History of Nursing in Pacific Canada

Report of proceedings of the annual convention of the British Columbia Hospitals' Association. British Columbia Hospitals' Association 1918

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  THE LIBRARY
THE UNIVERSITY OE
BRITISH COLUMBIA   REPORT OF PROCEEDINGS
OF THE
First Annual Convention
OP THE
J3ospitals of British Columbia
HELD AT
VANCOUVER
IN THE
B. C. University Auditorium
ON
June 26th, 27th and 28th, 1918.
Baitrnuurr
G. A. ROEDDE, LTD., PRINTERS
1918  PREAMBLE.
The first Convention of the Hospitals of British
Columbia was called together June 26th, 27th, 28th,
1918, through the suggestion and efforts of the Board
of Directors and Superintendent of the Vancouver
General Hospital. The objects of assembling all the
Hospitals together were as follows:
Firstly—To promote efficiency in the Hospital
work of the Province;
Secondly—To help each other with their struggling problems;
Thirdly—To form a B. C. Hospital Association
and thus unite all the Hospitals in co-operative efforts
to promote hospital development.
These objectives were accomplished, and one of
the most successful Conventions ever assembled was
the result. All attending the Convention were much
profited and greatly pleased. The excellent papers
and keenly interesting discussions follow hereafter.
M. T. MacEACHERN, M.D., CM.,
President of the B. C. Hospital Association. List of Officers of the B. C. Hospital Association, elected last
Convention.
Honorary President Hon. Dr. J. D. McLean, Victoria
President  Dr. M. T. MacEachern, Vancouver
First Vice-President Mr. R. S. Day, Victoria
Second Vice-President Mayor Gray, New Westminster
Secretary  Mrs. M. E. Johnson, Vancouver
Treasurer Dr. C. H. Gatewood, Vancouver
Executive Committee:
Dr. F. X. McPhillips, Vancouver
Miss M. McMillan, Nanaimo
Mr. C. Graham, Cumberland
Miss L. S. Gray, Chilliwack
Miss Pitblado, Kamloops
Mr. M. L. Grimmett, Merritt
Mr. D. G. Stewart, Prince Rupert
Dr. H. C. Wrinch, Hazelton
Miss B. E. Langley, Fernie
Miss H. Campbell, Vernon EXECUTIVE COMMITTEE OF THE BRITISH COLUMBIA HOSPITAL ASSOCIATION  PROGRAMME
WEDNESDAY, JUNE 26th, 1918.
10:00 A.M.-12:00 Noon.
Prayer—By Major The Rev. C. C. Owen, CCS.
Address of Welcome—Civic—By His Worship Mayor Gale.
Address of Welcome—Board of Directors of the Vancouver General
Hospital—By Dr. C. H. Gatewood, Chairman of Board of Directors, Vancouver General Hospital.
Convention Address—By Dr. M. T. MacEachern, Superintendent of the
Vancouver General Hospital.
Address—Subject, "Hospital Standardization"—By Dr. R. E. McKechnie,
F.A.C.S., Member of Consulting Staff, Vancouver General Hospital."
Address—Subject, "The Hospital; Past, Present, Future"—By Dr. A.
S. Munro, Member of the Board of Directors, Vancouver General Hospital.
Paper—Subject, "The X-Ray. Department"—By Dr. W. A. Whitelaw,
Radiographer to the Vancouver General Hospital.    Discussion.
2:00-4:00 P.M.
Paper—Subject, "Problems of the Hospital in Outlying Districts"—By
Dr. W. R. Wrinch, Superintendent Hazelton General Hospital.    Discussion.
Paper—Subject, "Small Economics in Hospitals"—By Miss J. F. Mac-
Kenzie, R.N., Lady Superintendent of "The Provincial Jubilee Hospital,"
Victoria, B. O   Discussion.
Paper—Subject, "Hospital Architecture," by Mr. J. A. Benzie, Architect, Vancouver, B. C   Discussion.
Paper—Subject, "Standardization of Hospital Equipment and Supplies"
—By Mr. R. B. Leders, Purchasing Agent for the Vancouver General Hospital.   Discussion.
4:00-5:00 P.M.
Round Table Conferences—Conducted by Miss G. N. Sinclair. Superintendent Royal Columbian Hospital, New Westminster, B. C, and Miss J.
F. MacKenzie, Superintendent of Nurses, Provincial Jubilee Hospital, Victoria, B. C.
Evening Session—8:00-11:00 P.M.
Address—Subject, "The Hospital as a Community Service"—By Dr. H.
E. Young, Secretary Provincial Board of Health.    Discussion.
Address—Subject, "The Duty of the State to the Individual"—By Mr.
J. J. Banfield, Member of the Board of Directors, Vancouver General Hospital.    Discussion.
Address—Subject, "The Public Health Problem of this Province"—By
Dr. R. H. Mullin, Director of Laboratories, Vancouver General Hospital.
Discussion.
Address—Subject, "The Tuberculosis Problem of the Province"—By Dr.
A. P. Proctor, Major C.A.M.C   Discussion.
THURSDAY, JUNE 27th, 1918.
10:00 A.M.-12:00 Noon.
Paper—Subject, "The Elimination of Chronic Hospital Cases by Proper
Dental Diagnosis and Treatment"—By Dr. Milton Jones, Vancouver, B. C.
Discussion.
Paper—Subject, "Financing the Hospital"—By Mr. M. L. Grimmett,
Member of the Board of Directors, Merritt Hospital.   Discussion.
Paper—Subject, "Hospital Accounting"—By Mr. Geo. S. Haddon, Managing Secretary the Vancouver General Hospital.   Discussion. Paper—Subject, "Infectious Diseases and the Control of Same"—By
Dr. E. D. Carder, Physician to the Infants' and Children's Wards, the Vancouver General Hospital.   Discussion.
Paper—Subject, "The Hospital Laboratory"—By Dr. R. H. Mullin,
Director of Laboratories, Vancouver General Hospital.   Discussion.
2:00-4:00 P.M.
Paper—Subject, "The Standardization and Affiliation of Training
Schools in British Columbia"—By Mrs. M. E. Johnson, Superintendent of
the Bute Street Hospital.   Discussion.
Paper—Subject, "The Modern Trained Nurse"—By Miss Maude MacLeod, Superintendent of Nurses, Vancouver General Hospital.    Discussion.
Paper—Subject, "The Food Problem of Today as It Affects the Hospital"—By Miss G. Sinclair, Superintendent of the Royal Columbian Hospital, New Westminster.   Discussion.
Paper—Subject, "The Hospital Dietary"—By Miss E. Kinney, Dietitian
to the Vancouver General Hospital.   Discussion.
Paper—Subject, "The Assistance of Publicity to the Hospital"—By Mr.
R. S. Somerville, Member of the Board of Directors, Vancouver General
Hospital.   Discussion.
4:30-5:30 P.M.
Round Table Conferences—Conducted by Miss K. Campbell, Superintendent of Cumberland Hospital, and Miss M. P. MacMillan, Superintendent of Nanaimo Hospital.
5:30-12:00 P.M.
Capilano Motor Ride and Dinner at Canyon View Hotel, as Guests of
the Board of Directors, Vancouver General Hospital.
FRIDAY, JUNE 28th, 1918.
10:00 A.M.-1:00 P.M.
Address—Subject, "The Workmen's Compensation Board"—By Mr. E.
S. H. Winn, Chairman of the Workmen's Compensation Board; Dr. G. B.
Hall, Medical Officer of the Workmen's Compensation Board.   Discussion.
Paper—Subject, "Maternity Work in the Small Hospital"—By Dr. W. B.
Burnett, Obstetrician to the Vancouver General Hospital.   Discussion.
Paper—Subject, "The Hospital Pharmacy"—By Mr. E. Hall, Pharmacist
to the Vancouver General Hospital.   Discussion.
Paper—Subject, "The Administration of Anaesthetics"—By Dr. T. H.
Lennie, Chief Anaesthetist to Vancouver General Hospital.   Discussion.
Business—Election of Officers, By-Laws—2:00-6:00 P.M.
Motor Ride and Visit to Royal Columbian Hospital, New Westminster,
and Provincial Mental Hospitals.
8:00-10:00 P.M.
Convocation of Nurses, Vancouver General Hospital, to which all visitors to the Convention are invited.
GOD SAVE THE KING. REPORT
The Convention was called to order at 10 a.m. by Dr. C. H.
Gatewood, Chairman of the Board of Directors, Vancouver General Hospital.
Prayer by Rev. H. G. King.
OPENING  DEVOTIONAL  SERVICE.
Conducted  by  the  Rev.  Harold  G.  King,   Rector  of  St.  Paul's   Church,
Vancouver, B. C
Scripture Reading—Ecclesiasticus XXXVIII, 1-14.
The Lord's Prayer.
Prayers adapted from the Manual of the Guild of St.  Barnabas for
Nurses:
"O Lord God Almighty, pour down, we pray Thee, upon all those
engaged in the care and nursing of the sick, a spirit of tender love to
Thee, and of pitiful compassion towards all sufferers, Be Thou in every difficulty their Guide, in temptation their Defence, in weakness their
Strength, in weariness their Rest; that transformed by Thy Spirit into
the image of Thy holiness, they may finally attain to that blessed Home
of everlasting rest and joy, where Thou, with the Son and Holy Spirit,
livest and reignest, One God for ever and ever. Grant this, O heavenly
Father, for Jesus Christ's sake,' our blessed Lord and Saviour.   Amen.
O Father of mercies, and God of all consolation, bless we pray
Thee, and comfort the sick to whom Thou hast sent us, and sanctify
to them their pain, that, being cleansed from their sins, they may serve
Thee with their whole heart, and be one day counted worthy to attain
to Thy everlasting kingdom; through Jesus Christ, our Lord. Amen.
The grace of our Lord Jesus Christ, and the love of God, and the fellowship of the Holy Ghost, be with us all for evermore.   Amen.
ADDRESS  OF WELCOME.
Board of Directors of the Vancouver General Hospital,
By Dr. C. H. Gatewood, Chairman of Board of Directors of the
Vancouver General Hospital.
Ladies and Gentlemen:
It affords me great pleasure and honour to welcome you here
on the occasion of the first Convention of Hospitals for British
Columbia ever held, and this welcome I extend to you is on behalf of the Board of Directors of the Vancouver General Hospital,
which Board, in conjunction with the Superintendent, conceived
and developed the idea of this meeting. In doing this they felt
that they were accomplishing something which was of great need
in this Province, and realizing that the getting together to discuss our mutual difficulties, to organize for greater efficiency, in
short, to improve our hospitals in every way possible, was a good
work to launch. I welcome you whether from large or small hospitals, whether
from Protestant or Catholic. Remember, we are all here with one
object and one purpose, and the next three days will be busy ones
for us all and we must get right down to business every minute
that we are here.
I extend to you the freedom of the Vancouver General Hospital and I feel sure that this is the sentiment of all other hospital
representatives in the city who are present at the Convention.
