a n t i l e p a r a l y s i s . 3 The development of the Vancouver school hygiene program was supported by a growing p u b l i c awareness of the l o c a l school c h i l d r e n ' s poor state of h e a l t h . While t h i s awareness developed f i r s t among those who had p r o f e s s i o n a l r e s p o n s i b i l i t y for school c h i l d r e n , i t soon led to expressions of concern by parents, the municipal government, and voluntary o r g a n i z a t i o n s . C e r t a i n commonly held a t t i t u d e s encouraged the t r a n s l a t i o n of t h i s awareness into a c t i o n : the i n c l u s i o n of responsiveness to s o c i a l i l l s w i t h i n the d e f i n i t i o n of r e s p e c t a b i l i t y predisposed many c i t i z e n s to support ameliorative programs; the in c r e a s i n g acceptance of female p a r t i c i p a t i o n i n p u b l i c a f f a i r s encouraged l e i s u r e d middle-class women to be a c t i v e i n t h e i r support of s o c i a l reform; and enthusiasm for a p p l i c a t i o n s of science, coupled with 178 a sentimental view of childhood, made school hygiene a p a r t i c u l a r l y appealing cause. Knowledge of pioneer school hygiene programs elsewhere provided both a d m i n i s t r a t i v e models for Vancouver and increased s e n s i t i v i t y to the i l l h ealth of l o c a l school c h i l d r e n . D e t a i l s of e a r l y school hygiene work 4 done i n B r i t a i n and the United States i n the 1880s and 1890s, and i n Germany even e a r l i e r , were a v a i l a b l e to Vancouver doctors through t h e i r p r o f e s s i o n a l l i t e r a t u r e . Moreover, the C i t y Medical Health O f f i c e r , Dr. F.T. U n d e r h i l l , had had the opportunity for more d i r e c t contact with the B r i t i s h experiments while studying for a p u b l i c health diploma i n Scotland i n the 1890s. 5 Schools had been brought w i t h i n the purview of Vancouver p u b l i c hea l t h a u t h o r i t i e s by the f i r s t Health By-law, passed i n 1887, which empowered the C i t y Medical O f f i c e r to v i s i t schools i n order to examine the p u p i l s for i n f e c t i o u s disease and to inspect the b u i l d i n g s for proper v e n t i l a t i o n and s a n i t a t i o n . ^ The h e a l t h of school c h i l d r e n was, however, only one of that o f f i c e r ' s r e s p o n s i b i l i t i e s , and over the years i t received a t t e n t i o n only when e s p e c i a l l y threatened, as, for example, during school-centered epidemics. 7 During the 1903-1904 school year, the Board of School Trustees entered the f i e l d of school hygiene by e s t a b l i s h i n g annual t e s t i n g of school c h i l d r e n ' s v i s i o n a f t e r teachers complained that the poor eyesight of some c h i l d r e n was i n t e r f e r i n g with t h e i r schoolwork.** In 1907, U n d e r h i l l noticed that s k i n i n f e c t i o n was widespread i n the schools, and at h i s suggestion the Trusees authorized more complete medical i n s p e c t i o n of p u p i l s . 9 In e f f e c t , the School Board had thereby taken over a d m i n i s t r a t i v e a u t h o r i t y for the school 179 hygiene program from the C i t y Health Department,^ an<} i t was under t h e i r aegis that school hygiene work would come to maturity. Funding for ordinary school expenditures, i n c l u d i n g those for school hygiene work, was provided i n two ways: a minor part was provided as a P r o v i n c i a l Government grant; the r e s t was determined by the School Board, included i n the C i t y budget, and c o l l e c t e d by the C i t y Treasurer, p r i m a r i l y as taxes. Extraordinary expenditures, although they could be paid out of municipal revenue with Council's permission, were u s u a l l y met by sale of debentures s p e c i f i c a l l y authorized by a vote of the municipal r a t e p a y e r s . 1 1 The f i n a n c i a l r e l a t i o n s h i p between the two elected bodies was not conducive to harmony - Aldermen feared that ratepayers might hold them responsible for the l e v e l of o v e r a l l municipal expenditure although they had no c o n t r o l , apart from t h e i r powers of persuasion, over ordinary school expenses. 1 2 On occasion, the f r i c t i o n inherent i n the l e g a l r e l a t i o n s h i p between Council and Board became o v e r t . 1 3 To e n l i s t f i n a n c i a l support for the school hygiene program, administrators p e r s i s t e n t l y e x t o l l e d i t as a humanitarian s e r v i c e to c h i l d r e n , as a c o n t r i b u t o r to the future strength of the n a t i o n , and as a prudent expenditure which insured that c h i l d r e n were p h y s i c a l l y able to take advantage of the educational f a c i l i t i e s already provided by school t a x e s . ^ 4 Response to such r h e t o r i c v a r i e d with economic c o n d i t i o n s , but was s u f f i c i e n t l y p o s i t i v e to allow school hygiene programs to expand over the period of t h i s study. 180 Thus Vancouver was ready i n 1907 to develop school hygiene s e r v i c e s : awareness of poor health among school c h i l d r e n , f i r s t awakened among those who worked close to them, had spread to others i n the community; the School Board had shouldered a d m i n i s t r a t i v e r e s p o n s i b i l i t y for the school hygiene program; and the costs of t h i s work were acceptable to ratepayers. * * * The school hygiene services which were developed i n Vancouver between 1907 and 1920 f a l l i n to f i v e categories: examination of p u p i l s for h e a l t h problems, p r o v i s i o n of medical and dental treatment, c o n t r o l of the spread of i n f e c t i o u s disease w i t h i n the schools, p r o v i s i o n of hygienic school premises, and education i n personal hygiene. In t h i s s e c t i o n , each of these w i l l be examined i n t u r n , and the ef f e c t i v e n e s s of the program b r i e f l y discussed. i Medical examination of school c h i l d r e n was implemented by the appointment of a School Medical O f f i c e r . This appointmment r a i s e d a number of c o n t r o v e r s i a l issues: how much should be spent on school hygiene work, what l e v e l of p r o f e s s i o n a l competence was necessary for school medical personnel, and whether i t was important to employ female s t a f f to attend female p u p i l s . The C i t y Medical Health O f f i c e r , who had suggested school medical examination, urged that a ph y s i c i a n be appointed. The School Trustees preferred to h i r e a nurse, who would be les s expensive and who, being a woman, would be a s u i t a b l e examiner f or the older g i r l s (some of whom objected to examination by a male doctor). 181 The Trustees gave way on expense and competence, but stood f i r m on sex, appointing Dr. Georgina Urquhart as part-time School Medical O f f i c e r i n 1907. 1 5 Two years l a t e r , the r e l a t i v e importance of competence and sex as q u a l i f i c a t i o n s f or the p o s i t i o n was again a l i v e issue. When Urquhart resigned i n the summer of 1909 to be m a r r i e d , 1 6 the Trustees decided to expand the scope of the school hygiene program and appoint a f u l l - t i m e Medical O f f i c e r . They asked the Vancouver Medical A s s o c i a t i o n to suggest four doctors, two men and two women, to be considered f or the post. When the A s s o c i a t i o n supplied only the names of two male doctors, the Trustees added the names of two female a p p l i c a n t s , i n c l u d i n g L a z e l l e Anderson, the woman they had appointed as i n t e r i m Medical O f f i c e r . Of the four, they chose Dr. F.W. Brydone-Jack, a nominee of the Medical A s s o c i a t i o n . 1 7 The issue of women i n school medical work d i d not die. Within weeks of Brydone-Jack's taking o f f i c e , a nurse was added to the school medical s t a f f . 1 0 In 1914, when a female doctor was given a part-time appointment as A s s i s t a n t School Medical O f f i c e r , there was considerable pressure from women i n Vancouver ( p a r t i c u l a r l y through the U n i v e r s i t y Women's Club) to have older g i r l s examined only by her. The School Board r e s i s t e d t h i s pressure, on grounds of e f f i c i e n c y , u n t i l 1917, when Irene H. Moody received the larg e s t number of votes i n the e l e c t i o n of Trustees and was chosen Board Chairman by her colleagues. She championed the cause of female examiners for older g i r l s , and the Trustees agreed to the appointment of a second female A s s i s t a n t School Medical O f f i c e r , ensuring that a l l g i r l s could be examined by women.19 182 Moody also obtained the appointment of female j a n i t o r s for the g i r l s ' sections of the two high schools. Reading through the euphemisms i n recorded arguments for the l a t t e r appointments, one must conclude that an important duty of the female j a n i t o r s was to help g i r l s who f e l t i l l during t h e i r menstrual periods or had not yet learned to cope with menstruation.^ u The form of medical examination given to Vancouver school c h i l d r e n v a r i e d over time, both i n the l e v e l of q u a l i f i c a t i o n of the examiner and i n the thoroughness and frequency of examination. The eyesight examination begun i n 1903 was given by classroom teachers once a year. 21 Between 1907 and 1909, the school doctor twice a year examined the te e t h , eyes, nose, t h r o a t , s k i n , and h a i r of each p u p i l . 2 2 (Such examination w i l l be r e f e r r e d to here subsequently as "ordinary examination".) In 1910, t h i s ordinary examination 1 was required by p r o v i n c i a l statute to be given to each c h i l d i n the province once a 23 year, but Vancouver was by then i n s t i t u t i n g examinations which were both more frequent and more thorough. Under the system used there u n t i l 1913, a doctor each year gave each c h i l d an examination which checked the heart and lungs as w e l l as the parts of the body included i n the ordinary examination. (This type of examination w i l l be r e f e r r e d to here as "thorough examination".) To save the examining doctor's time, teachers were once again e n l i s t e d as paramedical personnel, t e s t i n g c h i l d r e n ' s sight and hearing before t h e i r thorough examinations and r e f e r r i n g any problems to the doctor. In a d d i t i o n , a school nurse checked each c h i l d about every two months for c l e a n l i n e s s and i n f e c t i o u s j • 24 disease. 183 In the post-boom period between 1913 and 1920, the school population increased f a s t e r than the number of medical o f f i c e r s employed by the School Board, and several adjustments were made, with the r e s u l t that fewer c h i l d r e n received thorough examinations and that teachers and nurses assumed a more responsible part i n g i v i n g examinations. Beginning i n 1913, only three d i f f e r e n t grade l e v e l s received thorough examinations, the others r e c e i v i n g ordinary examinations, and only entering p u p i l s received thorough examinations i n 1915. Beginning i n 1919, nurses rather than doctors gave ordinary examinations to most p u p i l s , and doctors gave thorough examinations to p u p i l s i n only three grades, one i n the beginning, and one i n each of the intermediate and senior l e v e l s of s c h o o l . 2 ^ Teachers assumed r e s p o n s i b i l i t y i n 1913 for recording height and weight of c h i l d r e n i n t h e i r c l a s s e s . During t h i s period of decreasing use of the thorough examination, nurses were v i s i t i n g schools ever more frequently to check for c l e a n l i n e s s and i n f e c t i o u s disease. By 1920, they were v i s i t i n g nearly a l l schools several times a week, and three schools - a l l drawing p u p i l s from poorer parts of the c i t y - had d a i l y v i s i t s by a nurse. 2^ Although regular medical examination had checked for signs of mental d e f i c i e n c y and had d i r e c t e d the most serious cases to s p e c i a l classes i n a c e n t r a l l y located s c h o o l , 2 7 systematic examination for t h i s problem f i r s t became part of the Vancouver school hygiene program when a ps y c h o l o g i s t , Martha L i n d l e y , was added to the school s t a f f i n 1918. She established a c l i n i c where c h i l d r e n thought to be mentally retarded spent a week being tested and observed both at work and at play. Those whom she f e l t would hinder the progress of other p u p i l s or would p r o f i t 184 from t r a i n i n g s u i t e d to t h e i r l i m i t e d a b i l i t i e s were assigned to s p e c i a l c l a s s e s . In the f i r s t two years, over 1100 c h i l d r e n were i n d i v i d u a l l y examined. The f l u c t u a t i o n s i n the form of medical examination can be seen as a p r o g r e s s i v e l y f i n e r tuning of the school hygiene program to the r e a l health needs of the p u p i l s : f i n a n c i a l resources were applied f a i r l y crudely to those needs i n the e a r l y , reasonably a f f l u e n t years; a more precise sense of the task came with experience. T h i s , along with the economic stringency of the depression of 1913, led to a program of medical examination i n which the expanded r o l e of teachers and nurses allowed both economy and day-to-day a t t e n t i o n to the p u p i l s ' h e a l t h . i i School medical examination was i n s t i t u t e d on the assumption that when a h e a l t h prolem was i d e n t i f i e d , i t would receive treatment: school nurses were to n o t i f y parents of any problems discovered through examination. However, many parents were unaware of the importance of treatment, or were not concerned enough to seek i t even when n o t i f i e d . School nurses v i s i t e d homes, and, by teaching and persuasion, encouraged such parents to provide the treatment t h e i r c h i l d r e n needed. 2 9 Parents who were too poor to pay for treatment posed a problem which notices and v i s i t s could not solve, and i n response to which the School Board acted more d i r e c t l y to provide treatment. In 1914, i t e s t a b l i s h e d i n i t s o f f i c e b u i l d i n g a school c l i n i c to t r e a t poor c h i l d r e n for minor contagious diseases and other ailments of the sort for which even parents who could a f f o r d i t refused to seek a doctor's 185 a t t e n t i o n . i l ) From 1915 u n t i l 1920 (the end of the period of t h i s study), more than 1500 cases were treated annually i n t h i s c l i n i c . 3 1 For treatment of serious or d i f f i c u l t cases among poor c h i l d r e n , the School Board depended on other community resources. I n i t i a l l y , r e f e r r a l s for free treatment were made on a r o t a t i n g basis to various s p e c i a l i s t s by the school nurses, a f t e r the l a t t e r had determined that the f a m i l i e s involved were too poor to pay. 3 2 By 1920, most of the r e f e r r a l s for free treatment were made to the Children's C l i n i c at Vancouver General H o s p i t a l . School nurses attended that c l i n i c to receive i n s t r u c t i o n s from c l i n i c doctors regarding treatment for school c h i l d r e n , and then saw that the prescribed treatment was urged upon the pa t i e n t s ' p a r e n t s . 3 3 Programs to miti g a t e other i l l e f f e c t s of poverty on health were undertaken by the School Board with some assistance from c h a r i t a b l e o r g a n i z a t i o n s . School showers were i n s t a l l e d so that c h i l d r e n from deprived homes could clean themselves. 3 4 M i l k was provided at school for malnourished c h i l d r e n by the Imperial Order of the Daughters of the Empire and by Parent-Teacher A s s o c i a t i o n s . 3 ^ C l o t h i n g was provided by the School Board and various c h a r i t i e s , i n c l u d i n g an or g a n i z a t i o n of teachers for providing r e l i e f to needy p u p i l s . 3 * 5 Eyeglasses were provided for poor c h i l d r e n , at f i r s t by the same teachers' r e l i e f o r g a n i z a t i o n , l a t e r by the School B o a r d . 3 7 The Board also provided some s u r g i c a l appliances and wheelchairs, but d i d not give such a i d r o u t i n e l y . 3 8 186 Open-air c l a s s e s , which were popular i n many c i t i e s 3 9 as an integrated remedy for the i l l e f f e c t s of poverty on h e a l t h , were frequently urged upon the Vancouver School Board by school h e a l t h s t a f f and by voluntary associatons. 40 These classes - designed to make d e l i c a t e , anemic, undernourished c h i l d r e n more robust - combined formal education with r e s t , e x e r c i s e , fresh a i r , and p l e n t i f u l nourishing food. The School Board had c e r t a i n classrooms constructed so that they could be converted into open-air classrooms, 4 1 but went no f u r t h e r . In 1919, the Rotary Club took up t h i s p r o j e c t , e s t a b l i s h i n g an open-air c l a s s i n t h e i r Cambie Street free c l i n i c for the tube r c u l a r . There were close connections between t h i s ' c l a s s and the school system, since school medical s t a f f selected c h i l d r e n for the c l a s s , and the school nurses continued to supervise these c h i l d r e n while they were i n the open-air c l a s s . 4 2 The school dental program, the School Board's most ambitious plan of treatment, grew d i r e c t l y from medical examination. As e a r l y as 1909, the School Medical O f f i c e r reported to the School Board on the general neglect of c h i l d r e n ' s teeth. (She claimed that only 10 percent of the pu p i l s showed any sign of a d e n t i s t ' s care. ) 4 3 The idea of a school dental c l i n i c was discussed over several years with the Vancouver Dental A s s o c i a t i o n , which gave i t s b l e s s i n g , but l i t t l e m a t e r i a l support. In 1914, a f t e r the P r o v i n c i a l Department of Education had also approved, a dental c l i n i c was opened i n the Vancouver School Board o f f i c e b u i l d i n g . 4 4 The dental c l i n i c s t arted i t s work on a very small scale -operating only 30 hours a month, 4 5 but s t e a d i l y expanded i t s s e r v i c e s ; 187 i n 1916, i t increased i t s operation to three and a h a l f hours each morning of teaching days; 4^ i n 1917, a second d e n t i s t and dental c h a i r were added to the c l i n i c ; 4 7 i n 1918, a second c l i n i c was opened at Florence Nightingale School to serve the eastern part of the c i t y ; 4 8 and i n 1919, a portable c l i n i c was set up to v i s i t a l l the schools i n t u r n , doing p r o p h y l a c t i c work and g i v i n g temporary treatment. 4 9 By 1920, f i v e part-time d e n t i s t s were being retained by the Board to operate these clinics.5° The number of c h i l d r e n treated also increased s t e a d i l y : i n 1914, i t was 122 (1% of the school population); by 1919, i t had reached 1372 (8% of the school population).51 However, the dental f a c i l i t i e s were r a r e l y able to keep up with the number of c h i l d r e n who had been recommended by the nurses for free treatment.52 p o r example, those who made a p p l i c a t i o n for treatment i n 1917 had not a l l received treatment by September 1918. 5 3 The endless l i n e of patients r a i s e d fundamental questions about who should receive treatment i n the school dental c l i n i c : the Board's o r i g i n a l intent was that i t be used by c h i l d r e n whose parents were too poor to pay for dental care - such c h i l d r e n as those for whom the school nurses arranged free medical care.5 4 However, there were three c l e a r d i f f e r e n c e s between the problem of dental treatment and that of medical treatment: the vast m a j o r i t y of c h i l d r e n needed dental treatment (90% was a frequent estimate55). whereas only a m i n o r i t y of c h i l d r e n needed medical treatment (perhaps 40%);-^ parents were less w i l l i n g to provide dental than medical care, probably because the former was r a r e l y e s s e n t i a l for s u r v i v a l , whereas the l a t t e r was frequently seen to be 57 SS so; and d e n t i s t s were i n short supply, whereas doctors were n o t . J O 188 The net r e s u l t was that there were more c h i l d r e n who needed dental treatment and who were u n l i k e l y to receive i t p r i v a t e l y than the de n t i s t s of Vancouver were w i l l i n g to serve free of charge. The School Board had to consider whether, i f i t undertook to provide needed treatment for poor c h i l d r e n , i t should not also provide for a l l c h i l d r e n who were not r e c e i v i n g needed treatment, and whether, on the other hand, i t s i n d i s c r i m i n a t e p r o v i s i o n of free treatment would not i n t e r f e r e with parents' f i n a n c i a l r e s p o n s i b i l i t y for t h e i r c h i l d r e n . 5 9 The Board had to decide which was less undesirable: allowing c h i l d r e n to s u f f e r from dental neglect or encouraging parents to shun t h e i r r e s p o n s i b i l i t i e s . The School Board's s h i f t i n g p o l i c y with regard to dental fees i n d i c a t e s i t s reluctance to sel e c t e i t h e r of these a l t e r n a t i v e s . Throughout the period of t h i s study, a school nurse had to i n v e s t i g a t e a c h i l d ' s home s i t u a t i o n and decide that the family income was substandard before the c h i l d could q u a l i f y f or treatment i n the free school c l i n i c . 6 ^ xhe l i n e of demarcation was reasonably high - a school d e n t i s t estimated that f u l l y h a l f the c h i l d r e n r e q u i r i n g dental treatment would q u a l i f y . 6 1 I t was low enough, however, that some c h i l d r e n were barred from treatment although t h e i r f a m i l i e s ' income was i n s u f f i c i e n t to pay a p r i v a t e d e n t i s t . 6 2 As e a r l y as 1916, the school d e n t i s t suggested that the school c l i n i c open i n the afternoons to tr e a t such c h i l d r e n , charging a small fee to cover the cost of time and ma t e r i a l s , J nothing was done about the suggestion at that time. However, beginning i n 1920, a modest charge for treatment i n the c l i n i c was introduced (about one quartter the d e n t i s t s ' regular fees, with exceptions being made for c h i l d r e n from the Alexandra Orphanage, the 189 Children's Aid Society, the B l i n d School, the Rotary C l i n i c for Chest Diseases, and for others who were " s p e c i a l cases".* 3 4 i i i The major weapons against the spread of i n f e c t i o u s disease w i t h i n the schools throughout the period of t h i s study were i s o l a t i o n and d i s i n f e c t i o n . A c h i l d found by a school nurse or classroom teacher to be i l l with an i n f e c t i o u s disease was immediately sent home, and had to remain away from school u n t i l an authorized medical examiner c e r t i f i e d him or her free from i n f e c t i o n . I f the c h i l d had measles, s c a r l e t fever, d i p h t h e r i a , or some other dangerous i n f e c t i o u s disease, the teacher or nurse n o t i f i e d both the School Medical O f f i c e r and the C i t y Medical Health O f f i c e r . Those two o f f i c i a l s then worked together to l i m i t the spread of the disease, the School Medical O f f i c e r assuming r e s p o n s i b i l i t y for fumigation of the classroom, burning of i n f e c t e d textbooks, and repeated i n s p e c t i o n of the c h i l d ' s exposed schoolmates during the incubation period, and the C i t y Medical Health O f f i c e r superintending any necessary fumigation, p l a c a r d i n g , or quarantine of the c h i l d ' s home.65 Excl u s i o n from school for i n f e c t i o u s disease i n t e r f e r e d s e r i o u s l y with school work. When there was a case of mumps, whooping-cough, measles, or chicken pox i n a family, a l l i t s c h i l d r e n were excluded from school, even those who had pr e v i o u s l y had the disease. Thus, c h i l d r e n i n large f a m i l i e s could be away from school for nine to twelve weeks while mumps worked i t s way through a family. Although less s t r i n g e n t forms of quarantine were being used before World War I i n Europe and the 190 United States, and although the School Medical O f f i c e r was w i l l i n g as ea r l y as 1913 to consider adoption of such procedures, i t was 1927 before Vancouver did so, seemingly because of objections by the C i t y Medical Health O f f i c e r , who preferred to avoid any chance of reduced p r o t e c t i o n for the c h i l d r e n . 