I feel sure that when we finish this very excellent programme
you will all say it has been good for you to be here. I trust that
the enthusiasm which has marked the opening of this Convention will permeate throughout the entire sessions, and a good result will surely follow.
The first order of business which it is my honor to put before the Convention is the appointing of a Chairman and Secretary for the Convention sessions.
Moved by Dr. Henderson, seconded by Mr. Stewart:
THAT Dr. C. H. Gatewood be the Chairman for the Convention sessions;
Carried.
Moved by Dr. R. H. Mullin, seconded by Mr. G. Haddon:
THAT Miss Jessie E. McKenzie of the Provincial Jubilee Hospital, Victoria, be appointed Secretary of the Convention sessions;
Carried.
DR. GATEWOOD—
I thank you indeed for the honor you have conferred on me
in appointing me as Chairman. As we have a long programme
ahead of us, I will not take up any further time. I regret to inform
you that Mayor Gale of the City of Vancouver cannot- be present
this morning but may be here at one of our later sessions. I have
much pleasure now in calling on Dr. M. T. MacEachern, Superintendent of the Vancouver General Hospital, for the Convention
address.
CONVENTION   ADDRESS
By Dr. M. T. MacEachern, General Superintendent, the Vancouver General
Hospital,
—to—
The Delegates of the B. C. Hospital Convention:
June 26th, 1918.
For the first time in the history of this Province have the various
hospitals been summoned together. This, therefore, is truly an unusual
occasion, which without doubt, marks a new era in hospital work and advancement in this Province. You have come from far and near all over
this Province, having dropped your many and varied activities and are
here assembled to receive and to dispense information which will throw
light on the many and varied difficulties and problems of your respective
hospitals. You are here assembed, regardless of the kind of hospital you
represent, whether small or large, private or public, maternity or general, Catholic or Protestant. You are here assembled with fine motives and
purposes, and no doubt you will leave this  Convention not disappointed
8 but greatly profited, as everything possible has been done to give you a
useful and pleasant time.
The Board of Directors of the Vancouver General Hospital together
with the official staff have been delighted to arrange this meeting, realizing that, like ourselves, you all must have difficulties and problems to meet
daily, and some of these are so perplexing that assistance for their solution is needed. Through this "get together" meeting, therefore, we can acquaint ourselves with improved methods of hospital management, leading
to greater efficiency and economy. You all will benefit in various ways,
but there is one we must mention in common particularly, and that is in
the enthusiasm you will carry back again to take up your respective duties.
You will go back better hospital administrators and workers.
The hospital of today is much more important than of former years.
The functions of the hospital are indeed many, and much wider in their scope
than formerly.    One writer summarizes the functions as follows:
1. The Care of the Sick;
2. The Training of Doctors and Nurses;
3. The Extension of Medical Knowledge;
4. The Prevention of Disease.
I could say a great deal of each of these functions, but the whole trend
of papers and discussion in our Convention will cover this. The hospital
should be a health center in your community, and from it should radiate
all the health interests of the community. Each institution has a certain
obligation to every patient that enters its doors, and that obligation is—to
get the patient well and back to normal as soon as possible. A hospital
is nothing more than a factory in which the broken down and diseased are
repaired as far as human skill will permit.
This is a day of conservation and large economy problems are facing
our country constantly. The hospital has an economic function or obligation to fulfill. All patients within its doors are non-producers, and the
work which they were doing when in their usual health must now be carried on by some other person. The patient also requires someone to look
after him and a doctor to prescribe treatment. Therefore, the sick patient affects the producing capacity of four people. Hence the economic
problem which each hospital must handle. Therefore, the hospital must
extend to that patient such a service that they may be speedily returned to
health and producing capacity, and you must as hospital administrators and
workers, realize your obligation to the patient and that the result to be obtained as quickly as possible means that you must surround yourselves
with capable executive officers or assistants and your institution must be
efficient in every respect and a "hospital" in the truest sense of the
word.
Many of you represent institutions of from five to one hundred beds,
and right here I desire to impress upon you the importance of such institutions. Every community of one thousand to two thousand people possibly
have one of these hospitals. Some of you may have thought that your institution was so small that you should not attend the Convention or that
perhaps you shoud not enter into the discussions or that you should not
give a paper. I want to emphatically impress you that this is not the case
and that your presence here is of vital importance and the institution which
you represent is most important. No matter what institution you came from,
no matter what size it is, yet they all have the same purpose, the same
duty, the same obligation to perform, and that is primarily, "the care of
the sick." Hospitals may be classified into many kinds and in fact, the Hospital Standardization Committee has many classes, but for all practical
purposes there is only one and that class includes such institutions which
give to the patient the service which they require and which the patient
deserves. From the outset of this Convention, therefore, realize that you
represent an important institution and in your opinion, the most important
of all.
Throughout this Convention I imagine I hear from time to time something like this,, "Oh, there is no use discussing that.   We can't do it in our institution." After this Convention the word "can't" will be dropped
from your vocabulary so far as hospital administration is concerned.
Every subject discussed will have bearing on your work, and it is one
of the fundamental principles laid down in this Convention, that all papers
and discussions must be practical and applicable to the institutions represented.
The hospital management today resolves itself into a profession or
art, and demands administrators of good executive ability as well as technical knowledge. Good management can only come when there is good
organization and system. Just as the large enterprises or railways must
have organization and system, so must you in your hospitals, whether
large or small, and you must carry this organization and system down
through the smallest details even. The Medical Profession using your hospital wants the highest grade of efficiency therein. A good service means
"Efficiency" and "Economy," and no institution is efficient which does not
perform all its functions thoroughly without waste. You have never stopped
to realize the amount of waste around the institution, and it is not all
found in the garbage can. You waste the time of the directors and trustees when you cannot give them a comprehensive idea of the work done
and the unit of cost at any time. You waste the time of the attending doctors when you cannot provide adequate facilities to carry on their work.
You waste the time of the patients when you cannot give them the advantage of such facilities as will hasten recovery. You waste the time
of your nurses by not having definite set standard ways of doing things,
when you make them do the same thing over and over day in and day-
out, work which could be done by an ordinary person. You waste money
when you purchase useless articles or equipment that are far from the
standard supplies as needed. You waste money, time and energy by employing inexperienced persons in responsible and executive positions. You
waste money, both for the patient and the hospital, when you keep convalescent patients in beds which should be occupied by acutely ill persons. I might go on and on but I trust that you will all analyze your institution along the same lines as I have quoted. Therefore, we are holding
this Convention to have all the hospitals fall in line with a motto of Efficiency. Then only will you get results. It doesn't always require expenditure of money to produce efficiency. This Convention will show you
through their exhibits that considerable equipment and supplies at least,
can be obtained for very little money, and a great deal can be made at
home.' During this Convention I trust that you will spend all possible
time examining the equipment and supplies here assembled, and get acquainted with standard goods and prices. The dealers in hospital supplies in this city have been very good to come up here and show their lines
at indeed, a great deal of trouble and expense to themselves.
You will therefore realize what I said in a recent letter to you, that
we have a great deal to accompish at this Convention, and you will note
what a very heavy" programme we have, covering every phase of hospital
work. I trust that you will all take an active part in the discussions, and will
ask you to be as brief as you can and to the point. If we should run
through this programme quicker than we have planned, we require the
time for Round Table Discussions.
DR. GATEWOOD—
The next paper on the programme is, "The Hospital, Past,
Present and Future," by Dr. A. S. Monro, Major C.A.M.C., Director
of the Vancouver General Hospital. As the Doctor has been called
out of the city, I am going to ask Dr. MacEachern to read his
paper.
THE   HOSPITAL—PAST,   PRESENT   AND   FUTURE.
By Dr. A. S. Munro, Major C.A.M.C, Director Vancouver General
Hospital.
To most of us the pastime of indulging in memories of the events and
conditions of former days only serves to  accentuate more strongly our
appreciation of present day advantages, not only of things in general but
10 of hospitals in particular. A retrospect, however pleasant it may be, affords
to us but a tithe of the fascination as compared with the dazzling prospects
that a view of the future unfolds.
Experience, the best of all teachers, has been our mentor in the past
and has enabled us to overcome many a difficulty and over-throw obstacles
that seemed at the time almost unsurmountable.
While feeling a justifiable pride in the excellence of our present-day
hospital attainments, we remain yet unsatisfied and press on with strength
renewed to attempt a solution of the many problems that confront us in this
work.
Gathered here today from every quarter of this great Province are
those who have identified themselves with the work of caring for the sick
and suffering through the agency of the hospital. You will listen to the
papers and addresses given on the many and varied aspects of hospital
management and will, I hope, discuss them freely, and finally by all getting together, find a solution that will lead to a better and more efficient
service.
A broad survey then of the hospital question, comprising as it does
the past, present and future, may profit all at this juncture and, it is hoped,
will stimuate us to renewed effort in the future.
It is within the memory of most of us, and I need not go back more
than two decades, to recall the great change that has taken place in public
opinien towards the hospital- Then it was a matter of life or death, such
as a severe accident or illness that required surgical treatment that compelled the unlucky one to be sent to hospital. How the friends and neighbors talked about it and commiserated with the relatives that had such
a calamity of having to send their dear one to the hospital had occurred!
Or perchance the sick one had no home but belonged to the great army
who have no settled abode, and then of course the hospital was the only
place for such, but how he was pitied.
No self-respecting woman, how evermuch she dreaded the coming ordeal
of maternity or the upsetting of her household, resultant upon its advent,
would entertain for a moment the suggestion of going to the hospital.
The hospital was only for the outcast and the unfortunate.
To ask parents to place their children in the hospital for the purpose
of having, say an operation for removal of the tonsils done or any other
common affection, was often sufficient to immediately bring about a
change in medical attendants and the physician who had the temerity to
propose such a thing became the subject of adverse criticism by the community at large.
Public opinion, however, was not altogether wrong in the attitude it
assumed towards the hospital. The facilities afforded by many of them
for the caring for the sick were no better or even as good as that approached by a well appointed home. 'The accommodation in many institutions provided only for the homeless, the unfortunates or those who required a major surgical operation, and even in the latter case, every effort
was made if the patient had a good home to have the operation done there
rather than go to the dreaded hospital.
It was not uncommon in this city no longer than fifteen years ago to
see major operations performed at the home of the patients. As for the
minor ones, only the last five years has seen them transferred from the home
to the hospital. What then has brought about this marvelous change of
opinion in the public mind towards the hospital? The change is due to
better service and the hospital is not alone in this respect. We see on
every hand the improvement and efficiency of the public utilities and the
improved service the public are receiving from them.
In the case of the hospital the factors most influential in molding public
opinion were:
First—Improved accommodation and equipment. This meant new buildings that provided for all classes of the community, the private room, semi-
private and semi-public beds, and better general wards. The hospital now
took on the aspect of a fine home. The surroundings were no longer dull
and dreary but on the contrary a homelike comfort was aimed at and the
11 patient made to feel his stay in the hospital would be as pleasant as circumstances would permit. Special attention was also given to the dietary
of the patient and today this important branch of the service is in the hands
of a specially qualified dietitian. It is now possible, when the condition of
the patient permits, to have as varied a meal as can be obtained in any
well appointed restaurant.