6 6 Before the World War I, c h i l d r e n with i n f e c t i o u s skin disease were also frequently excluded from school for extremely long periods. Even under regular treatment, ringworm could l a s t for months, and pe d i c u l o s i s ( i n f e s t a t i o n with l i c e ) often lasted as long, because parents were not pe r s i s t e n t enough i n removing eggs from t h e i r c h i l d r e n ' s h a i r . In many cases, however, the school medical s t a f f decided that an affe c t e d c h i l d would be allowed to attend school i f he or she was r e c e i v i n g regular treatment. The establishment of the school c l i n i c i n 1915 made the necessary treatment a v a i l a b l e d i r e c t l y from school medical personnel. Over the next few years, the number of c h i l d r e n able to receive such treatment increased as school nurses made more frequent school v i s i t s . 6 7 Vancouver school medical personnel augmented the time-tested i s o l a t i o n and d i s i n f e c t i o n with b a c t e r i o l o g i c a l methods of f i g h t i n g i n f e c t i o u s disease, but t h e i r success i n applying these methods was not uniform. During the second decade of the century, they made increasing use of laboratory diagnostic t e s t s for diphtheria. 6** During the diph t h e r i a epidemic which ran from September to December 1919, they used these t e s t s i n combination with quarantine and innoculation with a n t i t o x i n : throat and nasal swabs were taken from a l l pu p i l s and teachers exposed to the disease; within twenty-four hours, reports on these were obtained from the Vancouver General H o s p i t a l laboratory; and 191 those who had produced d i p h t h e r i a - p o s i t i v e c u l t u r e s were r e t e s t e d , put under quarantine, and given a n t i t o x i n . * 5 9 In co n t r a s t , from 1913 to 1919, only a mi n o r i t y of school c h i l d r e n had been vaccinated against s m a l l p o x , 7 0 even though v a c c i n a t i o n was a v a i l a b l e through the school Medical Department.7-* P u b l i c opposition was such that that s i t u a t i o n p r e v a i l e d despite l e g i s l a t i o n r e q u i r i n g v a c c i n a t i o n , despite the occurrence of smallpox w i t h i n the c i t y , and despite warnings by the p r o v i n c i a l , c i t y , and school medical o f f i c e r s of the t e r r i b l e e f f e c t an outbreak of smallpox might have on Vancouver's unprotected p o p u l a t i o n . 7 2 Because the lack of success i n v a c c i n a t i o n programs was due to publi c o p p o s i t i o n , i t i s worthwhile to examine i n some d e t a i l the i n t e r a c t i o n of pub l i c health a u t h o r i t i e s with parents over the issue of va c c i n a t i o n . In March 1920, a case of smallpox was discovered i n Mount Pleasant School. The in f e c t e d c h i l d came from a boarding home where twenty-seven other c h i l d r e n resided, eighteen of whom also attended Mount Pleasant School. C i t y and school medical personnel joined together to examine a l l the c h i l d r e n of the school for v a c c i n a t i o n marks and to vaccinate those without them. Parents who objected to v a c c i n a t i o n were required to keep t h e i r c h i l d r e n at home during the incubation period. The P r o v i n c i a l Board of Health then determined that the relevant sections of the Health Act should be enforced f or the whole of the c i t y . Thus, a f t e r the Easter h o l i d a y s , each school c h i l d had to present e i t h e r a c e r t i f i c t e of v a c c i n a t i o n or a notarized statement that the parents objected to v a c c i n a t i o n on conscientious grounds. During the ho l i d a y , 2000 c h i l d r e n were vaccinated at free c l i n i c s set up at Vancouver 192 General H o s p i t a l and at f i v e p u b l i c schools. When schools reopened, 3000 c h i l d r e n presented statements of conscientious o b j e c t i o n . Despite these f a c t s , the previous v a c c i n a t i o n of about a quarter of the 18,000 school c h i l d r e n i n the c i t y , 7 3 a n d the p r o b a b i l i t y that yet other c h i l d r e n had been vaccinated by t h e i r family doctors during the h o l i d a y s , i t i s c l e a r that thousands of parents were not complying with the law. Nor did the School Trustees, always s e n s i t i v e to parental opinion, choose to force them to do so. Instead, the School Board ordered school p r i n c i p a l s to admit unvaccinated c h i l d r e n to school, but to urge parents to comply with the P r o v i n c i a l A c t . 7 4 The pattern of c r i s i s , coercion, and r e s i s t e n c e continued on into the 1920s, but with a higher threshold for alarm, more thorough enforcement of v a c c i n a t i o n regulations,and more organized r e s i s t e n c e to such enforcement. For two years a f t e r the 1920 outbreak, there was no s i g n i f i c a n t incidence of smallpox i n Vancouver. However, there were 38 cases reported among Vancouver school c h i l d r e n i n the 1922-1923 school year, 63 during the 1923-1924 school year, and 148 during the 1924-1925 school y e a r . 7 5 In March 1925, the Surgeon General of the United States ordered Immigration O f f i c e r s to refuse entry to people from Vancouver who did not have proof of recent v a c c i n a t i o n . 7 ( 5 In response, the P r o v i n c i a l Government once more required that the c i t y comply with the Health Act; and C i t y C o u n c i l , amidst a storm of objections from a n t i - v a c c i n a t i o n i s t s , r e l u c t a n t l y agreed to do s o . 7 7 The School Board, as required by an o r d e r - i n - c o u n c i l , d i d exclude those c h i l d r e n , teachers, and j a n i t o r s who f a i l e d to present e i t h e r a c e r t i f i c a t e of v a c c i n a t i o n or a statement of conscientious o b j e c t i o n . 1093 p u p i l s were 193 excluded for non-compliance i n A p r i l , and 324 had s t i l l not complied i n September.7** Of those c h i l d r e n r e c e i v i n g p h y s i c a l examination i n 1927 and 1928, only 40% and 46%, r e s p e c t i v e l y , had smallpox v a c c i n a t i o n marks. 7 9 Thus, there continued to be a large number of p u p i l s s u s c e p t i b l e to smallpox, and i t i s not s u r p r i s i n g that cases continued to be found among Vancouver school children.**^ (/> During those years, the school medical s t a f f used both o l d and new methods to prevent the occurrence and spread of i n f e c t i o u s disease among school c h i l d r e n , and parents g e n e r a l l y accepted the assurances of medical s p e c i a l i s t s that the preventive measures they adopted were necessary. However, as the example of smallpox shows, the a u t h o r i t y of experts was subject to popular veto. i v School a u t h o r i t i e s were aware that some d e f i c i e n c i e s i n the school premises themsleves - u n s a t i s f a c t o r y l i g h t i n g , v e n t i l a t i o n , plumbing, or cleaning of the schools - were hazardous to the p u p i l s ' h e a l t h ; and, when the School Medical O f f i c e r reported such unhygienic conditions,** 1 they took what steps they could to remedy them. In most cases, the d e f i c i e n c y was a matter of maintenance, and i t s r e p a i r presented no d i f f i c u l t y . However, some d e f i c i e n c i e s were induced by the growth of the Vancouver school population, which, as fi g u r e 1 shows, was quite steady. The r e p a i r of such d e f i c i e n c i e s - accomodations which were unhygienic because overcrowded and makeshift** 2 - was more d i f f i c u l t , since funds f o r c o n s t r u c t i o n of new schools were obtained through money by-laws r e q u i r i n g the d i r e c t approval of ratepayers. U n t i l 1918, the 194 Figure 1. School Enrollment 195 ratepayers had approved school money by-laws, and schools b u i l t during those years of ample funding had up-to-date arrangements for the health and comfort of p u p i l s - mechanical v e n t i l a t i o n , n atural l i g h t entering from the p u p i l s ' l e f t ( i n many, e l e c t r i c l i g h t as w e l l ) , and i n d i v i d u a l water c l o s e t s which flushed automatically a f t e r each u s e . 8 3 However, i n January 1918, Vancouver ratepayers began a long ser i e s of r e j e c t i o n s of school money by-laws, and the hygiene problems connected with overcrowding grew more acute. School v e n t i l a t i o n became an issue of public debate just as ratepayer resistance to municipal expenditure was s o l i d i f y i n g . The v e n t i l a t i o n i n a number of Vancouver schools had long been i n s u f f i c i e n t . The School Medical O f f i c e r had p u b l i c l y commented on the s i t u a t i o n i n h i s annual report of 1910, c i t i n g i t as a cause of pale faces, headaches and poor powers of concentration, and did so again i n h i s report of 1915. The C i t y Medical Health O f f i c e r had also complained to the School Trustees about v e n t i l a t i o n . 8 4 The Trustees were confronted with schools which had been designed according to one engineering p r i n c i p l e mechanical v e n t i l a t i o n by furnace or a u x i l i a r y fans - and with advisors Q C who favoured another - v e n t i l a t i o n through open windows. J Unfortunately, when a number of the Vancouver schools had been b u i l t , t h e i r mechanical v e n t i l a t i o n systems had not been properly completed (whether due to parsimony, negligence, or less f a s t i d i o u s taste i s not c l e a r ) . The ducts through which s t a l e a i r was blown had been vented, not to the outside, but only to the a t t i c . Thus when the fans were turned o f f , the a i r which had been removed was free to d i f f u s e back into the school rooms, which were without movable windows. 8^ The Trustees 196 had asked for reports and estimates on school v e n t i l a t i o n work,87 a n d had discussed the problem with Aldermen when the 1916 School Board budget was being drawn up. However, since the e f f e c t s of the depression of 1913 were s t i l l being f e l t i n the c i t y , s t r i c t economy was the municipal aim, and schools continued to have v e n t i l a t i o n problems.88 Late i n the winter of 1916, the issue of proper school v e n t i l a t i o n was taken up by the p u b l i c . There was c r i t i c i s m of the School Board by parents who were genuinely concerned about t h e i r c hildren's h e a l t h , by ratepayers who charged the School Board with mismanagement of tax d o l l a r s , and by i n d i v i d u a l s with personal grudges. The issue i n s p i r e d public meetings, fulminations i n the press, delegations to School Board meetings, and a request for r e s i g n a t i o n of the Trustees en masse.**9 The Trustees c l e a r l y f e l t themselves caught between public o u t c r i e s for expenditure and public reluctance to have taxes i n c r e a s e . 9 ^ They forwarded a money by-law for school heating and v e n t i l a t i o n to C i t y Council, and, while waiting for the issue to come before the ratepayers, ordered the school windows rehung so that they could be opened. 9 1 In January 1918, the ratepayers d e l i v e r e d t h e i r v e r d i c t on the v e n t i l a t i o n c r i s i s - the by-law was d e f e a t e d . 9 2 During the years when school money by-laws were being rejected r e g u l a r l y , economic stringency led to overcrowded, stopgap school accommodations which were a far cry from the imposing structures and modern sanitary f a c i l i t i e s which the Trustees had proudly constructed e a r l i e r i n the decade. The enforced lowering of standards i s symbolized by a temporary classroom in the area served by the Charles Dickens School. This f a c i l i t y had no drinking fountains or inside t o i l e t s , and 197 the path through knee-high grass to i t s p r i v i e s was unpaved. 9 3 v Since Trustees, school medical s t a f f , and concerned c i t i z e n s agreed that i l l h e a l t h stems from ignorance, i t was determined that h e a l t h education of both parents and c h i l d r e n should be undertaken as part of the school hygiene program. P r i n t e d m a t e r i a l on good n u t r i t i o n was sent home w i t h c h i l d r e n , 9 4 parents were i n v i t e d to attend the medical examination of t h e i r c h i l d r e n who were coming to school f o r the f i r s t t i m e , 9 5 a n c j school doctors and nurses spoke at Parent-Teacher A s s o c i a t i o n meetings. 9^ Probably the most e f f e c t i v e educators of parents were the school nurses. T h e i r advice on such d i v e r s e matters as i n f a n t feeding, treatment of head l i c e , and improvement of v e n t i l a t i o n 9 7 came to be t r u s t e d even by mothers who had e a r l i e r been i n d i f f e r e n t or h o s t i l e to h e a l t h measures. 9 8 For the education of c h i l d r e n , school time was used f o r t a l k s on home n u r s i n g , personal hygiene, and f i r s t a i d by the school medical p e r s o n n e l , 9 9 and f o r i l l u s t r a t e d l e c t u r e s on care of the t e e t h by d e n t i s t s . 1 0 0 An a f t e r - s c h o o l program f o r education i n c h i l d c a r e , L i t t l e Mothers' League, was set up f o r ol d e r school g i r l s . I t was designed to reduce i n f a n t m o r t a l i t y : d i r e c t l y , by t r a i n i n g g i r l s who were r e s p o n s i b l e f o r t h e i r s i b l i n g s w h i l e t h e i r mothers worked, or who would i n a l l l i k e l i h o o d have c h i l d r e n of t h e i r own to care f o r someday; and i n d i r e c t l y , by t r a n s m i t t i n g i n s t r u c t i o n through these g i r l s to t h e i r m o t h e r s . 1 0 1 The School Medical O f f i c e r had suggested as e a r l y as 1910 that demonstrations on home nu r s i n g and c h i l d care be given to g i r l s i n 198 the upper g r a d e s , 1 0 2 and the Head Nurse reported i n 1914 on L i t t l e Mothers' League classes i n various eastern c i t i e s of Canada and the United States which she had v i s i t e d . 1 0 3 j. t w a s 5 however, the U n i v e r s i t y Women's Club which provided the f i n a l impetus for e s t a b l i s h i n g L i t t l e Mothers' League classes i n Vancouver. A delegation of i t s members appeared before a School Board meeting i n the f a l l of 1916, asking that L i t t l e Mothers' League classes be organized, and i n d i c a t i n g that they had obtained promises from merchants to provide the necessary equipment, and from Vancouver General Hospital nurses to volunteer as l e c t u r e r s . The School Board decided to have school nurses conduct the sessions, but g r a t e f u l l y accepted the o f f e r of equipment, presumably baby clothes, d o l l babies, and the l i k e . In 1917, classes started i n f i v e s c h o o l s . 1 0 4 In 1924, the work of the L i t t l e Mothers'. League was incorporated into the Home Economics curriculum so that a l l g i r l s would be exposed to the material rather than just those who were free to attend a f t e r - s c h o o l m e e t i n g s . 1 0 5 v i How we l l did the school hygiene program achieve i t s o b j e c t i v e to create healthy children? It i s c l e a r that many i n d i v i d u a l c h i l d r e n b e n e f i t t e d from the eyeglasses, surgery, dental treatment, and free milk provided through the school hygiene program. The o p t i m i s t i c annual reports of the school medical s t a f f should be read with caution, but i t seems c l e a r that - as they claimed - school c h i l d r e n came to be cleaner, to take better care of t h e i r teeth, and to have lower incidence of skin disease as a r e s u l t of the school program. 1 0* 3 A comparison of s t a t i s t i c s from school medical examinations i n 1911 (the e a r l i e s t year 199 f o r which comparable f i g u r e s are a v a i l a b l e ) and 1920l°7 supports these impressions, and suggests, moreover, that the h e a l t h of the school p o p u l a t i o n as a whole improved. (See t a b l e 1.) Promotion of h e a l t h r e q u i r e d both means and knowledge, and school hygiene programs provided both. They s u p p l i e d school c h i l d r e n w i t h c e r t a i n resources f o r improvement of h e a l t h , and spread h e a l t h education w i d e l y i n the community: every time a school nurse checked a c h i l d ' s s k i n or h a i r , sent n o t i c e s to parents, or v i s i t e d a home, she was i m p l i c i t l y saying "111 h e a l t h i s a matter f o r concern, do not ignore i t . " Not s u r p r i s i n g l y , the Vancouver school hygiene program d i d not create a community of h e a l t h y c h i l d r e n . Poverty, ignorance, apathy, and i n s u f f i c i e n t r e g u l a t i o n of hazardous c o n d i t i o n s continued to encourage i l l h e a l t h . However, i n a few years, the program d i d achieve important r e s u l t s by s y s t e m a t i c a l l y seeking out the h e a l t h needs of school c h i l d r e n , m a r s h a l l i n g community resources to meet those needs, and teaching the community to value good h e a l t h . The S e c r e t a r y of the P r o v i n c i a l Board of H e a l t h commented repea t e d l y d u r i n g the l a s t years o f the second decade of t h i s century upon the increased understanding and a p p l i c a t i o n of p r i n c i p l e s of good h e a l t h by the people of B r i t i s h Columbia. The wartime experiences of those who served i n the armed forces undoubtedly c o n t r i b u t e d to that c h a n g e , 1 0 8 but i t i s d i f f i c u l t to b e l i e v e that school hygiene programs, which d i r e c t l y touched more of the p o p u l a t i o n , d i d not a l s o p l a y a s i g n i f i c a n t p a r t . 200 Table 1 SCHOOL MEDICAL EXAMINATION STATISTICS FOR 1911 AND 1920 1911 1920 School population 11,385 17,933 Number of examinations and inspections 54,139 83,273 Number of notices sent to parents 5,451 10,401 Cases of s k i n disease ( p e d i c u l o s i s , ringworm, scabies, unclean) 1,223 970 Cases of pulmonary disease 67 74 Cases of anemia 870 120 Cases of heart a f f e c t i o n s 94 287 Cases of enlarged t o n s i l s or adenoids 1,822 1,479 Number with carious permanent teeth 3,280 Number with d e f e c t i v e teeth 3,615 Source: Vancouver Board of School Trustees, Annual Report, 1911, p.65; 1920, pp.35, 47-48; 1922, pp.116-117. 201 In the foregoing d i s c u s s i o n , c e r t a i n r e c u r r i n g influences are discernable i n the p o l i t i c a l process which shaped the Vancouver school hygiene program between 1907 and 1920. Among them, economic c o n s t r a i n t s and current reform i d e a l s are of p a r t i c u l a r s i g n i f i c a n c e . Before elaborating on those, i t i s worth enumerating some ways i n which c h a r a c t e r i s t i c s of leaders i n the school system influenced the program and i t s development. Irene Moody's energy, charm, and determination led the School Board to accept several hygiene measures of s p e c i a l importance to women and g i r l s . The nearly constant presence of at l east one doctor on the Board ensured that school hygiene work had a proponent at the center of d e c i s i o n making. Because of F.W. Brydone-Jack's s e l f confidence, f o r c e f u l n e s s , and genuine i n t e r e s t i n school he a l t h work, the Trustees were kept aware of new developments i n the f i e l d of school hygiene, and of areas of urgent need w i t h i n the Vancouver system while he was School Medical O f f i c e r . In c o n t r a s t , Harold White, who became School Medical O f f i c e r i n 1922, was more hes i t a n t i n making demands and stood rather i n awe of superior a u t h o r i t y . His p a s s i v i t y may have contributed to the lack of expansion of school hygiene work i n the 1920s. The most obvious influence on the development of school hygiene work was the general perception w i t h i n the community of i t s own wealth. The sense of p r o s p e r i t y , common during the economic expansion of the f i r s t dozen years of the century, encouraged the School Board to spend l i b e r a l l y . Beginning with the collapse of the r e a l - e s t a t e and b u i l d i n g boom i n the autumn of 1912, economic conditions i n Vancouver d e t e r i o r a t e d . In 1913 and 1914, investment was discouraged by rumors of 202 war i n Europe and lack of confidence i n the P r o v i n c i a l Government, and a severe f i n a n c i a l c o l l a p s e i n Vancouver ensued. The unemployment rate soared, and the outbreak of war added to the economic d i s r u p t i o n . 1 0 9 In 1916, although the c i t y economy was again expanding, i n f l a t i o n set i n , becoming severe i n 1 9 20. 1 1 0 The sense of economic i n s e c u r i t y induced by these events caused the School Board to economize, and ratepayers to defeat money by-laws. This a l t e r n a t i o n between l i b e r a l i t y and economy i s displayed i n figu r e s 2 and 3. The dashed l i n e i n f i g u r e 2 shows that the actual value of school services purchased began to decline i n 1914, and did not r i s e again u n t i l the end of the War. The dashed l i n e i n f i g u r e 3 may be i n t e r p r e t e d as showing that the same i s true of the value received by ratepayers for t h e i r taxes. The s o l i d l i n e i n that f i g u r e shows, however, that school taxes had an i n c r e a s i n g l y adverse e f f e c t on r e a l property considered as an investment. Many ratepayers d i d not disapprove of f u r t h e r expenditure on education. The d i s t r i b u t i o n of a f f i r m a t i v e and negative votes on the heating and v e n t i l a t i o n by-law i n January 1918 shows that wards i n suburban areas tended to favour i t s passage, while downtown wards d i s a p p r o v e d . 1 1 1 Those vot i n g i n suburban areas were l i k e l y to regard taxes on t h e i r homes as a housing cost comparable to rent.. In downtown wards, many voters owned property for income purposes and were l i k e l y to oppose higher taxes as not merely part of the g e n e r a l l y r i s i n g cost of l i v i n g , but as a decrease i n income. 203 Figure 2. Total Non-capital Expenditure per P u p i l E n r o l l e d 1 1 ! 1 1 ! 1 i • 1 1 ! 1 1 1 1 i \ i M i l M i ! i 1 1 1 1 1 I 1 i | 1 1 i i i M M M i l 1 1 1 I i ; i i i i ! i l l ! 1 | 1 1 i i i 1 I M l ! • \ 1 I 1 i i 1 1 ! A 1 i N. 1 I i i M M « V j I i i M l I \ 1 1 1 i 1 ! I I 1 \ | j ! 1 1 1 M i l 1 1/ h - i 1 \ 1 | 1 1 1 i 1 M M ( i 1 1 1 | 1 1 1 i 1 . • I M i I ] 1 1 1 i 1 * X I I ! i j \ | | 1 / * * * ^ k i l l / I I I I i j \ 1 1 1 fi' \ i i ' r n . i . IS i i i ! V? L i I— i I 1 v 1 1 j I I —i / I i f w r i M i ! I 1 T j I / i 1 I V I I I M I I M M 1 1 > 1 / / 1 1 M M i l l l I 1 1 \ i / i | / l 1 1 M |- i j \ i 1 1 1 \ i i j / 1 ; ' 1 I ! i M M 1 <V i- i 1 ! 