Second—Better nursing. Of more importance even than accommodation is the quality of the nursing service provided. In this respect the
public feel that a high state of efficiency has been reached in the nursing
profession and have shown their confidence by demanding not only in the
hospital but in the home the elimination of the untrained nurse. Nurses
are like other people. Some are better adapted for certain work than others. In the hospital this specialization of service is carried out to a large
extent, and the larger the institution the greater the need of it, with consequent advantage to all concerned. The public understand the advantage
of this and appreciate it accordingly.
Third—Advance in medical and surgical science requiring expensive
equipment and laboratory facilities only to be found in connection with
modern hospitals, has been an important factor in the influencing of public
opinion in favor of the hospital. A hospital composed of buildings; beds,
furniture, etc., and without up-to-date laboratories, X-Ray departments and
operating rooms, is nothing more than a glorified boarding house. The
public appreciate the value of these essential features in a hospital and consequently those who are sick are not only willing but anxious to go where
the fullest facilities are offered for getting them well. The people are
learning that the essential preliminary to intelligent treatment is a correct
diagnosis and in many cases it is necessary to go to the hospital to have this
made.
In the treatment of disease, the use of medicine or the knife is not the
only means of even the most desirable in many cases. We know that the
X-ray, radium, electricity in various forms, hydrotherapy, thermotherapy
and massage are essential to successful results in the treatment of many
of the ailments. This demands an expensive and costly equipment and the
hospital is the place the public look to to provide these facilities. Above
all, the motive animating those who are responsible for the care of the sick,
from the hospital director down to the humblest orderly, is one of service.
No hospital however well equipped and staffed can do its best work without
this atmosphere of service mingled with a spirit of kindliness and sympathy-
pervading the entire institution. The public are quick to appreciate all these
various factors that go to make up the hospital of today, and equally quick
to criticize those who are responsible for their absence.
The future of the public hospital and the place it will occupy in the
esteem of the community in which it is located will depend largely upon the
quality of service it can render to those who require it.
The displacement of the candle and the kerosene lamp by electric light;
the horse vehicle by the power car; the old back-yard well by the modern
waterworks, are all too well known to necessitate any enlargement on my
part upon the advantage of these changes. In a like manner the change
from caring for the sick in the home to the hospital has come and is here
to stay. The attitude assumed by the people towards the public utilities
before mentioned has ever been in favor of better service, and when this
was not forthcoming under private ownership to compel the civic, municipal
or provincial authorities to take over and assume the responsibility and
provide the service demanded.
The system under which the public hospitals of British Columbia are
conducted offer, in my opinion, many advantages over the purely municipal
or civic control.
The remedy for a poor service in any community is directly in the
hands of the people in that community but at the same time a closer supervision by the State of all hospitals would undoubtedly lead to a higher
standard of efficiency generally.
The war has brought about so many radical changes that State control
of many of our most vital necessities are now accepted by the public as a
12 matter of course and without question. Who will venture to predict the
permanency of these changes in the period after the war and what will be
their effect upon the relation of the hospital to the community?
A beneficient socialism that would provide, at the expense of the State,
for the care of the sick and injured is as yet too Utopian for realization, but
the trend of events are along these lines.
The Medical Insurance Act of Great Britain, the work of Lloyd George,
and passed only a few years before the war commenced, was a great advance
in state control of sickness. Every worker receiving less than a certain
minimum wage came under the provisions, and instead of a more or less
haphazard dependence upon hospitals and medical men in time of sickness,
he is now cared for by a systematic organized public service.
In this young country, as well as in the older centers, the hospital will
be required to provide a larger and better service and it is not too much
to say that the day is not far distant when all but the minor and the most
trifling ailments will be cared for in the public hospital. The advantages of
such a system from an economic point of view are manifest. The saving
in time and cost alone would be immense, to say nothing of the added gain
to the patient in being enabled to recover from his sickness in the shortest
possible time.
The excellence of a public service is directly dependent upon the demand
of the public for it, and the hospital of the future will no doubt reflect
public opinion in this regard and provide the service demanded of it.
In conclusion, may I urge upon you the need of higher ideals in our
work, a broader service and an earnest effort to measure up to all requirements of the future.
DISCUSSION.
DR. RIGGS—
I must say that I think the paper has gone pretty well over the field,
viewing the relationship of the hospital to the public for the last few years
and the great change which has come over this relationship. Undoubtedly
today the public appreciate hospitals. I have in my practice very little
difficulty in getting patients now to go to the hospital, where some years
ago it required a great deal of persuasion. This undoubtedly is due to the
change in the hospitals and the greater efficiency as provided by hospitals,
and I have no doubt we are still in process of evolution and in the future
will possibly come to that definite scheme that was mentioned in Dr. Munro's
paper, where most of the sick shall be treated, not so much at home, but
in hospitals, and it shall be more or less under State supervision. That
will require a good deal of working out, and I am glad to say that the
subject Mr. Banfield will take up tonight will deal much more thoroughly
with the question of the State's duty to the individual along the hospital
line.
The hospitals today are striving, I think, to provide the proper equipment to look after people in their affliction. It means better means of
diagnosis as well as proper line of treatment, and the hospital is very often
the only place where this can be got. Therefore, it is necessary the hospitals should be equipped with every facility. Besides buildings, beds and
nurses they must be a great deal more than just "boarding houses," and
that means that every hospital should have something in the line of apparatus
and equipment to do this work. It means an X-ray apparatus of greater
or less extent, but suitable for the work that has to be done. It means at
least a small laboratory where bacteriology and some pathology can be done,
and no hospital today I think is doing its duty to the public, not providing
the service to the public, unless they are equipped with at least these two
things. After all, hospitals exist for the sake of the public; they exist for
the sake of the patient", and unless we aim in the future at providing everything that science can bring to us to bear upon the fact of getting the
patient well as soon as possible, we are hardly doing all that we can.
DR. WRINCH—
One thing that struck me in regard to this paper which I think indicates
the trend of events toward which we are going and toward which we must
work—and that is the tying of the public more closely to the hospital in its
13 ownership. If you will instill this into its management in this respect, that
the hospital is not operated by a private company or corporation doing
business with the public to make what they can out of them, but rather
that it is the public property—in as much as the city water works for
example, the public must come more and more attached to the hospital
and the sooner we can get the public to fully realize this the sooner do I
believe that we can better do the work of the hospital, and the public get
more value therefrom—as well as dividing the responsibility, taking it off
the shoulders of a number of worthy, disinterested, generous people who are
now carrying more than they should. If this very interesting paper stimulates this idea then I think it is along very valuable and necessary lines.
MR. GRIMMETT—
We laymen have to be lead in this most important subject, that is—the
hospital of the future. We depend upon the medical profession to lead us
right; doubtless they will, but just one word I want to say—that we, the
general public are looking to the medical profession for this leadership and
we feel when we look at the medical profession today, that we have leaders
whom we can trust; we feel that they will not fail us, and if, to use a well
known expression, if they "blaze the trail," we will be happy to follow and
will support them in every way possible.
DR. GATEWOOD—
I will now call on Dr. Whitelaw for his paper on "The X-Ray
Department."
THE X-RAY DEPARTMENT.
By Dr. W. A. Whitelaw, Radiographer to the Vancouver General Hospital.
The object of this paper is to present to you in a concise form the
character of the work which is required of an X-ray laboratory in a
modern hospital, whether it be of twenty-five or five hundred beds; to give
you an idea of the equipment and the cost, as well as suggestions for the
employment of a Roentgenologist.
The X-ray in modern medicine has reached a stage where it is considered indispensable both in hospital work and in private practice, and it
is unnecessary to say that it should be a part of the equipment of every
modern hospital of whatever size.
Although of comparatively recent development, thefe have been two
great advances made in X-ray apparatus within the past fifteen years. The
first was the introduction of the Interrupterless Transformer about the
year 1905-1907 by Clyde Snook, of Philadelphia, and the second, the intro-
ductioa of the Coolidge Tube by Mr. Coolidge, of the General Electric
Corporation of America, within the past five years. These instruments
have made the work of the Roentgenologist infinitely more simple, more
accurate and consequently more capable of producing results.
The work done in a modern X-ray laboratory consists of three parts,
viz.: plate work, fluoroscopy and treatment. The main use of the X-ray
was formerly to show fractures and locate foreign bodies. While still very
important and in constant use, this is only a small portion of the work
that is regularly being done. The work in fractures alone has been wonderfully improved by new -methods, while the localization of foreign bodies,
although at times rather complicated, is so accurate that it can be definitely
relied upon.
Stereoscopic work, that is, the taking of two plates at different angles
and viewing them in such a manner as to give a sensation of depth, or the
third dimension, has been of the greatest assistance in giving proper ideas
of fractured joints and of foreign bodies.
The location of kidney stones and gall-stones is a regular part of our
.daily routine. Gall-stones were formerly thought most difficult to present
on an X-ray plate, but now, without doubt, from 20% to 40% at the very
lowest estimate, can be defined.
Radiograms of the head have proven of inestimable value, not only to
fractures, but in determining the location of pus, particularly in the accessory sinuses, such as the mastoid, the sphenoidal, the maxillary and the
14 frontal. The greatest advances, however, in modern work have been made
in the detection of pulmonary tuberculosis, and in gastro-intestinal lesions.
It is often possible to demonstrate tubercular lesions of the chest before the
clinical signs give any direct evidence of the presence of the disease, and
although the converse is true, the X-ray in the diagnosis of the early stages
of pulmonary tuberculosis has become of such value that no chest examination can be considered complete without a visit to the X-ray laboratory.
On the other hand, the gastro-intestinal tract yields itself peculiarly to
diagnosis by the present modern X-ray. methods. It is probably correct that
not more than 50% of accurate diagnoses can be made by clinical findings
alone, whereas I am safe in stating that 98% of all malignant conditions in
the gastro-intestinal tract can be accurately diagnosed, 95% of ulcer of the-
stomach, and from 90% to 95% of ulcers of the duodenum, and by a combination of clinical and X-ray methods, the error is reduced to such a
degree, that it will be a long time before a similar advance is made.
The advent of the Coolidge tube has changed treatment, particularly in
deep therapy, that is the treatment of deep-seated carcinomata, such as those
in the breast, the uterus and in the bones. The dosage can now be given
with accuracy, and the same dose repeated weeks or months later with
certainty, and dosage can be given and work done which was impossible
with the old type of machine and the gas tube.