1 | / 1 1 1 M M i 1 j | i J{ t i ! i 1 1 i l / i l 1 i I ' i l l l 1 ! i 1 1 1 1 \ / i l l ] 1 1 I I I ! i i : 1 1 i 1 i 1 / M M I i i i i I 1 . j , ; 1 i i i ! I | 1 1 M l ! 1 1 ! i l l l j j i « f > j ^ i 1 1 1 ! I * M M 1 1 M I 1 ! ! i ! (J( i [ 1 / i ^ i | i 1 1 1 i I i l l J i ; ; 1 I / \ i , 1 1 j 1 i I 1 ! i ! i ! 1 | 1 f\ / i 1 1 ! I I 1 j | j ! I i i 1 |\ 1 i ! M M j ! ' : i i 1 1 1 T 1 1 1 I 1 1 i 1 ! M M ' 1 : : i i n i 1 1 / ! 1 1 l i i i 1 i 1 I 1 ! M 1 M i . i i i i i / 1 1 j j M M ! ! I M i l M M i i i I ! I I 1 | M i l I ! ; M . ; ! 1 1 1 1 1 1 1 1 , I | i M 1 I 1 I M M l l > . i i / i ! 1 1 * ~ M i 1 ' OL 1 1 i 1 1 i M ' M 1 i I I I ! ! f ! ! 1 i h K — — — 1 ! | ! 1 1 i i ! 1 i ! M 1 i M ; 1 | i i i M M I I I ! i , [ , 1 y_ 1 1 1 1 i 1 ! M M 1 1 M ; " 1 I / I 1 1 1 i ! i M M 1 j | i i : ! M ! i 1 1 1 1 I M M I 1 ! M i l i ; t j 1 1 1 I ! 1 M i ! 1 1 1 j . ! : i 1 1 i i j | i l l l 1 I 1 i j ; ; , j • ! h ) 1 1 1 i 1 i 1 1 M M 1 ! i 1 ! ; ; '• , i -1 i 1 1 I 1 M M i I i M M ! ; i . 1 i | j 1 M l I- i i ; ! i M M 1 1 I i M M 1 i i 1 1 I 1 1 I | I M M 1 : M : ! i • 1 i 1 I j 1 1 j 1 1 ! M M ! : I i ! M • 1 1 1 1 1 1 1 1 1 ! i l l ! M M 1 ! 1 1 I i I i I 1 M M 1 M i i l l ! 1 i I 1 1 I 1 i j 1 I M M M M 1 i 1 I j i | I 1 1 1 M i l M M i M ! 1 i i t 1 ! 1 1 1 1 M l ! 1 M 1 M M i 1 1 1 i i M M M M i i M 1 i I i I M M M M i M ! M M ! 1 j 1 i I I M M M M i ; ; ! i | 1 1 1 1 i | ! M M M M 1 i 1 1 1 1 I I 1 1 1 M M . M M 1 M ! 1 : i 1 I i i 1 1 1 1 1 1 i j i ! ! j M M . M i l 1 1 M M • ' 1 i i 1 1 1 I i 1 i 1 1 j 1 i M M i i i : : ' M M M 1 i i 1 1 i t i 1 1 1 1 l [ I I I : i i ; 1 i i i i j 1 i i i j 1 j i i 1 M ' i , : M 1 U ) i i I , 1 i i ! I i i J 1 i i i t / i i 1 1 1 I I I i i 1 \ 1 1 I 1 ... f i i -1— — -\ n h o ft a 1 •\ 1 * •3 •fl ( - /• 7 & i n \ •"J X I I - I r i f , 9 V r o 1 J 1 i t y 3 C. J L S: - r : » b r a i ' i i i M M 1 1 I \ M M i 1 i i i ! ! ! 1 I M i l M M ! 1 : i M ; 204 Figure 3. School Revenue Expenditure per D o l l a r of Assessed Valuation 205 As economic conditions d e t e r i o r a t e d , the School Board abolished c e r t a i n supervisory p o s i t i o n s , increased c l a s s s i z e , and shaved d o l l a r s o f f the night-school budget. They also took more d r a s t i c measures, reducing teacher s a l a r i e s by ten percent i n the summer of 1915, and levying fees for attendance at high school i n 1 9 1 9 . 1 1 2 we have seen that the school hygiene program was not exempt from the e f f e c t s of economy: dental fees were imposed, work which had been done by doctors was assigned to nurses, thorough medical examinations were given less frequently, and the s a n i t a r y c o n d i t i o n of the schools suffered from the e f f e c t s of overcrowding. However, i n comparison with o v e r a l l school expenditure, the school hygiene progrm fared rather w e l l . Comparison of figures 2 and 4 shows that while the t o t a l school expenditure per p u p i l dropped more than 25% i n r e a l terms (dashed l i n e ) from 1913 to 1920, the medical and dental expenditure per p u p i l rose s l i g h t l y . During the second decade of t h i s century, school hygiene work was a new preoccupation of both p u b l i c health and educational experts, and was held to be an important i n d i c a t i o n of an up-to-date school system.* 1 3 Since Vancouver School Trustees c l e a r l y were concerned to be up to date (contemporaries claimed that they were a t t r a c t e d to " f r i l l s and f a d s " 1 1 4 ) , t h i s vogue can serve to e x p l a i n the p r e f e r e n t i a l treatment they gave school hygiene work. The i n t e l l e c t u a l climate of the time o f f e r s a deeper explanation. Some powerful reform movements of the day held as fundamental the b e l i e f s that c h i l d r e n were the key to s o c i a l improvement and that health was a public r e s p o n s i b i l i t y . In that c l i m a t e , the Trustees could e a s i l y see t h e i r e f f o r t s to guarantee every c h i l d ' s r i g h t to health a l l y i n g them with a great company of reformers Figure 4. Medical and Dental Expenditure (a) per P u p i l E n r o l l e d (b) as a F r a c t i o n of Total Non-capital Expenditure 1 1 i 1 1 1 1 ! 1 1 M M M M M M I I 1 I - J - < 1 1 1 I I 1 1 | M 1 1 1 < I . i i i 1 \| 1 1 1 ! 1 M M 1 I I 1 |v ) , j f i 1 1 I I I ! / ! \ I 1 1 1 1 ! M M • M l 1 i i 1 1 I I I ! / | 1 I I 1 1 1 I 1 1 ! 1 1 M i l / | 1 1 I 1 1 1 1 1 M i l 1 1 i 1 ( 1 / . 1 / ! v 1 ' A ' M l ! / / 1 1 1 A W 1 \j 1 > ' I ! \ . ' \ 1 1 1 1 / ' 1 i 1 * I —r\ v 1 I * / I i 1 1 ' ! T, 1 1/ ! > 1 ' 1 1 1 | / ! i % r 1 I « n r 1 I i 1 1 1 I I 1 \ 1 \ 1 1 7 , 1 1 % ) / 1 1 1 1 1 I 1 1 1 | I 1 1 i I 1 1 I I s 1 I i ! 1 1 \ / i i 1 \ 1 1 / \ ' / 1 1 11 (C 1 1 1 ! \ 1 a. 1 1 A i 1 \ i 1 f \ 1 <.\ > . ! / 0 V 1 1 \ i 1 I ) 11 A 1, l\ , ( r ><? \U — — / 1 1 1 n t\ \ 1 1 1 J 'J 1 1 J 1 1 1 1 1 I 1 1 1 ( t\ I 1 . 0 0 V. k _ 1 1 i i i \ 1 1 \ 1 I i \ / 1 I | \ / i i 1 r t r " \ i i / I 1 I i 1 1 A 1 ! 1 1 1 1 1 i 1 1 1 I 4 1 ( n ^ r 1 ? n I f f 7 O I I 1 ; t I i T t > r 0 ) L J L ! 1 I i I \ | 1 O i } 1 1 1 u I i 1 | 1 i i 1 1 C i i I 1 1 1 I i I 1 1 1 1 1 1 1 I i v 1 1 M M ! I "i i i I- 1 I j 1 1 1 1 1 1 I | 1 M I i 1 • s I i i i M M 1 j 7 i i l 1 ! 1 1 1 j 1 1 1 I 1 1 I 1 1 1 1 1 ! 1 1 1 1 | ] I M M I j I 1 M i l 1 i 1 i 1 I I 1 1 i 1 1 1 i 1 1 I i 1 1 l 1 1 1 1 1 I 1 1 1 1 1 1 1 1 i l l I I n l l 1 1 1 1 1 M M 1 I 1 \j I i I 1 i I i 1 1 i I 1 1 1 i 1 U - i -207 tempting to create a new and b e t t e r s o c i e t y . NOTES ON CHAPTER 5 Abbreviations: B.C.B.H. B r i t i s h Columbia, Board of Health. Annual Report. B r i t i s h Columbia, Department of Education. Annual Report. B.C.D.E. M.H.O. Vancouver, Health Department. Medical Health O f f i c e r ' s  Annual Report. Man. Comm. V.C.A., Vancouver Board of School Trustees Management Committee. Minutes. Province The Vancouver D a i l y Province. Sch.Bd.Ann.R. Vancouver Board of School Trustees. Annual Report. School Board V.C.A., Vancouver Board of School Trustees. Minutes. 1. For the general development of publ i c health services i n Europe and the United States between 1850 and 1920, see George Rosen, A Hi s t o r y of P u b l i c Health (New York, 1958), ch.6-8 and W.M. Frazer, A Hi s t o r y of E n g l i s h P u b l i c Health, 1834-1939 (London, 1950). For the development of Canadian p u b l i c h e a l t h s e r v i c e s , see R.D. Defries (ed.) The Development of P u b l i c Health i n Canada (Toronto, 1940), and N e i l Sutherland, C h i l d r e n i n English-Canadian Society (Toronto, 1976) , pt.2. 2. The d e s c r i p t i o n given i s based on reports of school medical personnel made a f t e r medical i n s p e c t i o n of school c h i l d r e n had been e s t a b l i s h e d . I t i s reasonable to i n f e r that conditions which were at leas t as poor existe d i n the preceding decade. 3. M.H.O., 1920, p.21; Sch.Bd.Ann.R., 1907, p.24; 1908, p.40; 1909, pp.40-41; 1910, pp.43-45; 1911, pp.54-55, 59, 63, 65; 1912, pp.31-32; 1913, pp.29-33; 1914, pp.29-30; 1915, pp.36-39; 1916, pp.37-40; 1917, pp.37-39; 1918, pp.37-40; 1919, pp.32-33, 37. 4. For general reading on school hygiene work i n B r i t a i n , the United States, and Canada see Rosen, pp.365-374; Frazer, pp.254-258; A.H. Hogarth, Medical Inspection of Schools (London, 1909; Ernest Bryant Hoag and Lewis M. Terman, Health Work i n the Schools (Boston, 1914); What American C i t i e s Are Doing for the Health of School C h i l d r e n V.C.A. Vancouver C i t y Archives. 208 209 (R u s s e l l Sage Foundation; New York, 1911); Sutherland; F.W. Brydone-Jack, "Medical Inspection of Schools" and the d i s c u s s i o n of that paper i n B.C.B.H., 1917, pp.G162-G170; T.V. Hunter, "Medical Inspection from the Standpoint of the Parent, the Teacher and the P h y s i c i a n " and the d i s c u s s i o n of that paper i n B.C.B.H., 1913, pp.U66-U76; F.S. Minns, "The Method of Dealing with Tuberculosis i n the Pu b l i c Schools of Toronto", P u b l i c Health J o u r n a l , v.7 (1916), pp.145-148; L i n a Rogers St r u t h e r s , The School Nurse (New York, 1917), ch.2. 5. U n i v e r s i t y of B r i t i s h Columbia L i b r a r y , Woodward L i b r a r y Memorial Room, "Biographies of E a r l y B r i t i s h Columbia Doctors", ( t y p e s c r i p t , 3 v o l s . ) . 6. V.C.A., Vancouver, By-laws, no.7, sees. 23 and 24. 7. For such an example, see B.C.B.H., 1897, p.1184. 8. B.C.D.E., 1903-1904, p.A56; Sen.B.Ann.R., 1903, p.17. 9. Province, 9 February 1907, p.15; School Board, 8 February 1907. 10. School hygiene programs i n North American c i t i e s were e i t h e r under the School Board, the Health Department, or the coordinated su p e r v i s i o n of both. (What American C i t i e s Are Doing for the Health of  School C h i l d r e n , p.6; Hoag and Terman, pp.305-314; Brydone-Jack, PP.G162-G163; Sen.B.Ann.R., 1914, pp.34-35. The l a s t work c i t e d i n d i c a t e s reasons for p r e f e r r i n g c o n t r o l by the School Board.) 11. J.H. Putman and G.M. Weir, Survey of the School System [of B r i t i s h Columbia] ( V i c t o r i a , B.C., 1925), pp.21, 511. 12. I b i d . , pp.32-33. 13. Province, 24 November 1916, p.17; School Board, 12 June 1916. 14. For example, Brydone-Jack, p.G162; Sch.Bd.Ann.R., 1913, p.13. 15. B.C.D.E., 1906-1907, p.A41; Province, 13 A p r i l 1907 , p.9; 11 May 1907, p.2; 4 J u l y 1907, p.11; School Board, 10 May 1907; 9 August 1907. 16. Although female teachers were required to re s i g n upon marriage, there i s no reason to bel i e v e that Urquhart was forced to re s i g n because she was marrying, since B e l l e Wilson, married and with at lea s t one c h i l d , joined the school medical s t a f f i n 1914. 17. Man. Comm., 17 September 1909; 16 December 1909; School Board, 15 February 1909; 17 May 1909; 21 June 1909; 16 August 1909; 18 October 1909; 21 December 1909; Province, 17 August 1909, p.10; 22 December 1909, p.2. 210 18. School Board, 31 January 1910; 21 February 1910; Man. Comm., 25 January 1910. 19. Sch.Bd.Ann.R., 1917, pp.8, 35; Man. Comm., 25 January 1915, 29 January 1917; School Board, 21 December 1916; Province, 13 December 1916, p.4. The controversy over the sex of school medical personnel was t y p i c a l of that over issues concerning women during the period. Women had been i n c r e a s i n g l y a c t i v e p o l i t i c a l l y on behalf of many womanly i n t e r e s t s . They emphasized women's d i s t i n c t i v e nature, and i n contrast with more recent f e m i n i s t s , sought expanded v o c a t i o n a l o p p o r t u n i t i e s for women by s t r e s s i n g female uniqueness, rather than female e q u a l i t y . The male School Trustees were t y p i c a l of men i n publ i c p o s i t i o n s both i n agreeing that women have d i s t i n c t i v e needs and t a l e n t s , and i n being l e s s f o r c e f u l than women i n pressing for implementation of the l o g i c a l consequences of that p r o p o s i t i o n . 20. Province, 28 March 1917, p.4; School Board, 27 March 1917. 21. B.C.D.E., 1903-1904, p.A56; Sch.Bd.Ann.R., 1903, p.17. 22. Sch.Bd.Ann.R., 1907, p.24; 1908, p.40; 1909, p.40. 23. B r i t i s h Columbia, Statutes, (1910) c.45, "Schools Health Inspection Act". B r i t i s h Columbia was the f i r s t Canadian province to require annual medical examination of school c h i l d r e n . 24. Sch.Bd.Ann.R., 1910. pp.39-40; 1911, pp.53-56; 1912, p.31. 25. Sch.Bd.Ann.R., 1913, pp.29, 35; 1915, p.41; 1916, p.41; 1917, pp.35, 38; 1919, pp.34, 38-39; Man. Comm., 10 September 1918; School Board, 12 December 1916. 26. Sch.Bd.Ann.R., 1913, p.35; 1919, p.38; 1920, pp.42-43. 27. School Board, Reports attached to Minutes, Municipal Inspector's Report, 16 October 1913; B.C.D.E., 1911, p.A41; 1911-1912, p.A48; Man. Comm., 14 September 1911. 