In setting up an X-ray laboratory in a hospital, the question naturally
comes, what shall we buy, what type of machine, what kind of apparatus,
and how much money have we to spend? We must, first of all, consider
that our X-rayL equipment will much of it be scrap in five or six years,
partly because it will have become antiquated, and partly because of wear
and tear. In my opinion, it does not particularly matter what type of
machine is purchased so long as it is of a good standard make. It does
matter, however, whether you can get service to keep your machine in
repair and parts very quickly if you need them. The same rule holds good
for an X-ray machine as holds good for any other highly developed machine,
such as an automobile, for instance. Most automobiles of whatever standard make are worth the money that one pays for them, but one requires
mechanics and equipment to keep them running, particularly after they
have been in use for two or three years. The same is true of the X-ray
machine. Aside from these circumstances, the equipment to be bought
depends almost entirely on the amount of money that the hospital can
afford to pay, and on the amount and character of the power which can be
supplied.
I have made a rough estimate of the cost of equipping three different
types of hospitals. First of all, the hospital which has in the neighborhood
of twenty-five beds, I believe an equipment adequate to do the ordinary
work such as would be carried on in a place of this size, could be purchased
from $750 to $1,000. The machine included in this estimate is a smaller
type and incapable of doing gastrointestinal work, heavy treatments, or
difficult cases, such as very stout individuals, etc.
Hospitals from twenty-five to one hundred beds would require, in my
opinion, a larger and heavier equipment, whose cost would approximate
$2,000. Hospitals of one hundred beds or over should be supplied with a
first-class equipment,* and, depending on their size, have duplication of the
same. The cost of an equipment sufficient for an hospital of this size
would be approximately $4,000. Naturally, these figures are only approximate, for the simple reason that individual tastes vary, and the conditions
within the hospital itself are such that work of a more difficult nature might
be demanded of smaller hospitals, and naturally a more expensive equipment required.
Much X-ray work is rendered useless by the fact that the technique is
improperly carried through to- a logical conclusion. Many plates are
improperly exposed, but equally as many are destroyed or their value
rendered useless by improper development and poor work in the dark room.
In addition, many X-ray laboratories nullify their work to a very great
degree by failing to have a proper filing system, proper records and proper
reports.   Their plates lie about in any dark corner where it is handiest
15 to leave them, are dusty and improperly filed and recorded. The filing
system of a small hospital should be as complete as that of the large.
The organization required for an X-ray laboratory naturally depends
on its size. In the smaller hospital the Roentgenologist himself, who is
usually a doctor, and should of necessity be so, is forced to do his own
work—operating, developing and reading the plates. The larger the hospital, the more assistance will be required.
In the Vancouver General Hospital, in addition to the Roentgenologist,
we have an operator, who in this particular case is a trained nurse, and
there is also a man who does all the developing and filing, and has all the
care of the plates. These assistants were trained within the laboratory
and have become very expert in a comparatively short time. The trained
nurse was able at the end of two months to take splendid pictures of all
extremity work. ,In the smaller hospital there is no reason why the bulk
of such work cannot be done by an assistant who has been trained to both
operate the machine and look after the plates, etc. Judging from our own
experience at the Vancouver General, I should say that a competent nurse
in any of the small hospitals might do it very satisfactorily, leaving the
more difficult work and the reading of the plates to the Roentgenologist
himself.
The cost of operating the X-ray laboratory will naturally depend on the
amount of work done. The greater the amount of work, the lower the
cost per patient. In all hospital work there is a very considerable amount
of charity work which naturally increases the operating cost as compared
with the total receipts. In the year 1916, which is the last figures I have,
the cost of operating, aside from salaries, was 25% of the total receipts
and the laboratory itself has always paid its way, not of course including
the initial outlay for equipment. In any event, if the laboratory did not
pay its way, it should be considered as one of the indispensable diagnostic
aids in the work of a modern hospital and placed in the same class as the
clinical, pathological or bacteriological laboratories.
DISCUSSION.
DR. HENDERSON—
I have enjoyed this paper very much. One point I would like to bring
up, and that is—"the relationship of the small hospital and the outside
surgeon to the larger city hospital"—particularly as .regards the X-ray.
Of course the small hospital is incompetent, as a rule, to furnish such
elaborate equipment as you; find in the city hospital here, but it is not
that point which * want to take up—I want to call your attention to the
abuse of the X-ray. I do not know that the experience I have had is
entirely unique, and there may be others who have had similar experiences.
In the matter of fractures—prior to the introduction of the X-ray the
result in treatment of fractures was reasonably good—reasonably good legs
and arms resulted from the treatment of fractures at that time, and according to diagnosis at that time. We who have not got the elaborate X-ray
are compelled to continue our treatment according to the old method. We
sometimes get good results, we sometimes get fairly useful limbs, but unfortunately the majority of individuals like to have their photographs taken, they
like to be photographed, and many of us like to have our insides photographed as well as our outsides. These people whom we have treated by
obsolete methods reach the city and they want an X-ray picture.
A man wanted to have a photograph of his leg. Now, when I was a
younger man in the profession, I was always brought up to be careful to
avoid looking at a leg that was treated by some other surgeon. I have
invariably followed that course, until that surgeon invited me to examine
it. Now our friend with the fracture comes down to the city and he begins
to wonder if his leg is a little shorter, more crooked or less handsome than
it ought to be, and he goes and has it photographed. Now there are many
cases where that is perfectly proper. A man has a right to go to a surgeon
and that surgeon has a right to treat him if he thinks he can do him any
good. The man asks to have a photograph of his leg and that surgeon
takes him to one of our best hospitals, takes him to the Vancouver General
16   Hospital, the Royal Columbian Hospital, New Westminster, the Provincial
Jubilee, Victoria, and has his leg fracture photographed and the gentleman
is handed the photograph on payment of his fee, which in most cases is a
little excessive, and he has his picture to make such use of as he chooses,
sometimes for mere curiosity, but very often to try and make trouble. Is
that a  good thing?
I hope I am not exaggerating the situation.    I would like to hear others
on the subject and myself set right—and I would like to know if there is
any cure for such a grievance, if it may be regarded as such.
DR. RIGGS—
The cure is the instalment of an up-to-date X-ray.
DR. WRINCH—
I have greatly enjoyed the paper. I have had the same trouble as
Dr. Henderson and had to put in an X-ray to keep our patients from running away to the city.' We have had several cases like that. We had a
man with fracture of both forearms, and he was very anxious to get a
good right arm. It was doing very well—the bones were in direct line—
but in order to avoid this very thing that I understand sometimes happens,
we cut down on the fractures, because if we did not do so this individual
would have come to the city and might have said it was a bad union. We
have to meet this—we have to get an X-ray in outlying districts and protect
ourselves, and from the other standpoint also—the patient has a good right
to the best he can get.
DR.  MacEACHERN—
I would like to ask Dr. Whitelaw whether or not the patient who has
an X-ray taken is entitled to the plate or a picture thereof.
DR. WHITELAW—
As far as the practice of the laboratory in the Vancouver General Hospital is concerned, the patient never sees a plate except at the request of the
surgeon attending. A report is always given the surgeon attending, and
as a matter of law, the plates are kept in the hospital. If the patient pays
for the X-ray he is entitled to a print, but no more. The plates are on file
and are always kept on file. The only time they are given out is at the
request and with the consent of the attending surgeon himself.
CHARLES GRAHAM—
I have been very much interested in the paper and appreciated
Dr. Henderson's remarks.
I have heard several times that if a man has a fracture and he thinks
he has not had proper treatment, he is not entitled to go elsewhere. I
think that any man at all, whatever he has, if he is not satisfied with the
treatment he is getting, has every right in the world to go anywhere that
he chooses, so long as he is willing to pay for it, and I also think that if
he wants to have an X-ray, if the doctor has not the proper facilities, he
has a right to go elsewhere. I do not wish to lay any blame on the medical
man on that point, but if the man is willing to come to Vancouver, he is
perfectly entitled to any information regarding the fracture and is also
entitled to get all the information that he can possibly get, irrespective of
what has transpired previously.
The X-ray should be at the use of the public and under expert
direction.
DR. GATEWOOD—
We are pleased to have with us today Dr. R. E. McKechnie
who will address us on "Hospital Standardization," a very live
subject now on this continent.
"HOSPITAL   STANDARDIZATION."
By Dr. R. E. McKechnie, F.A.C.S., Member of Consulting Staff, Vancouver
General Hospital.
In  discussing standardization of hospitals there  are certain  features
which are imperative for the proper care of patients.   A hospital to be con-
17 s'dered doing its full duty to its community does not necessarily need to
have the maximum of these features, but in standardizing there must be set
a minimum, below which a hospital will not be considered as functionating
properly, lacking the minimum of equipment and facilities for treating patients.
Coming down to the history of hospitals, we find that there has been an
evolution from the time the first hospital was started. The Mohammedans
and Arabs have the honor of starting the first hospital, and the hospitals as
first started would come under the head of "Custodial," that is, they took
possession or custody of infirm or sick people. The first hospitals were
practictally for indigent and infirm people, and as far as treating them was
concerned, there was very little of that done because the medical profession at that time did not amount to very much, so that it was really taking
care of people that needed to be taken care of. In the course of time with
the progress of the medical profession there was also an evolution in hospital
development. We had remedial functions added to custodial, but although
treatment was initiated, these hospitals still possessed their custodial functions, and were loaded up with cripples, the aged and indigent. This condition was later somewhat relieved by poor houses, homes for the aged, etc.
It is comparatively recently that the third function of hospitals has been
developed, namely,—the "Educational," which seems to take advantage of the
opportunities afforded by a hospital to better train all those who care for
the sick, and thus in turn benefit to the utmost those for whom hospitals
were founded.
It is interesting to note the establishment of hospitals on the Continent.
Courtez in Mexico, established the first hospital in America. Canada has the
honor of establishing the second hospital, that was the Hotel Dieu in Montreal, so that Canada is pretty well to the forefront as regards beginning its
hospital life. There was a hospital started on Manhattan Island, New York
State, which constituted the third hospital. The dates for these are: Courtez, 1524; Hotel Dieu, 1639; Manhattan, 1663.
Now as regards the utilizing of facilities in hospitals for teaching purposes, Guy's Hospital, London, began teaching in 1723, Edinburgh in 1741
and Vienna" in 1745, so that we find in Great Britain we had two hospitals
which started teaching, making use of their facilities, before any were
started on the Continent, even in the great teaching centre of the City of
Vienna.
Now as to what a modern hospital should be: Of course the first duty
is the "care of the patient," the-care of those who are entrusted to us, to
see that they are getting the very best of attention, treatment and so forth,
and this point comes up with other problems which are pretty wide and pretty
deep, and some which our laymen think have very little to do with the efficiency of the hospital.
One of the first things is the proper case taking, the making of case reports in regard to patients. Now this is a pretty broad question. It does
not only compel the attending physician to go thoroughly into the case but he
has to have it down in black and white so that others may see if he is doing
his work properly and see whether he has used every means possible to arrive at his diagnosis. In connection with case taking, that is not only
especial in surgical work; we should find out everything that has been
done, the manner of the treatment and the results, and some go so far
that if the results have been poor, that there should be a note saying where
the fault lies, whether it has been an incurable case, whether the fault lies
with the patient in not submitting to treatment, whether it is the fault of the
surgeon or the hospital;_ if the hospital has not had proper equipment or
efficient staff, etc. Now, if that were all down on a case report and subject
to scrutiny and careful investigation later, what would result? Looking as
a surgeon, of course I see the surgeon's point of view. There would be in
course of time, if case reports were carefully prepared and submitted to the
proper authorities, the board of directors and medical staff, data from which
you could arrive at a conclusion whether the doctor was doing good work,
whether he was doing poor work, and if it could be remedied.   How is the
18 general public going to know whether or not a man is able to look after
the public? The hospital appears to have a function to protect the public,
and this gives it its opportunity. It is not the mere taking of case reports
which we expect to do so much good, for case reports have been taken from
time immemorial. But it is the thorough utilization of these case reports
in the manner just indicated, which will increase the good done, improve
the service of the hospital and prove a great benefit to hospital patients.
So I would explain to the laymen the great advantage of having case reports carefully taken and followed up to the limit, and full advantage taken
of these case reports later on to see the kind of work being done by the
different men in that hospital. It is going to redound to the credit of the
hospital and to the patient, and if one hospital does it and another hospital
does it, it is going to be to the advantage of the general public itself.
Now as to the duties of the hospital in regard to its patients, we come
to what is to be done when the patient has died. There is a great deal of
knowledge that the undertaker gets hold of and nobody else does, and he
only gets hold of it in pieces, he does not know what he is handling. There
is a decided prejudice against post mortem examinations, and it is a case
of having the public educated to a higher level. Now take in the Vienna
General Hospital, high or low, no difference what rank or society, every
patient who dies in it must have a post mortem examination and a report
made on the cause of death. What does that do? The post mortem examination finds out exactly what the patient died of, and if this result were
put down in black and white and added to the case report and checked up
by the proper authorities against the doctor's diagnosis, is not that going to
make the doctors more active in seeing that their cases are diagnosed properly? Making a general rule of post mortem examinations would redound
not only to the benefit of the profession itself, in making better men, but
see what an advantage this would mean to the general public if it is going to
make the doctors better in handling their cases. Surely, that needs no argument to show that the public is going to benefit in the long run.
Then as regards other functions of the hospital, we have the Educational pure and simple. These case reports and post mortems are going to
educate the doctors, but there are other functions which the hospital can
do along educational lines, and should do. Of course, in British Columbia,
as long as there is no medical school our hospitals cannot be utilized for
the purpose of educating medical students, but we can educate the doctors,
we can educate our internes. This education of internes while it affects
the interne, still we must not lose sight of the fact that the public reaps
the benefit of the interne who later on comes out into practice. Dr. Ed.
Martin says the new interne is just about twenty per cent, efficient, and that
an interne who has been a year in the hospital goes out with eighty per
cent, efficiency, and if a year will add sixty per cent, efficiency, it shows
the great efficiency of the hospital, and the public again reaps the benefit.
Now we come down to the use of the hospital for training nurses. We
all know about the Sarah Gamp. There are many Sarah Gamps in the
community still, but it goes without saying that Sarah Gamp could not do
the work that a trained nurse can do, cannot be of the assistance to a
doctor in handling his patients that a trained nurse can be. It is a great
advantage to a community to have a sufficient number of trained nurses in
it ready to respond to the call of the community. The only way to train
them is in a hospital, so we find that the modern hospitals are largely going
in for the training of nurses. When I was a house surgeon in the Montreal
Hospital, the training school was started there, and that was the first training school in Montreal, i.e., in 1890.
I do not wish to prolong this, my ten minutes are already up, but looking over the subject as a whole, what things should a hospital look after?
Here is a sentence that I culled out of a recent report: "Every hospital
staff should demand and every hospital furnish all known equipment for
diagnosis." This is the aim that every hospital should have. The means
for diagnosis are often costly and complicated and the individual physician
cannot be expected to have a full equipment or even be able to handle a
19 iull equipment himself, so that some other body other than the individual
doctor has got to have this equipment, and I consider it is the duty of the
hospital to furnish that equipment, and the duty of the public to support the
hospital to furnish that equipment, for it all goes to the advantage of the
general public itself. If the hospital has not that equipment, if its funds
will not permit it to obtain the equipment in all its departments, then what
should it do with a case which comes to it which requires the aid of these
means to obtain a diagnosis or follow up any certain line of treatment? It
should be the practice of such a hospital to tell the patient, "You should
go to some other hospital which is properly equipped to do full work." I
think that this is the honest point of view to take. If a doctor has a patient and is not able to handle that case, he is not perhaps a specialist in a
certain line and the case does not come within his line of work, what is
the honest thing for him to do? The honest thing is to get a doctor to
handle that case who is specially qualified to handle it. So with the hos^
pital, it should be honest enough to say, "this case should not be treated
here, it should go where it can be properly treated."
DISCUSSION.
SISTER FRANCES—
In the very early days here in Vancouver, thirty years ago, we began
nursing in a very crude way. We were clean, we were thorough and we
came out of good hospitals. We came out of the Montreal General Hospital, we came out of the Winnipeg General Hospital, and nurses still follow from these excellent training schools. They were taught nursing, they
were taught cottage hospital work and they did slum work in those days.
Winnipeg nurses went to the prairies and some came to Vancouver. They
were the best nurses, and I was always glad to get a Winnipeg nurse.
However, nurses' conditions have greatly altered as well as hospitals,
with the varying conditions which have arisen since. In the early days very
few people with money went to the hospitals, and usually they were men
and women, and the women only went for maternity. When they went you
always reduced your charge. Later on, however, when money was more
easily made and families were growing up in these homes, there was a
tendency to send their sick members to the hospital where they could receive
better attention and not upset home so much.
The curriculum of .study for nurses today is very high all over and in
the Vancouver General Hospital. These girls that come to the Vancouver
General Hospital do not have to be taught to spell, they do not have to be
taught to pronounce Latin terms, they do not have to be taught writing.
This preliminary education which they must have is of great advantage to
them in their work. This was not the case with the pupils of the early
days, who hadn't the many advantages and often had to teach each other.
The Vancouver General Hospital have raised their standard and it is only
reasonable to expect that the standard of nurses should be better than
thirty years ago. The nurses of today are not - prepared, however, for
cottage work or slum work, nor are they fit for travelling nurses or missionary nurses to Alaska for instance, as was required thirty years ago.
I think today the standard of the hospital should be just as Dr. McKechnie has stated in his excellent address. When we look back and see
the wonderful progress hospitals have made, how more scientific they have
become, how much more thorough, and yet we see a great deal yet to be
done in the way of standardization of the work.
I am glad he made mention of post mortems. These are most important, for how many, many mistakes have been rectified and how many
doctors benefited by post-mortem examinations. These should not be at
the discretion of the public or the friends, but they should be at the discretion of the attending physician and hospital management. Correct
diagnosis and careful investigation of all cases is our duty today when
dealing with the sick.
In conclusion, I may say that I am glad to have had the privilege of
being the first lady speaker at this Convention, as I am the first nurse in
Vancouver.
20 MR. GRIMMETT—
I am very pleased to hear this excellent address of Dr. McKechnie on
"Hospital Standardization." I did not gather whether the doctor recommended post-mortem examinations should be necessary and made compulsory in all cases when necessary. I think the doctor does recommend that,
and as a layman I agree.
The case of a man—a carpenter—who met with an accident, ribs broken,
went into our hospital, was there about two weeks and was progressing very
favorably! One night he was taken seriously ill and died in a few minutes.
Naturally, the attending physician did not know what the cause of his
death was, nor for a time did they know exactly how to arrive at this cause.
They felt that they had no power to have a post mortem on the deceased,
so very ingeniously they suggested this—that as the patient had met with
an accident just two weeks previously there was sufficient grounds to order
a coroner's inquest. Before the inquest could be held, of course the post
mortem had to be done and the cause of death ascertained. This instance
shows how earnestly the doctors desire to obtain this information, and
therefore, legislation, if necessary, should be enacted to allow this privilege.
On the death of every person there should be an examination of that kind,
particularly if there is any doubt as to the cause of death. To bring this
about that work and education must be carried on by the physicians
themselves.
DR. RIGGS—
I think that if we grasp the question of hospital standardization at this
Convention we will be doing well. I intimated before that hospitals are
run for the public and for the public alone, and that the benefit which the
doctor, physician or surgeon obtains from the hospital is in doing his work
thoroughly. If the public, the laymen generally, would grasp that idea—
that the situation of the hospital today is up to them, that it should be run
under guidance and leading, but they must grasp the principle that they are
going to take a hand in the condition of hospitals today, and that it is with
their help good results can be obtained. The public must understand if
they do not get proper treatment it may be their own fault, because they
have not taken any interest in the hospital, they have not seen that their
hospital is up to the standard and that their hospital is utilizing all the
scientific methods that can be used. The onus is not alone on them. You
must put a certain amount on the medical profession who must educate the
public. We are all glad, individually, to educate the public; we are only
too glad to tell them all that we know about this sort of thing, yet, unless
they will fall in line and help, it cannot be done. I think the public is quite
willing to do so, yet it comes down to education and they must be given a
certain amount.
We must go further than that if we intend to interest the public. We
must have certain standards of hospitals.' We must ariive at a certain standard for British Columbia. We must have certain means of diagnoses, such
as X-Ray, Clinical and Pathological Laboratories, etc., and in addition,
we must have good training schools for nurses and a hospital prepared to
carry on post mortem work and case reports. We must therefore bring
pressure to bear upon the powers of the people so that we shall have not
only the means for doing these things but also the public funds and public
moneys available to carry this on.
It is a hard thing to convince the public that the greatest asset to a
community is the health of the individual in that community, and until they-
are forced they will not part with their public funds, and yet these funds
are necessary for the means of furnishing hospitals and carrying on their
work. We must get the Government, the City Councils, the Municipalities to
supply the money as required, and let everybody realize the old saying, "No
man liveth unto himself," (and according to the Post Mortem does he die
unto himself.)
Therefore in conclusion, I would urge that the hospital have more public
support, and you who are here must do your part in educating the public
to demand these things; demand them from your Hospital Board, demand
them from the Provincial Legislature or the Council, or the Municipality.
21 Only by these means can we get to the point of a fully equipped hospital
ready to do careful and scientific investigation of all cases; and remember,
while the doctors may be quite energetic in pushing this along, they are
doing it from the standpoint of doing the very best service to the public,
working for their welfare as well as earning their livelihood.
DR.  WILKES—
I do not intend to say much at this time, but ch'efly on the line of Dr.
McKechnie's paper in regard to Post Mortems and Case Reports. When I
was at the hospital as a student and as house surgeon, case reports and post
mortems, of course, were the rule of the day. Dr. McKechnie laid stress
upon case reports and post mortems as being a stimulus to efficient physicians and surgeons to better and more accurate work with a close checking on diagnoses and findings. It never occurred to me in that light before
altogether, but I realize that there is nothing more important in our work
than a carefully compiled case report, and if necessary, post mortem report of such cases which die without a definite diagnoses. The value of
such an accurate record, together' with the surgeon's findings upon the case
at that time, is a close check on all.-work done. Then again, how often do
patients come back again and again, when clinical and pathological reports, as well as that of previous operations, are of great value.