28. Man. Comm., 31 November 1917; 12 February 1918; Sch.Bd.Ann.R., 1918, pp.45-46; 1919, pp.44-45. By the end of 1920, there were f i f t e e n s p e c i a l classes i n eleven d i f f e r e n t schools and a s o c i a l worker had been added to the s t a f f to work c l o s e l y with parents of retarded c h i l d r e n , to encourage employers to h i r e graduates of the s p e c i a l c l a s s e s , and to give students who were placed i n jobs c o u n s e l l i n g and support as they made the t r a n s i t i o n from school to work force. (Sch.Bd.Ann.R., 1920, pp.54, 56-58.) This program received glowing praise from s p e c i a l i s t s i n the f i e l d of mental hygiene and was a showpiece of the Vancouver School Board. (Sch.Bd.Ann.R., 1928, p.17; V.C.A., Vancouver Board of School Trustees, Reports Received, Municipal Inspector's Report, 17 May 1920; Putnam and Weir, p.391; School Board, 22 November 1920.) 211 29. Sch.Bd.Ann.R., 1911, pp.54-55; 1913, pp.35-36; T.V. Hunter, pp.U66-U71. 30. B.C.B.H., 1915, p.124; Sch.Bd.Ann.R., 1915, pp.38-39. 31. Sch.Bd.Ann.R., 1915, p.38; 1916, p.40; 1917, pp.38, 41; 1918, p.38; 1919, p.33; 1920, p.47. 32. B.C.B.H., 1913, p.U71. The School Board i n i t i a l l y approached the Vancouver Medical A s s o c i a t i o n , asking what should be done with poor c h i l d r e n r e q u i r i n g treatment. (Man. Comm., 24 January 1911.) A l l evidence i n d i c a t e s that the c i t y ' s doctors were h i g h l y cooperative. (For example, Man. Comm., 9 October 1917; Sch.Bd.Ann.R., 1913, p.35; 1916, pp.39-40.) 33. Sch.Bd.Ann.R., 1919, p.39; 1920, p.46. 34. School Board, 15 June 1914; Vancouver Board of School Trustees B u i l d i n g Committee, Minutes, 4 June 1914; Sch.Bd.Ann.R., 1911, p.59. 35. Sch.Bd.Ann.R., 1920, pp.39-40, 44-45; Man. Comm., 11 May 1920; School Board, 17 May 1920. 36. Man. Comm. 14 January 1914; Sch.Bd.Ann.R., 1919, p.39; School Board, 17 November 1913; B.C.D.E., 1913-1914, p.A64; The Vancouver D a i l y  Sun, 10 February 1915, p.3. 37. Sch.Bd.Ann.R., 1917, p.41; 1919, pp.39-40; 1920, p.47. Man. Comm. 13 September 1918. 38. For example, "Recommend that the a c t i o n of the Municipal Inspector i n purchasing, with the approval of Mr. Welsh, Chairman of the Board, a wheel c h a i r c o s t i n g $20. to be loaned to Mrs. D.B. Webster, 3252-26th Avenue East, [Mr. Webster was a plumber on a c t i v e m i l i t a r y service] for the t r a n s p o r t a t i o n of her c r i p p l e son to school, be endorsed. I t i s to be understood, however, that the present Board do not wish t h i s to be regarded as e s t a b l i s h i n g a precedent." (Man. Comm., 22 January 1916.) Also see Man. Comm. 13 November 1917. 39. Minns; A.J. Greene, "Open A i r School Movement, 1904-1912", P u b l i c Health J o u r n a l , v.3 (1912), pp.547-552; St r u t h e r s , ch.8; Great B r i t a i n , Board of Education, Report of the Chief Medical O f f i c e r , 1909, pp.144-147; 1910, sec.11. 40. Man. Comm., 14 March 1912; 8 June 1915; Sch.Bd.Ann.R., 1913, pp.36-37; 1917, p.36; 1919, pp.35-37. 41. Sch.Bd.Ann.R., 1913, p.36. 42. Sch.Bd.Ann.R., 1917, p.36; 1919, p.35; 1920, p.44; Rotary Club of Vancouver, S i l v e r J u b i l e e Souvenir, 1913-1938 (Vancouver, 1938), p.15; School Board, 29 August 1919. 212 43. Sch.Bd.Ann.R., 1909, p.40. 44. Sch.Bd.Ann.R., 1911, p.57; 1912, p.34; 1914, p.33; Man. Comm., 14 October 1911, 31 October 1912, 16 January 1913, 13 November 1913; School Board, 7 January 1914. The Dental A s s o c i a t i o n d i d o f f e r to examine 200 p u p i l s i n each of three schools to a s c e r t a i n the need for dental treatment. (School Board, 17 November 1913.) De n t i s t s also did free work before the school c l i n i c was set up. Nevertheless, t h i s support was skimpy when compared to the free treatment given year a f t e r year by Vancouver's doctors i n response to requests from the school medical s t a f f . 45. Sch.Bd.Ann.R., 1914, p.33. 46. Sch.Bd.Ann.R., 1916, p.42. 47. Sch.Bd.Ann.R., 1917, p.44; Man. Comm. 29 January 1917, 11 A p r i l 1917. 48. Man. Comm., 2 February 1918. 49. Sch.Bd.Ann.R., 1918, p.44; 1919, p.43. 50. Sch.Bd.Ann.R., 1920, p.91. 51. Sch.Bd.Ann.R., 1914, p.33; 1919, p.43; 1922, pp.116-117. 52. Sch.Bd.Ann.R., 1916, p.42; 1917, p.44; 1918, p.44; School Board, 29 January 1918. 53. Sch.Bd.Ann.R., 1918, p.44. 54. Man. Comm. 14 October 1911; 31 October 1912. 55. For example, Sch.Bd.Ann.R., 1915, p.40. 56. Sch.Bd.Ann.R., 1909, p.41. 57. This reasoning i s supported by the School Medical O f f i c e r ' s statement that parents would not as a ru l e take c h i l d r e n to doctors for minor diseases. (Sch.Bd.Ann.R., 1915, p.39.) A Regina d e n t i s t claimed that 90% of mothers were i n d i f f e r e n t to dental defects i n baby teeth. (W.D. Cowan, "Dental C a r r i e s i n School C h i l d r e n and Dental Inspection", P u b l i c Health J o u r n a l , v.4 [1913], p."602.) Family income seemed to make l i t t l e d i f f e r e n c e i n care given c h i l d r e n ' s teeth. (J.G. Adams, "School Children's Teeth, Their U n i v e r s a l l y Unhealthy and Neglected Condition", Dominion Dental J o u r n a l , v.24 [1912], p.210; A.E. Jamieson, "Inspection and Care of School Children's Teeth", Dominion Dental J o u r n a l , v.23 [1911], p.206. The l a t t e r work describes a v i s i t to a school room " i n the heart of the wealthiest s e c t i o n " of Edmonton. 20% of the c h i l d r e n had received dental a t t e n t i o n , 50% had abcesses, 39 of the 40 c h i l d r e n examined had decay i n e i t h e r temporary or permanent teeth.) 213 58. Man. Comm. 29 January 1917, 10 September 1918. A.W. Thornton, "The Dentist as a S o c i a l Worker", P u b l i c Health J o u r n a l , v.4 (1913), p.75 states that "every dental c o l l e g e on the continent i s being beseiged for graduates." In that same year, i n Vancouver, there was one doctor for every 667 people. (See chapter 2, fig u r e 1, here.) 59. For an example of th'e debate among Trustees on free dental treatment vs. low-fee treatment, see Man. Comm. 29 January 1917. These queries were commonplace i n the period. See for example, "Medical Inspection and i t s Consequences", P u b l i c Health J o u r n a l of Canada, v . l (1910), p.596. 60. Sch.Bd.Ann.R., 1916, p.42. The income per family member per week was not to exceed a s p e c i f i e d sum i f a c h i l d was to q u a l i f y . The sum rose from $3, to $4, and f i n a l l y to $5 by 1920. (Sch.Bd.Ann.R., 1917, pp.8-9; Man. Comm. 9 October 1917, 30 January 1920.) 61. Sch.Bd.Ann.R., 1917, p.45. 62. Sch.Bd.Ann.R., 1916, pp.41-43; 1919, p.40. 63. Sch.Bd.Ann.R., 1916, pp.42-43. 64. Sch.Bd.Ann.R., 1920, pp.13, 50; 1922, p.50. Man. Comm., 24 June 1920, 26 J u l y 1920, 31 J u l y 1920, 10 August 1920. The Chief Dental O f f i c e r suggested free examination and the f o l l o w i n g minimum fees: Cement f i l l i n g s - 50 cents; P o r c e l a i n f i l l i n g s - 75 cents; Simple amalgam f i l l i n g s - $1.00; Compound amalgam f i l l i n g s - $1.50; E x t r a c t i o n (permanent teeth) - 50 cents; E x t r a c t i o n (temporary teeth) - 25 cents; General anesthetic - $3.00; Proph y l a c t i c treatment - 50 cents. (Man. Comm., 10 August 1920.) 65. Sch.Bd.Ann.R., 1911, pp.52-55; 1919, pp.33-35; B.C.B.H., 1917, pp.G156-G157. 66. B.C.B.H., 1913, pp.U59-U61; 1917, p.G156; Sch.Bd.Ann.R., 1927, pp.40-41. The regulations on exclusion were p r o v i n c i a l ones, but p r o v i n c i a l health regulations could be ignored with impunity by l o c a l a u t h o r i t i e s . See for example, B.C.B.H., 1913, pp.U60-U61; 1917, pp. G152, G154-G155. 67. Sch.Bd.Ann.R., 1910, p.43; 1911, pp.54-55; 1913, pp.39-40; 1915, p.39; 1920, pp.42-43. 68. The data a v a i l a b l e i n the reports of the Board of School Trustees are these: Year 1912 1913 1916 1917 1918 1919 1920 Number of swabs taken 372 47 88 117 623 1420 1125 (Sch.Bd.Ann.R., 1912, p.31; 1913, p. 29; 1916, p.39; 1917, p.38; 1918, p.38; 1919, p.33; 1920, p.35.) 214 69. Sch.Bd.Ann.R., 1919, pp.33-34. 70. This statement i s based i n part on inference. The foll o w i n g s t a t i s t i c s are a v a i l a b l e : Percent. P u p i l s with Percent. School P u p i l s of Pop. Vaccination Examined Year Population Examined Examined Marks with Marks 1913 12,990 10,430 80 2889 28 1916 13,805 12,315 89 1253 10 1917 15,069 12,469 83 2798 22 1918 15,849 10,394 66 2734 26 1919 16,955 12,836 76 3002 23 The rate of va c c i n a t i o n for 1914 and 1915 i s not l i k e l y to have been s i g n i f i c a n t l y higher than the rate for the years l i s t e d , since i n 1913 several c l a s s e s , i n c l u d i n g the entering c l a s s , were examined. (Sch.Bd.Ann.R., 1913, pp.29, 34-35; 1916, p.37; 1917, 37; 1918, p.36; 1919, pp.32, 41; 1922, pp.116-117.) 71. School Board, 26 August 1908; Man. Comm. 8 October 1918, 10 March 1920. 72. Sch.Bd.Ann.R., 1911, p.66; 1913, pp. 34-35; B.C.B.H., 1917, pp.G6-G7, G151-G158. 73. See note 70. 74. Man. Comm., 13 A p r i l 1920; Sch.Bd.Ann.R., 1920, pp.36-37. Antipathy to va c c i n a t i o n was strong throughout the province. People are reported to have scratched t h e i r own arms with a needle, or jumped out of windows to escape v a c c i n a t i o n . Objections to va c c i n a t i o n stemmed from a v a r i e t y of motives: h o s t i l i t y to den i a l of an i n d i v i d u a l ' s c o n t r o l over h i s own body, b e l i e f that smallpox vaccine was contaminated with micro-organisms of such dread diseases as s y p h i l i s , leprosy and t u b e r c u l o s i s , fear of blood-poisoning as a l i k e l y r e s u l t of v a c c i n a t i o n , d i s l i k e , on cosmetic grounds, of possessing a v a c c i n a t i o n scar, and suspicions that v a c c i n a t i o n was not an e f f e c t i v e means of immunizaion. Indeed, the frequent use i n the province of impotent lymph for v a c c i n a t i o n , and the s i m i l a r i t y between symptoms of chicken pox and the prevalent mild form of smallpox provided grounds for suspicions of i n e f f e c t i v e n e s s . (V.C.A., The Alarm, O f f i c i a l B u l l e t i n of the A n t i - V a c c i n a t i o n and Medical Freedom League of B r i t i s h Columbia, v . l , no.l (27 March 1925), p.3; B.C.B.H., 1913, pp.U57-U58.) 75. B.C.B.H., 1922-1923, pp. E14-E19; 1923-1924, pp.Q20-Q21, Q24-Q27, 1924-1925, pp.N22-N29. 76. Province, 17 March 1925, p . l ; 18 March 1925, p . l ; 19 March 1925, p.26. 215 77. Province, 21 March 1925, p . l ; 24 March 1925, p.7. 78. Sch.Bd.Ann.R., 1925, pp.17-18. 79. Sch.Bd.Ann.R., 1927, p.43; 1928 s p.48. 80. Sch.Bd.Ann.R., 1927, p.45; 1928, p.51. 81. For example, V.C.A., Vancouver Board of School Trustees, Reports Received, School Medical O f f i c e r ' s Report, 12 A p r i l 1917; School Board, 28 November 1916, 7 January 1920; V.C.A., Vancouver Board of School Trustees B u i l d i n g Committee Minutes, 13 March 1914, 4 June 1914; Sch.Bd.Ann.R., 1910, pp.40-41; 1911, pp.58-59; 1915, p.42; 1919, p.35; 1920, pp.35-36. 82. B.C.D.E., 1912-1913, pp.A54-A55; 1913-1914, p.A62; School Board, 2 October 1920; Sch.Bd.Ann.R., 1920, pp.35-36; 1919, p.35; 1911, p.58; 1910, pp.40-41. 83. Sch.Bd.Ann.R., 1911, p.58. Also see the photographs, Sch.Bd.Ann.R., 1912, pp.33, 35. 84. Sch.Bd.Ann.R., 1910, pp. 40-41; 1915, p.42; Vancouver Board of School Trustees B u i l d i n g Committee Minutes, 27 January 1914. 85. P u b l i c health doctors and engineers divided over the best way to v e n t i l a t e school b u i l d i n g s . T y p i c a l opinions are expressed i n the f o l l o w i n g : "Schoolroom V e n t i l a t i o n " , P u b l i c Health J o u r n a l , v.3 (1912), pp.464-465; W.A. Evans, " V e n t i l a t i o n i n Schools", P u b l i c Health J o u r n a l ,  State Medicine and Sanitary Review, v.2 (1911), pp.319-322; J.F. Goodchild, "The Open Window", P u b l i c Health J o u r n a l , v.4 (1913), pp.3-9; "School V e n t i l a t i o n " , P u b l i c Health J o u r n a l , v.3 (1912), pp.85-86; "School V e n t i l a t i o n " , P u b l i c Health J o u r n a l , v.3 (1912), pp.205-206 [ S i c : two a r t i c l e s with t h i s t i t l e appeared.]; Charles P. Bond, "School B u i l d i n g " , P u b l i c Health J o u r n a l , v.3 (1913), pp.375-377; S.S. Kennedy "Heating and V e n t i l a t i n g Modern School B u i l d i n g s " , P u b l i c Health  J o u r n a l , v.4 (1913), pp.661-664; J.H. Puntin, "School B u i l d i n g s , Some Notes on Hygienic P r i n c i p l e s I n f l u e n c i n g Design", P u b l i c Health J o u r n a l , v.4 (1913), pp.654-660. 86. Sch.Bd.AnnR., 1910, pp.40-41; School Board, 22 March 1917. 87. V.C.A..Vancouver Board of School Trustees B u i l d i n g Committee Minutes, 27 January 1914; Province, 1 December 1916, p.18, l e t t e r from F.W. Welsh; School Board, 31 March 1917. 88. School Board, 16 March 1916; Sch.Bd.Ann.R., 1916, p.8; 89. School Board, 12 December 1916, 27 March 1917; Province, 1 December 1916, p.18; 7 December 1916, p.23; 12 December 1916, p.2; 28 March 1917, p.4. 216 90. School Board, 27 March 1917. 91. School Board, 31 March 1917; V.C.A., Vancouver Board of School Trustees, Reports Received, B u i l d i n g Superintendent's Report, 29 June 1917, 12 J u l y 1917; Province, 10 January 1918, p.13. 92. Province, 11 January 1918, pp.6, 8. The vote on the by-law was 2384 for and 2379 against, but 60 percent was required for approval. 93. School Board, 2 October 1919. 94. Sch.Bd.Ann.R., 1918, p.19. 95. Sch.Bd.Ann.R., 1915, p.41. 96. Sch.Bd.Ann.R., 1920, pp.46-47, 37-38. 97. Sch.Bd.Ann.R., 1911, pp.54-55; 1912, p.18; 1910, p.43; B.C.D.E., 1913-1914, p.A64. 98. Sch.Bd.Ann.R., 1913, p.40-41; 1911, pp.55-56. 99. Sch.Bd.Ann.R., 1917, pp.40-41; 1916, p.42; B.C.D.E., 1911-1912, p.A50. In a d d i t i o n , the classroom teachers incorporated hygiene and f i r s t a i d into t h e i r teaching. These subjects were offered i n the Household Economics summer courses for p r o v i n c i a l teachers, and the school nurses were happy to give i n s t r u c t i o n to teachers. (B.C.D.E., 1916-1917, pp.A71-A73; E l i z a b e t h G. Breeze [Head Nurse for Vancouver schools], "The Nurse - A Teacher of Health i n the Schools", The Canadian Nurse, v.16 (1920), p.650. 100. Man. Comm.,.14 October 1911, 14 A p r i l 1914. 101. A good d e s c r i p t i o n of the aims and a c t i v i t i e s of L i t t l e Mother's groups i s found i n Str u t h e r s , pp.117-128. 102. Sch.Bd.Ann.R., 1910, p.43. 103. Sch.Bd.Ann.R., 1914, p.44. 104. Sch.Bd.Ann.R., 1917, p.40; School Board, 30 October 1916, 12 December 1916; Man. Comm., 2 November 1916, 14 November 1916, 23 January 1917; Province, 5 February 1917, p.8. 105. Sch.Bd.Ann.R., 1928, p.17. 106. Sch.Bd.Ann.R., 1908, p.40; 1913, pp.40-41; 1914, p.30. 107. Sch.Bd.Ann.R., 1911, p.65; 1920, pp.47-48, 35; 1922, pp.116-117. 108. B.C.B.H., 1917, pp.G5-G6; 1918, pp.A5-A6; 1918-1919, pp.B5, B7. 217 109. Margaret A. Ormsby, B r i t i s h Columbia: A H i s t o r y , (student ed.; Vancouver, 1971), pp.365, 367-369, 384; Alan Morley, Vancouver from  Milltown to Metropolis (2nd ed; Vancouver, 1969), pp.134, 136, 144-145, 147-148. 110. Canada, Dominion Bureau of S t a t i s t i c s , I n t e r n a l Trade Branch, P r i c e s and P r i c e Indexes 1913-1936, (Ottawa, 1938), p.103. 111. Province, 11 January 1918, p.8. 112. B.C.D.E., 1915-1916, p.A48, 1919-1920, p.C41; Sch.Bd.Ann.R., 1915, p.27; 1919, pp.15-16; 1920, pp.21-22; School Board, 30 March 1916, 28 November 1916. 113. George Hindle, The Educational System of B r i t i s h Columbia ( T r a i l , B.C., 1918), p.12; Review of Walters S. C o r n e l l , Health and Medical Inspection of School C h i l d r e n , Dominion Medical Monthly and Ontario Medical J o u r n a l , v.38 (1912), p.164. Interest i n school hygiene programs, as measured by the number of a r t i c l e s on that subject i n the Canadian p u b l i c a t i o n , P u b l i c Health J o u r n a l , peaked i n 1913-1914. 114. Sch.Bd.Ann.R., 1916, pp.7-8; Putnam and Weir, p.33. NOTES ON FIGURES, CHAPTER 5 Key to abbreviations may be found on page 208. Note on Figures 2 and 4: Non-capital school expenditure i s the sum of school revenue expenditure and P r o v i n c i a l Government grants to the C i t y for school expenditures. Note on Figure 3: Revenue expenditure per d o l l a r of assessed v a l u a t i o n i s obtained by d i v i d i n g school revenue expenditure by net assessed v a l u a t i o n for t a x a t i o n . The l a t t e r i s the sum of the assessed value of land and the indi c a t e d f r a c t i o n of assessed value of improvements. Sources for Figures: Sch.Bd.Ann.R., 1922, pp.116-117; 1928, pp.162-163; V.C.A., Vancouver, Annual Report, 1907, p.23; 1908, p. 13; 1909, p.14; 1910, p.15; 1911, pp.16-17; 1912, pp.16-17; 1913, pp.18-19; 1914, pp.18-19; 1915, pp.16-17; 1916, pp.18-19; 1917, pp.18-19; 1918, pp.16-17; 1919, pp.16-17; 1920, pp.16-17; 1921, pp.18-19; 1922, pp.18-19; 1923, pp.18-19; 1924, pp.18-19; 1925, pp.20-21; 1926, pp.22-23; 1927, pp.22-23; 1928, pp.22-23, 84-85; B.C.D.E., 1911-12, p.A46; Canada, Dominion Bureau of S t a t i s t i c s , I n t e r n a l Trade Branch, P r i c e s and P r i c e Indexes 1913-1936 (Ottawa, 1938), p.103. 218 CHAPTER 6 INFLUENZA IN 1918-1919 A CASE STUDY IN THE INTERPLAY OF MEDICAL SERVICES In time of epidemic, p u b l i c health s e r v i c e s , u s u a l l y the preserve of a small group of pr o f e s s i o n a l s and dedicated laymen, are thrust i n t o the l i m e l i g h t of p u b l i c a t t e n t i o n and subjected to great s t r e s s . In Vancouver during the 1918-1919 i n f l u e n z a epidemic, the combination of a high l e v e l of public concern and a threatened breakdown i n d e l i v e r y of c r u c i a l medical services r e i n f o r c e d the trend of the preceding few decades toward c e n t r a l i z a t i o n of power over public health matters i n the hands of designated bureaucratic s p e c i a l i s t s , and, p a r a d o x i c a l l y , increased the power of the p u b l i c at large. The working out of these two tendencies can serve as an o u t l i n e for the e v o l u t i o n of the p o l i t i c s of public health i n Vancouver during the epidemic period. * * * The i n f l u e n z a pandemic of 1918-1919 1 was devastating. No other i n f e c t i o n , war or famine has k i l l e d so many i n so short a period of time. M i l l i o n s died w i t h i n a year, and perhaps a quarter of the world's population was i l l with the disease. In B r i t i s h Columbia, the p r o v i n c i a l Board of Health estimated that at least t h i r t y per cent of the province's population suffered from an attack of i n f l u e n z a . 2 219 220 The pandemic was b a f f l i n g for medical a u t h o r i t i e s , both because i t s v i c t i m s were not those they expected, and because the epidemiological pattern i t s e l f was e r r a t i c . The i n f l u e n z a death rate among young adults was s u r p r i s i n g l y h i g h . 3 (Vancouver f i g u r e s support t h i s impression. See Figure 1.) Unlike such communicable diseases as tub e r c u l o s i s and typhoid fever, i n f l u e n z a did not show a c l e a r preference for the poorly fed and poorly housed. C e r t a i n groups -gasworks employees and Cornish t i n miners - were only l i g h t l y touched by the epidemic; others - co a l miners and pregnant women - suffered high m o r t a l i t y r a t e s . The epidemic's rate and pattern of development d i f f e r e d from place to place, as did i t s i n t e n s i t y . Although the pandemic reached both P h i l a d e l p h i a and Pi t t s b u r g h at about the same time, i t crested i n P h i l a d e l p h i a three weeks before i t d i d i n Pi t t s b u r g h . Some c i t i e s , Vancouver among them, suffered three waves of i n f e c t i o n ; others had only one, followed by a se r i e s of inconspicuous r i p p l e s . 4 Death rates ranging from 8.3 to 24.7 per 1000 population per annum were reported for North American c i t i e s . (See Table.) S i m i l a r l y , ususal procedures for c o n t r o l l i n g the spread of epidemic diseases were found i n e f f e c t i v e . While there were proponents of various procedures - ad m i n i s t r a t i o n of vaccine, i s o l a t i o n of the s i c k , segregation and quarantine of contacts, wearing of face masks, d i s i n f e c t i o n of pub l i c b u i l d i n g s - none of these were s u f f i c i e n t l y s uccessful to e n l i s t s o l i d support among those responsible f or public h e a l t h . 5 The i d e n t i t y of the micro-organism responsible for i n f l u e n z a was far from c l e a r . P f e i f f e r ' s b a c t e r i o l o g i c a l work during the 1890 221 Figure 1. Deaths by Age Group, Vancouver b. 1917 (Total Pop. 99,200) Ages 100 T I I T I 80 70 60 50 40 30 20 0 50 100 150 200 250 300 350 400 450 Deaths (Double for 80+ Age Group) 1918 (Total Pop. 105,800) Ages 100 T 90 80 70 60 SO I I T I 20 10 M 'A 0 50 100 150 200 250 300 350 400 450 Deaths (Double for 80+ Age Group) Shaded: Deaths Due to Influenza 1919 (Total Pop. 115,900) 1920 (Total Pop. 123,900) 300 3S0 400 450 Deaths (Double for 80+ Age Group) Shaded: Deaths Due to Influenza Ages 100 T I I T I 50 40 30 20 10 0 50 100 150 200 250 300 350 400 450 Deaths (Double for 80+ Age Group) 222 Table INFLUENZA DEATHS IN VARIOUS CITIES FROM THE BEGINNING OF THE EPIDEMIC TO THE END OF JANUARY 1919 Rate per C i t y Deaths 1000 of Pop. per annum Ph i l a d e l p h i a 14,198 24.7 Baltimore 4,358 23.6 Vancouver 795 23.3 San Francisco 3,616 23.1 Pittsburgh 4,972 22.9 Washington 2,892 20.8 Boston 5,771 19.1 Buffalo 2,742 18.8 Los Angeles 2,969 17.0 Winnipeg 1,021 16.7 Newark 2,348 15.8 New York 27,362 14.4 Toronro 2,284 14.3 Portland 1,363 13.5 St. Louis 3,207 13.4 Chicago 12,400 12.4 Seat t l e 1,328 11.1 Spokane 428 8.3 Sources: A l f r e d W. Crosby, J r . , Epidemic and Peace, 1918 (Westport, Conn., 1976) pp.60-61; Ontario, Board of Health, Annual  Report, 1919, p.236; Winnipeg, Department of Health, Annual Report, 1918, p.10; The Vancouver D a i l y Province, 17 February 1919, p.7; Vancouver, Annual Report, 1918, p.73. \ 223 i n f l u e n z a pandemic had led many medical men to accept the b a c i l l u s bearing h i s name (also c a l l e d Hemophilus influenzae) as the e t i o l o g i c a l agent of pandemic influenza. However, during the 1918-1919 pandemic, P f e i f f e r ' s b a c i l l u s was strangely absent from some cultures made from materials taken from i n d i v i d u a l s who were s u f f e r i n g from what, on a c l i n i c a l b a s i s , was c l e a r l y i n f l u e n z a . This led some b a c t e r i o l o g i s t s to conclude that a f i l t r a b l e v i r u s was the responsible micro-organism. However, since techniques for i s o l a t i n g and i d e n t i f y i n g v iruses were only beginning to be explored, experiments designed to e s t a b l i s h v i r a l r e s p o n s i b i l i t y were not c o n c l u s i v e . 6 Even diagnosis and treatment of influenza were problematical. Symptoms varied i n type, i n s e v e r i t y and i n duration. In some cases body temperature was comparatively low and pulse rate very high; i n other cases the reverse was true. Cases which ended f a t a l l y might experience e i t h e r hiccough and vomiting for several days p r i o r to death or l a s s i t u d e to the point of apathy, with absence of complaint of any kind; complications were common, but were not of one p a r t i c u l a r kind; nor were they more frequent i n servere than i n mild cases. 