In regard to post mortems, these are of great value, not only in out
of the way cases where the diagnoses is in doubt, but also in the common or simple cases. Personally, I find that I lose a clear picture of the
condition of the body as the result of disease unless I have that post mortem report in my mind. It is only by keeping such clear pictures in one's
mind through having post mortems of such cases, that good clinical experience can be obtained.
I therefore trust that in our hospital these two things will be worked up,
that is—the having of good reports on all cases and post mortems on as
many cases as are available.
DR.   HENDERSON—
The physician who has never made a mistake has never done a post
mortem.
DR.   MacEACHERN—
It is most gratifying to see such a splendid attendance at our first
Convention, and also such a great interest taken in the papers this morning.
During the afternoon session a number of interesting papers will be given
and we trust that there will be a good attendance. Tonight you will notice
an excellent programme" of subjects which are of wide and vital interest
to the people of this Province. You are privileged to invite any of your
friends in the city that you wish, to attend this meeting, as this will be
open to the public.
One of the objects of this Convention was, if possible, to form a B. C
Hospital Association, and if this is agreeable, it will be necessary to have
such a resolution and also the appointment of a committee to draft rules
and regulations for same.
Moved by Mr. Stewart, seconded by Mr. Grimmett:
THAT an Association be formed known as "The B. C Hospital Association, and a Committee appointed to draft rules and regulations.
Motion carried.
Mr. Grimmett, Mr. Graham and Dr. Gatewood were appointed.
Meeting adjourned, to meet at 2:00 p.m.
22 AFTERNOON  SESSION—June 26th, 1918.
DR.   GATEWOOD—
I am going to ask His Worship Mayor Gray of New Westminster and President of the Royal Columbian Hospital Board to
act as Chairman of the afternoon session today.
MAYOR GRAY—
I will now call on Dr. H. C. Wrinch, Superintendent of the
Hazelton Hospital, to give us his paper, "Problems of Outlying
Hospitals."
PROBLEMS   OF   OUTLYING   HOSPITALS.
By Dr. H. C. Wrinch,  Superintendent Hazelton General Hospital.
This paper is submitted with a frank apology from the writer for presuming to offer it on the strength of a most limited experience, and in the
feeling that its value will be in proportion to the amount of discussion accorded it rather than in the material submitted.
' In British Columbia we are proud, perhaps pardonably so, of our
"greatnesses." In our grandiose moments we speak of our thousands of
miles of coastline, our extensive fisheries with products of highest quality, our vast timber resources of magnificent trees, furnishing some of the
finest timber in the world; our mountains of mineral, valuable beyond the
possibility of comprehension; our fruits; our water powers; our wonderful harbors; these, and many other features of immensity are so familiar that in contemplation of them we are very apt to forget how in-
significent is our population in comparison.
This very disproportion between population and their vast heritage of
boundless resources is responsible for most of the problems of the hospital field. With a population of 400,000 scattered over a territory of almost
one million square miles, and with half of this population resident in a
few cities, we have a task, in attempting to provide for the scattered population, bristling with problems more numerous than can readily be enumerated.
As to a site—This is not usually a serious problem. Convenience t©
the transportation system by which patients from outlying territory must
be brought to a hospital should usually be given greater consideration than
the particular interest of the small local centre in the immediate proximity. A difficulty is created that might as readily have been avoided in
designating a hospital by the name of a town or village rather than in a more
general manner.
It might better be named after the county or district, or whatever
might be recognized as the territory from which it derives its patronage,
and hence, to which it might reasonably appeal for any special support.
Petty jealousies not infrequently exist between small places. These are
frequently trifling, and ought not to be allowed to affect the hospital, yet
they sometimes do. This is a case in which the injunction to avoid the
very appearance of evil might very well apply.
The outlying hospital should very clearly define its relation as being
general, to a district, rather than particular to a town or village. If its location and designation can be made to harmonize with this viewpoint, it
will facilitate the obtaining support from people some little distance from
it, and will help to dissipate the erroneous idea that every little centre
should have its own hospital. Such idea, if carried out, is fatal to that
measure of efficiency the outlying hospital might reasonably be expected to
develop.
Possible changes in systems of transportation necessary to the permanent
development of the resources of the district should not be forgotten. Plenty
of elbow room should be insisted upon. This is for a two-fold reason—
first, to prevent the encroachment of undesirable neighbors, that there be
nothing unpleasantly near, either by sight or sound, to jar the heightened
23 sensibilities of patients, whose vitality sometimes appears to hang in the
balance, requiring every favorable condition possible that the balance may
turn in the right way. And for a second the more positive reason—that
there may be beautiful and pleasant surroundings, in which the convalescent patient may spend the time in the open air under shady trees or
groves.
Every hospital should stand in the centre of a park, rather than within
the limited confines of a city block, much less within the limits of two or
three lots of a small town or village. Twenty to fifty acres or more would
be no handicap and would afford opportunity for studies in landscape effect
by the Superintendent in his leisure days. Convenience of water supply,
with possibilities for reasonable disposal of sewerage, should be given
careful consideration also.
Building Material—This becomes a matter of real thought and study.
The ideal, of course, would be solid stone structure, or at least a steel reinforced frame with stone facing, due consideration being given to appropriate ornamentation. The practical will probably resolve itself into a
frame building, neatly and plainly, finished, in which utility and capacity
at minimum cost are the primary considerations. But whatever may be
the character of the superstructure, the question of foundation walls, or at
least pillars, of concrete, should be insisted upon. This is an economy that
can hardly be ignored. The problem of the situation is to make the practical approach as near as possible to the ideal.
In designing the building the classes of population to be served and
the "color line"—where it exists—must be considered. The color line exists in the Province. In some outlying parts it is almost aS acute as in
the Southern States. It is out of no attitude of disregard for, or sympathy
with, the native races of our Province, that I seek to emphasize the importance of their being given accommodation entirely distinct in every particular from that provided for patients of our own race.
If it becomes known to the general public that this distinction is not
recognized, or even to some extent ignored, the people of finer sensibilities,
who are incidentally generally our most profitable patients, will, when
opportunity permits, go elsewhere for their care.
The Indian himself, together with all others who use the hospital, becomes a loser by this course, for the lessened patronage reduces the income, and hence also the efficiency of service, which is usually directly
dependant upon the income.
When we turn the - hospital over to the Matron, she will find it much
easier to meet the desires of her patients with a number of smaller wards
rather than say with two larger ones, designated respectively, "male" and
"female," with perhaps one extra as a special for obstetric cases.
In connection with construction, an ideal and almost essential feature
is a separate residence for nurses that they may not be only out of sight,
but also out of sound of the patients while off duty. And yet in practice
this is not always feasible at the beginning. But because of its impossibility at first, and because nurses may be found willing to work under the
less desirable conditions, it should not be ignored. Provision should be
made at earliest possible moment for this essential. The increased cost of
an extra building, together with cost of lighting, heating and upkeep are
the insurmountable obstacles for a time.
Disposal of sewerage is a real problem. Here again the ideal and much
the simplest process, is merely to instruct the building contractor to connect all soil pipes with the city system, having the architect see to it that
proper gradients are observed. But the practical may resolve itself in the
dry earth closet, or the septic tank system, the latter being by far the better
and should be feasible in any locality in which it is fit to erect a hospital.
The matter of heating and ventilation resolves itself into a choice of
systems and furnaces, which is a subject sufficient and worthy of a paper
in itself. It will be affected by the class of fuel obtainable and cost of laying
down material of plant. I recall a case where a heating plant material cost
$180.00 at shipping point, and the finished installation $800.00 including five
weeks' wages for nine days' work by mechanic for installing.
24 Lighting and water supply becomes a question of the most convenient
and economical source of a supply of power. Where this can be obtained
from city or corporation yearly it is merely a matter of cost. Where this
source is unavailable, the problem today is much simpler than it was
twelve or fifteen years ago. The development of oil as fuel, in conjunction
with gas, electric engines of a wide range of capacity, places this system
within the reach of the smallest institution. One requisite, however, must
not be overlooked in this connection. A plant of this nature requires an
engineer, or at least a handy man, who could make the proper plant his
first care and be willing to be usefully occupied in other mechanical work
at other times. The right man in this capacity could save the institution
from half to two-thirds his salary in cost of repair work of varied character. A storage battery in connection with this plant can be made to furnish sufficient power for the period of the day when engineer is off duty.
The power plant can also be utilized for pumping, wood-sawing, laundry and
other machinery. The electric part of it can be made to supply X-ray
and other electro-therapeutic purposes in addition to lighting.
Turning to the problems of administration and practical operation, the
hospital is confronted with a very wide range of work—wider perhaps than
is found grouped in any other single organization. The various departments of this work should be in the hands, in many cases, of highly trained
specialists, each of whom should, and can, command a generous remuneration. It becomes the interesting study of the executive of the hospital to
group these many and varied duties in the hands of as few individuals as
possible, or in other words, to engage only as many persons as means will
permit, and yet cover fully this very wide range of endeavor. That the
task is a load of superhuman proportions, will be admitted by any thinking
person; and yet there are not wanting persons who, when they find any
particular phase of the work in which they may be particularly concerned
at the time is not being accorded special attention, are not slow or niggardly
in the measure of their criticism.
The hospital executive, which by the way, may be a board or committee, or may be vested in the person of a single individual, is responsible
for having work done under the following, and a few other headings:
1. Physicians
2. Surgeons
3 Bacteriologists
4. Pathologist
5. Roentgenologist
6. Other specialists, Eye, Ear, Nose,
and Throat, Electrotherapy
7. Lecturers
8. House  Staff
9. Dispensing Officers
10. Admitting Officer
11. Secretary Treasurer
12. Employment Bureau
The country as a whole (and the hospitals, are no exception to the
rule), is just now confronted with a problem of shortage of labor and higher
wages, more acute than has ever been experienced. A natural corollary of
that condition is a spirit of independence and indifference on the part of
employees, which increases in intensity in inverse proportion to the skill
and training required by the occupation.
As a consequence of this it is much more difficult than formerly to
find individuals willing to take on work of more than one character. The
all-round, general-utility man or woman who would be invaluable in several different ways in hospital service, is becoming increasingly scarce.
It must be remembered that the outlying hospital (which is also a small
one) does not offer full time work along many of the lines referred to, but
they are all of them such as are to be found in the fully equipped hospitals and hence may occasionally be called for in the smaller one.
The income of a small hospital will only permit it to engage a limited
number of its staff—five, ten, twenty, or more, as the case may be.   Prob-
13.
Purchasing Agent
14.
Matron
15.
Nurses
16.
Orderlies
17.
Cooks
18.
Kitchen   Help,   House   Cleaning
Department
19.
Engineer
20.
Laundry
21.
Gardener
22.
Collection   Agency   of  Accounts
and of Private Subscriptions
&c
, &c
25 ably also this  is nearly as  many as  can be profitably occupied  for  long
enough time to warrant them being engaged.
Where the hospital is located near a large town it is possible, theoretically at least, to have part time workers along a number of lines of work.
This is impracticable in outlying hospitals and constitutes the real problem
of the situation.
To meet this (unfortunately it cannot be entirely overcome) it becomes
the task of the Executive Officer to associate with himself, in every department in which he can maintain one or more individuals, persons of as broad
capacity as possible, assigning to each as many allied duties as can be fairly
taken over by them. All that remains then is for himself to become responsible for everything else.
Some very real difficulties occur, on account of distance from the larger
laboratories, when the- need arises for prompt diagnoses by examination of
pathological specimens or material, as well as in the making of serum
tests, and autogenous vaccines. The attending physician or surgeon has
sometimes to content himself with less finely developed methods of diagnosis
and treatment. The outlying hospital cannot afford the luxury of a highly
trained pathologist and the necessary equipment for carrying out his
methods, while at the same time, it is out of the realm of practicability for
the few visiting physicians to find the time to do such work.
There remains two problems very difficult of solution because of their
comparative intangibility, viz., prejudice on the part of some who have never
been in the hospital and adverse criticism from some who have. The latter
is the more damaging of the two.
In biblical times the question was raised, "Can any good thing come
out of Nazareth?" a small obscure village. Today, people will ask, "What
can you expect from a small outlying hospital anyway? Let's go to the
city, where they do things." The mere fact of its being remote is accepted
by some (most unfairly) as bona fide and absolute evidence of inefficiency.
In answer to that it becomes the duty of the small hospital to "do things"
also. It must convince the critic. We must make its service so good that it
is only necessary for the critic or a member of his household or a friend to
once use the hospital, and his prejudice becomes converted into praise from
that time on.
The adverse criticism from someone who "has been in the hospital is
a much more damaging matter, and one very difficult to check. Doubtless
mistakes are sometimes made in all hospitals, and sometimes complaints
are not without foundation. Often, however, such complaints and adverse
criticism, when traced to their source, have been found to emanate from
someone who has received free or nearly free treatment, or who has been
rendered an account which he is too mean to pay, and is endeavoring to
hypnotize himself in the belief that he ought not to pay it. It is suggested,
therefore, in order to reduce to a minimum this obnoxious feature, that the
hospital make every effort to obtain fair renumeration for its services, and
settlement of accounts in the promptest manner possible. Other advantages
accruing from this course of action will be readily appreciated by members of this Convention. The problem of finance is one which I believe is not
limited, as a matter of interest, to the outlying hospitals only, but since
the committee have deemed it worthy of a place to itself on your programme, I will with your permission, leave it for later discussion.
In conclusion, I desire to record my firm conviction that the benefits of
a hospital to a community are so apparent that there can be found no insuperable obstacle, if the matter is properly presented to all persons concerned and judiciously followed up by taking them fully into confidence and
giving due emphasis to the principle that the hospital exists and is maintained purely for their good.
DISCUSSION.
MR.   STEWART—
I congratulate Dr. Wrinch on his hospital at Hazelton.   It is a splendidly equipped and managed institution.
DR.  MacEACHERN—
I also concur with Mr. Stewart that the Hazelton Hospital is an up-to-
26 date institution. It is quite possible that the small hospital can assume such
a condition that people won't pass by its door. In the State of Illinois, for
instance, there is a small hospital of fifty beds and patients come from three
hundred miles and even further, passing several hospitals along the line,
many of which are much larger, and passing many towns, making their
way to this small hospital. This goes to show that you can make your
hospital, no matter what size it is, just as efficient as is necessary to hold
and attract patients. Dr. Wrinch has introduced several problems which
confront the outlying smaller hospitals. Dr. Mullin will handle the Laboratory problem later in the Convention, and Mr. Benzie, Architect, is going
to take up some of the architectural problems. In regard to hospital surroundings. This is of great importance to every institution. There should
be lots of room around the hospital, park or trees and seats. Unfortunately, the Vancouver General Hospital has been crowded in on all sides
by the growth of the city, and this has given us a great deal of trouble
from the standpoint of noise which affects part of our buildings very
much. I think we should have a provincial regulation governing the erect'on
of buildings within a certain distance of every hospital and the regulating
of "silence zones" about the hospitals.
MR.   MORDY—
Case reports, post mortems and careful diagnoses are all of vital importance to our hospitals. In regard to these, and especially in regard to
case reports, this appears to me to be a matter of standardization for our
hospitals in British Columbia, and a work for our B. C. Hospital Association. The Association should get all these things in line and set us
a standard to work to, for if this is left to the laymen their information
on the subject is so slight that it would offer every diversity of opinion as
to what should constitute a standardized case report for instance. Therefore, all these should be carefully standardized for the use of the hospitals. However, there are many difficulties in our way in accomplishing
the ideal. Take the outlying districts: We cannot have the equipment
which would cover every possible diagnosis, yet I find that there is possibly an exception taken to the case of a patient who is not able perhaps
to afford treatment for several weeks or months and might perhaps be
able to^lurnish money which would enable him to go down to the city and
get an X-ray taken and a correct diagnosis made of his case which he
then could take back to Cumberland for instance, and get h's own, hospital physician or surgeon to continue the treatment on this diagnosis. It
is unfair to ask hospitals, especially if the man is willing to pay for it,
to put in such expensive facilities if it can be done expeditiously and conveniently elsewhere.
DR.   MacEACHERN—
(In reply to Mr. Mordy's discussion.)
Small hospitals should do a certain amount of laboratory work. A
certain amount of the more difficult or complicated work cannot be done in
bmaller hospitals, but if you get it done somewhere else the credit and
honor is yours and goes to your institution, for you are seeing that your
patient gets the best treatment. It is your duty as hospital administrators
to see that your patients get the service which they require.
Write your own case reports. Personally, I think I had better case
reports when I had a hospital of sixty-five beds and did them all myself,
and even better, I may say, than I will ever have in this hospital. You
people can do the same thing. You can have good case reports. You can
do a certain amount of laboratory work. You can see that your patient
gets as good service as in the large hospital. Whether you,do all the work
or not, the credit should come to the institution that has the patient and
renders the patient that service.
DR.   HENDERSON—
My hospital at Powell River is limited to sixteen beds, which probably
will rank as the smallest hospital represented in British Columbia. The
work there is what I might call "casual work." I have a good deal of trouble
with the small hospital in cases wanting to go to the larger institutions in the city.   I handle a great many emergency cases and I limit the work to
that kind of service.
Dr. Wrinch made reference to the fact that a small hospital doctor is
apt to be disregarded. As just an example of this, I had a personal experience lately. I presented a bill to an individual for payment (it happened to be a lady) and she asked me for an itemized statement of the
bill. The visits were made at a stated price. She said, "Oh my, I can go
to Vancouver and have a good doctor attend me for that."
MR.  GRIMMETT—
I was particularly interested in Dr. Wrinch's paper and there is one
matter that applies particularly to our hospital at Merritt; that is—the erection of a nurses' home. At the present time the nurses have no home.
They have their rooms in the top story of the building, which is very unsuitable for that purpose. The dining-room is small as also the sitting-
room, and there is no means whatever of having any social intercourse
with their friends. Some months ago I took up very strongly the question
of building a home. I am very pleased to say we have the money to do
so, but we met with every possible opposition from some of the members
of the board. The chief argument advanced is that at the present time
material is so dear, labor is so high that to proceed now would be a mistake. I take issue to such a stand, and am of the opinion that it will be
some years before there will be any marked reduction in the price of either
material or labor; but what concerns me particularly is this—that if I can
take this paper of Dr. Wrinch's home with me and read this portion of it
to the board, I am sure it will be a great assistance in that regard. I feel
that if there is any part of the staff of the hospital that should have a home
it is our nurses and they deserve it, and I am entirely out of sympathy with
any opposition to or any scheme which has not that in view, and so far as
it is in my power, I intend to prosecute this plan. If I am defeated, however, I will have to take the defeat with good grace, but if I have Dr.
Wrinch's paper it would be very useful to me in that regard.
I was very interested in the Indian question which Dr. Wrinch mentioned, and this is a very important one with us at Merritt, but as it will
be my privilege tomorrow to discuss financial problems of hospitals, in
which this question arises, I will defer any remarks I have to make on that
part of the paper.
MR.  MORDY—
I would like to suggest that all the papers be printed so that we will not
lose any part of any paper.
DR.   MacEACHERN—
All the papers will be printed in a report after the Convention is over,
If we can find the wherewithal to finance it.
MR.   COOK—
I wish to commend this very admirable paper which is not only brief
but most thoroughly practical and interesting.
MAYOR GRAY—
I will now call upon Miss J. F. McKenzie, R.N., Lady Superintendent of the Provincial Jubilee Hospital, Victoria, for her
paper, "Small Economies in Hospitals."
SMALL   ECONOMIES   IN   HOSPITALS.
By Miss J. F. MacKenzie, R.N., Lady Superintendent of the  Provincial
Jubilee Hospital, Victoria, B. C
Chairman, Ladies and Gentlemen:
For this paper, nothing very original or unusual can be anticipated.
This rather may be regarded as a presentation of every day economies,
born of personal and exhaustive attempts at making the most of ones
budget.
The keynote is, economical administration lies in the point of view of
the Superintendent and associates. Indifference in the attitude of the executive and heads of the departments is fatal.
28 A knowledge of prices and approximate amounts to be used, will cause
heads of departments to be more vigilant in checking waste and impressing
this upon subordinates.
The accounting system of a small hospital should be just as thorough,
accurate and efficient as a large hospital, but the system installed should
consist of simplicity in the form of records and reports, simplicity in the
daily workout and applications of accruing data; and simplicity in methods of collating and segregating data.
No system of cost finding will prevent the wholesale waste of food
stuff which will take place in every institutional kitchen where supervision
by the steward or housekeeper is lax or ineffective. As an alternative to
spending money accruing elaborate data, engage or appoint some person
with good "horse sense" to look after the leaks and compel observance of
the rules of discipline and thrift.
Stores—It is well to have a central store room, in charge of a well
trained responsible person, sufficiently interested in the economy of the
institution to check up daily requisitions, which have already been checked
and signed by the Lady Superintendent. For instance, the person in charge
knows there are 14 teaspoonfuls of tea in one ounce. Sugar has 24 tea-
spoonfuls in one-quarter pound.
She also knows the number of patients in each department. Daily requisitions and drugs should be on the table by 6.00 p.m., checked, signed and
ready for their respective departments.
Drug Rooms—Empty prescription bottles washed, sorted and put back in
stock. Pill boxes recovered by convalescent patients. All clean wrapping
paper and twine' may be saved to advantage. Replace stock supplies on
each ward, viz., lysol, bi-chloride, boracic acid powder, etc., by stock solutions. Soap should be cut in convenient sizes, and allowed to dry for two
(2) months, all small pieces utilized for enemas. All re-fill prescriptions
must be re-ordered and signed by the physician on the case, filed away for
three months, then use the opposite side of the prescription blanks for
scratch pads. There are usually sufficient number of requisition blanks,
which may be cut into convenient sizes for scratch pads. The utilizing of
all lines on the clinical records is a great economy at the end of the
year.