7 A doctor could not recommend any clear-cut course of treatment. No drug or vaccine could be depended upon to a l t e r the course of the disease. Although nursing care was seen as the sin g l e most important part of treatment, there was an acute shortage of nurses, and although h o s p i t a l s had nurses, a p r e s c r i b i n g doctor had to weigh the deleterious e f f e c t s of moving a patient any great distance against the ben e f i t s of h o s p i t a l nursing care. Even i f a doctor wished to h o s p i t a l i z e a patient, there might well be no bed available.** 224 It i s i r o n i c that, a f t e r decades of spectacular advances in medical knowledge and technology, and a concomitant increase of popular f a i t h i n medicine, the influenza pandemic reduced the medical community to a state of helplessness not unlike that which prevail e d during the epidemics of the p r e - b a c t e r i o l o g i c a l era. * * * The bare facts concerning Vancouver's epidemic are these: Influenza reached Vancouver on 5 October 1918. The disease spread r a p i d l y , the number of reported cases reaching a peak of 522 on 22 October. The deaths peaked f i v e days l a t e r , with 24 reported on 27 October. A second, more v i r u l e n t but less extensive, wave crested on 14 January, when 156 cases and 14 deaths were reported. The l a s t wave culminated with 19 deaths i n the week ending 8 March. By the end of March i t was over. 9 (See Figure 2.) At a conservative estimate, the epidemic sickened 30,000 and k i l l e d 900 of a population of about 100,000. 1 0 The epidemic put tremendous s t r a i n on doctors and nurses, the community's f i r s t l i n e of defence against sickness. Local doctors were quickly swamped. Emergency c a l l s from outside t h e i r p r a c t i c e s made normal at t e n t i o n to t h e i r ususal patients' needs impossible. Doctors worked u n t i l they collapsed from exhaustion, and then c a l l e d upon colleagues to carry on for them. 1 1 The shortage of nurses was acute. Since many had gone to war, there were only 200 graduate nurses normally on c a l l i n the c i t y i n 1918. By e a r l y January 1919, with many i l l with inf l u e n z a or acting as nurses for t h e i r own f a m i l i e s , only 125 of these 225 Figure 2. Course of the Influenza Epidemic Vancouver 1918-1919 500 226 were a v a i l a b l e for duty. Graduate nurses were therefore not generally a v a i l a b l e for home nursing, so t h e i r place was taken by p r a c t i c a l nurses, women who had completed only part of t h e i r nurses' t r a i n i n g , or simply by the ablest members of a f f l i c t e d households. Hospitals r e c r u i t e d women from the community as emergency nurses, sending them into wards to a s s i s t with a mask, a robe, a c l i n i c a l thermometer and as l i t t l e as t h i r t y minutes' t r a i n i n g . 1 2 Governmental response to the community's health needs i n t h i s period of i n s u f f i c i e n t medical resources was l a r g e l y determined by Dr. Freder i c k T. U n d e r h i l l , the C i t y Medical Health O f f i c e r . In 1918, t h i s s i x t y - y e a r - o l d Scot was a f a m i l i a r and respected part of Vancouver's medical scene. He had ar r i v e d i n the c i t y before the turn of the century, was appointed i t s f i r s t f u l l - t i m e Medical Health O f f i c e r i n 1904, and was subsequently president of the Vancouver Medical A s s o c i a t i o n . He had a reputation for firmness and p r i n c i p l e , but was tole r a n t and gentle i n h i s ways. 1 3 U n d e r h i l l had two fundamental purposes i n h i s work during the epidemic period: to co n t r o l the disease's spread, and to ensure that the s i c k and convalescent who needed assistance received i t . U n d e r b i l l ' s p o l i c y for cont r o l of the spread of in f l u e n z a was a conservative one, reminiscent of the s a n i t a r i a n approach popular i n mid-nineteenth B r i t a i n . He advocated an old-fashioned r e l i a n c e on personal hygiene, fostered by public health education campaigns, and on community s a n i t a t i o n . In September, when influenza was c l e a r l y working i t s way toward Vancouver along the l i n e s of t r a v e l , U n d e r h i l l wrote to Dr. Henry Esson Young, Secretary of the p r o v i n c i a l Board of Health, 227 urging that e d u c a t i o n a l b u l l e t i n s be issued throughout the province. W i t h i n h i s own sphere of o p e r a t i o n , he issued e d u c a t i o n a l m a t e r i a l s f o r a d u l t s and c h i l d r e n i n the form of l e a f l e t s and press r e l e a s e s . These urged a d u l t s to avoid crowds, wet f e e t , low n e c k l i n e s , and p u b l i c towels and d r i n k i n g cups, and advocated h i s "three C's" ( c l e a n mouth, c l e a n s k i n , c l e a n c l o t h e s ) , the c o v e r i n g of coughs and sneezes, and the opening of windows f o r v e n t i l a t i o n . For c h i l d r e n , he gave such homely advice as: Don't take a l i c k o f f another c h i l d ' s sucker. Don't play i n muddy d i t c h e s . Swat f l i e s - they c a r r y germs. Keep your school desk c l e a n and t i d y . 1 4 In the e a r l y days of the epidemic, U n d e r h i l l promoted such s a n i t a t i o n measures as fumigation and d i s i n f e c t i o n of p u b l i c gathering p l a c e s , and the adjustment of p u b l i c d r i n k i n g fountains to arc r a t h e r than shoot v e t i c a l l y . 1 5 In view of the i n a b i l i t y of medical science to c o n t r o l i n f l u e n z a , U n d e r b i l l ' s p r e v e n t i v e p o l i c y was s e n s i b l e - capable of improving the general l e v e l of community h e a l t h and u n l i k e l y to do harm. More d r a s t i c measures were taken i n a number of North American c i t i e s d u r i n g the pandemic. These i n c l u d e d p r o h i b i t i o n of any k i n d of p u b l i c meeting, c l o s u r e of s c h o o l s , compulsory wearing of i n f l u e n z a masks, and r e d u c t i o n of commercial hours of b u s i n e s s . 1 6 In f a c t , because of the h i g h l y contagious nature of i n f l u e n z a and the frequency of s u b c l i n i c a l cases, none of these measures was p a r t i c u l a r l y e f f e c t i v e , 1 7 but a number of renowned p u b l i c h e a l t h f i g u r e s favoured I o . . . t h e i r use during the pandemic. As i n f l u e n z a became epidemic i n Vancouver, i t s Government was urged to impose r e g u l a t i o n s f o l l o w i n g these precedents. 228 From the beginning of the epidemic, R.H. Gale, the mayor of Vancouver, advocated town c l o s u r e (a term which i n the event meant the s h u t t i n g of s c h o o l s , churches, r e c r e a t i o n a l f a c i l i t i e s , and the banning of p u b l i c g a t h e r i n g s ) . He was a master of soothing, b o o s t e r i s h statements and i r r e l e v a n t d i s t i n c t i o n s - " I t i s safe to s t a t e that there has been no l o c a l outbreak [of i n f l u e n z a ] , the cases reported being the r e s u l t of contact [with o u t s i d e r s ] o n l y . " 1 9 - which seem to have been d i c t a t e d by h i s p e r c e p t i o n of the p u b l i c mood. As the f i r s t cases appeared i n town, he promised to c l o s e schools i f even one case of i n f l u e n z a developed i n them, and to c l o s e the town " i n every sense of the word" i f the epidemic developed to any e x t e n t . 2 0 However, f o r n e a r l y two weeks, even though the epidemic spread, the mayor and other proponents of town c l o s u r e d i d not p r e v a i l against U n d e r b i l l ' s v i e w s . 2 1 U n d e r h i l l b e l i e v e d that town c l o s u r e would be i n e f f e c t i v e because hundreds would s t i l l gather together d a i l y i n l a r g e i n d u s t r i a l p l a n t s and department s t o r e s . Moreover, he b e l i e v e d i t would be p o s i t i v e l y harmful to the h e a l t h of c h i l d r e n , who, w i t h schools c l o s e d , would be removed from the c l o s e s u r v e i l l a n c e of teachers and school medical s t a f f on guard f o r i n f l u e n z a symptoms, and would i n s t e a d be free to roam the s t r e e t s , exposing themselves to v a r i o u s sources of i n f e c t i o n and n e g l e c t i n g e a r l y signs of the disease. I t was t h i s argument, concerning chidren's h e a l t h , which U n d e r h i l l used most f r e q u e n t l y against proponents of town c l o s u r e . 2 2 The s c h o o l s , however, could be c l o s e d e i t h e r by a d e c i s i o n of the School Board or by a p r o v i n c i a l o r d e r - i n - c o u n c i l given i n response to a request from the munincipal Government. Thus, i f Vancouver's schools 229 were to stay open, U n d e r h i l l had to convince both the School Board and the C i t y Council that h i s p o l i c y was i n the best i n t e r e s t of the public at large. U n d e r b i l l ' s contact with the School Board was mainly through Dr. Robert Wightman, a newcomer to town, who had r e c e n t l y been appointed c h i e f School Medical Officer.23 i n t h e i r frequent conferences, U n d e r h i l l had the advantage of greater age, long f a m i l i a r i t y with the community and an established reputation. It would have been natural for Wightman to defer to h i s judgment, and indeed Wightman did staunchly support U n d e r b i l l ' s open-school p o l i c y . 2 4 As an employee of the municipal Government, U n d e r h i l l had d i r e c t influence on the C i t y Council. On 8 October, when there were s t i l l only a handful of inf l u e n z a cases i n town, he met with Alderman W.R. Owen, chairman of the C i t y Council's Health Committee, Dr. E.D. Carder, A s s i s t a n t C i t y Medical Health O f f i c e r , and Wightman. They decided not to close the s c h o o l s . 2 5 Five days l a t e r , on a Sunday morning, there was a meeting of the executive of the Vancouver General Hospital Board, the President of the Vancouver Medical A s s o c i a t i o n , and members of C i t y C o u n c i l . Although the number of i n f l u e n z a cases was increasing r a p i d l y (there were 100 reported on the Saturday and 217 on the Monday), t h i s meeting approved U n d e r b i l l ' s p o l i c y of keeping the schools open. 2 6 The broader issue of town closure was more c o n t r o v e r s i a l . The i n i t i a l controversy was not within the municipal government (on 10 October the C i t y ' s Health Comittee met and decided that a general closure was not warranted), but between Vancouver and other parts of the province. By the middle of October, sixteen municipal Governments had applied to the province for general closure orders. Responding to 230 expresssions of fear t h a t , i f Vancouver d i d not c l o s e , the contagion would spread to the c l o s e d towns, the p r o v i n c i a l Government pressed Vancouver to conform. E v e n t u a l l y the C i t y of V i c t o r i a went so f a r as to approach the p r o v i n c i a l Government r e g a r d i n g quarantine against Vancouver. 2 7 Young, the Se c r e t a r y of the p r o v i n c i a l Board of H e a l t h , appears to have been sympathetic to the appeals f o r Vancouver to c l o s e . His judgment was l i k e l y to c a r r y weight, not only because of h i s o f f i c i a l p o s i t i o n , but because he was a t a l e n t e d doctor, a former p r o v i n c i a l cabinet m i n i s t e r , and a n a t i o n a l leader i n the f i e l d of p u b l i c h e a l t h . 2 8 In the midst of these r i s i n g pressures f o r c l o s u r e of Vancouver, Gale, Owen, and U n d e r h i l l met on Tuesday, 15 October, and decided that U n d e r h i l l should meet with r e p r e s e n t a t i v e s of the p r o v i n c i a l Government to d i s c u s s the i n f l u e n z a s i t u a t i o n . 2 9 The ensuing meeting, which took place i n V i c t o r i a l a t e r that same day, was a c o n f r o n t a t i o n between two schools of medical o p i n i o n about c o n t r o l of i n f l u e n z a