Operating Room—Gauze, swabs, and large gauzes are all reclaimed,
washed and resterilized. If anyone is interested in knowing our method
of washing reclaimed gauze, I will be glad to tell them. We have replaced all gauze and cotton pads in the wards, as well as in the operating
room, by Turkish towelling cut in sizes 12 in. x 14 in., folding it once and
stitching the folded edge. Catgut left over after operations, is boiled and
put in a solution of glycerine, alcohol and bi-chloride, then used for minor
operations.
Gloves with holes are patched and used for minor operations. When
loo old to be of further use, the fingers in good condition are cleaned,
powdered, rolled and used for finger cots. The balance of the glove is
used for compress rubber.
sKitchen—Whenever possible, drippings are used in place of cooking
butter, or its equivalent, crisco, etc. Browned drippings as a result of frying fish, etc., is used for soap grease; our chef makes all his own soap used
in the kitchen.
Rinds of bacon and ham are used for flavoring vegetables. All bread
crusts from the ends of the loaves are toasted and ground, used for gravy
and breading chops in place of cracker meal. Some hospitals in San Francisco, since the commencement of the war, are making bread % white flour,
% bran. % crumbs. The water used for cooking vegetables is poured into
the stock pot for their mineral salts.
Jelly made from fruit peelings and cores, the rind being used as flavoring. Melon rind pickled, seasoned and used as a relish. Our chef last
year put up 10,000 pounds of fruit, never using more than V/i ozs. of sugar
to the pound, we never lost one jar due to fermentation.
A daily requisition from all wards containing the names of the patients, the diet, etc., is sent to the chef.    He cuts all roasts and fowls, etc.,
29 consequently there is very little chance for waste. We give individual service in the nurses dining room.
One of the duties of the junior nurse, assisting in serving the njeals
in the wards, is to give individual service of sugar and bread.
The daily inspection of the garbage can is undoubtedly one of the best
methods to employ in the prevention of waste.
I could enumerate many more small economies, but time will not permit, and my paper would become tiresome.
The staff of the hospital can be of great service in conserving the food
supply of the hospital.
The nurses have more power to prevent waste of food in hospitals
than the administration or medical staff.
The simplification of the diet system of a hospital not only favors
economy in the purchase of food, but efficiency in service.
Food supplies must be purchased and the diets prescribed by the physician ' for patients, without more regard for the cost, than to buy at the
lowest prices demanded for commodities of standard grade. Medical and
surgical supplies of absolute purity and guaranteed quality must be purchased and dispensed alike to pay patients, paying high prices for private
treatment, and to free patients calling at the dispensary.
DISCUSSION.
MRS. C. J. WILKES—
I must commend Miss McKenzie on her excellent paper. Speaking as
a lay person, I may say there are many economies which we can effect in
hospitals. Today I want to take up the question of reclaiming used gauze.
The importance of reclaiming used gauze, owing to the high cost of
this material, which is now required for war purposes, has induced the members of the St. Paul's Hospital Auxiliary to devote a considerable part of
their time to this work, in conjunction with other economies in the hospital. The methods of reclaiming the gauze are the same as those used in
many other large hospitals such as the Pennsylvania Hospital of Philadelphia, the New York Hospital and others, and is accomplished as follows:
The soiled dressings are collected in low-priced 20-lb. automatic
paper bags, held in position by home made frames. Immediately after
the surgical dressings are completed the bags are taken to the laundry,
where the dressings are transferred to net bags, and placed in cold
water in the soaking tank. This water is changed three or four times
during the day. The following morning the net bags containing the
gauze are transferred to the sterilizing washer and washed by the following process:
First, two cold water washes without soap or alkali for ten minutes
each; 2, wash fifty-five minutes in hot soap and water solution; 3, rinse
twice in hot water for ten minutes each; 4, after a small amount of hot
water is placed in the washer, run the cylinder for forty-five minutes
under pressure of twelve pounds of steam. After the dressings are
put through the extractor, they are taken, while moist, to the gauze
room, where they are stretched, trimmed and prepared for final sterilization by the members of the auxiliary under expert supervision.
The trimmings and worn out pieces of gauze are saved and used as
waste in the engine room as required.
While it is generally believed that the process through the washing
machine, especially where steam is turned into the washer, sterilizes the
gauze completely and makes it safe for re-use, the fact that it is sterilized
in the regular way before being re-used, insures the absolute safety of its
application in this way. No case of infection has ever been known as a result of using reclaimed gauze.
The saving of money depends, of course, on the amount of gauze that
is used, but it averages from $15.00 to $20.00 per basket of gauze. This pro*
portionate saving is at least twenty-five per cent, and often as high as thirty-
three and a third per cent.
30 Other economies are the collection of medicine bottles of every description, which are cleaned and sterilized and used again, thereby saving the
management a considerable sum of money each year. Small boxes of all
kinds, and old linen, empty flour sacks, etc, are also collected and used in
many ways.
In. these strenuous times there is no better work for women than helping in any way they can the work of the hospital, as there is much to be done
and much to be saved.
MAYOR GRAY—
There is a great deal to be said on this subject and I trust that
the discussions later will have some bearing on this.
I will now call upon Mr. James A. Benzie, for his paper on
"Hospital Architecture."
"HOSPITAL  ARCHITECTURE."
By Mr. James A. Benzie, Architect, Vancouver, B. C
When invited to read a paper to you as delegates from British Columbia, on the subject of Hospital Architecture, my first intention was to prepare as a line of thought, drawings of a hypothetical building,, or what might
be called a model hospital for a given number of beds.
While such a line of illustrated thought might lead to good results,
on reflection I decided that a talk on general lines would be more advantageous to all interested.
In writing these notes I find myself addressing you in the capacity of
Medical Superintendents, and for the purpose of this reading I have decided
to let it go at that, as being more helpful in concentrating what I have to
say to you .
The subject of hospital architecture is really a very comprehensive one,
calling as it does for a more than general knowledge of .a wide range of
subjects, from architectural composition, building construction and engineering, to medical requirements and hospital administration, not to speak
of electrical, steam, mechanical and sanitary engineering. As no man can
possibly attain to master all such professions, the question naturally forms
in one's mind, "how then can complete success be attained in hospital
architecture?" And in looking back over the past, all my experience goes
to bear out that such a question can only be answered by a compromise,
namely, close co-operation of the medical and the architectural professions.
I could quote many instances from my own personal experience where
some building or another, or some detail or another has been an unqualified
success, or the reverse, altogether in direct ratio to the initial efforts put
forward by the architect on the one hand, and the medical superintendent on
the other hand, to successfully visualize in its early conception just what
function would be required of such building or item in question.
Naturally, there is a great difference of opinion as to the correct management of hospitals, and what may be considered efficiency by one, may
not be so considered by another. This, I think, is conceded by all. So it
behooves the architect, no matter how well he may be versed in hospital
requirements, to approach with an open mind the medical superintendent
with a view to gleaning just what his views are as regards requirements for
any new project or proposal, and so in like manner the medical superintendent, however well he may be versed in modern hospital construction
generally, should in turn lean on the architect for suggestions as to just
what composition and arrangement of modern materials would best meet
the requirements of the case in point.
Therefore, I say again, in any object, or project, in the realm of hospital architecture, the medical superintendent and the architect should at
its early conception get together, discuss and formulate—not what size
a given item should be, or what construction, but rather what are the requirements—and what are the functions, that such or so many items required will be called upon to perform, and information so gathered by con-
31 sultations should be amplified by consultations with heads of departments;
then, and then only,^ should an architect prepare preliminary sketches, and
once these are prepared the time is ripe to again get together, not primarily for the approval of the sketch plans, but rather for criticism. Any right-
thinking architect welcomes, and in fact is anxious, for an intelligent criticism of his early sketches, for many reasons, among which the natural
reason that the sketches have to be developed in any case, and had better
be revised before, than after considerable time and expense have been expended; and another reason why the architect is anxious for criticism, and,
in my opinion a very important one, is that the more a medical superintendent or member of building committee shall criticize the sketches, the
more shall he glean, and be able to size up and picturize in his own mind,
the intention of the sketches submitted, and for that very reason will his
criticism be all the more intelligent and helpful to the architect.
With the foregoing general remarks I might now try to outline in
sequence the line of procedure usually followed in the erection of a modern
hospital building, be it large or small:
1. Choosing the site—A site is unfortunately more often than not a
child of circumstance, maybe it has been bequeathed or gifted, sometimes
may be cast up, shall I say, by a political tide; in fact, more often than
not a site is not all that it should be, through no fault of the management or
selecting committee. A hospital site should be carefully selected; selected
with the same or even greater care than one might select a homesite. An
unsuitable site should rather be discarded, even at some financial sacrifice,
as a bad site will always be a negative force in the efficiency and success
of any institution.
The ideal site to my mind, should fulfil the following natural requirements Firstly—natural drainage, sunny aspect, bracing airy elevation,
while for choice sheltered from cold winds; and secondly, quietness, a restful vista, and generally one best suited to uplift the spirit of the patient.
Naturally, hospitals must be close to their activities, and so in and around
large communities, great judgment has to be exercised in the choosing of
a site to meet the natural requirements, and at the same time avoid the
natural disadvantages, such as noise from traffic or railroads, smoke and
dirt from factories, unsightly outlook and such like. This raises the question for a city hospital of distance from the centre of the city in which
respect local conditions must always be your guide, and given full consideration.
Naturally, a city requires an emergency hospital close in, whereas an
institution catering to a well-to-do class of paying patient may be further
afield, so that where a general hospital is required, judgment must be used
as to what might be the happy medium from all points of view in the
selection of the site.
2. Block Planning—The site having been definitely decided upon as
good, the next step is the general massing or block plan. This should be
decided on broad lines, that is, bearing in mind possible future extension
and development, and to so arrange the present part or unit, in such a way
that it may form a part of an ultimate scheme of development and that
with a minimum of structural alteration.
Naturally, the main consideration on the general disposition of the
buildings should first and last be given to sunlight, which, as a destroyer
of micro-organism you know more about than I can tell you. The general
block plan for a medium or large-sized hospital can naturally be laid out
in a variety of designs, but where space and money are not the determining
factors, possibly the best general arrangement is a series of pavilion buildings each isolated but connected by a system of covered ways for the distribution of supplies and administration. These covered ways may be partially or wholly closed in, while under the floor of such a subway may be
constructed for piping, etc., in a very economical manner.
Such systems and layouts are expensive, both on capital account and
administrative cost, and as it is not my intention in this paper to deal with
the large hospital in particular, I shall not go any further into the question,
tion.
32 Next in order of economy for general block planning, I would mention
what is known as a semi-block system, that is, a series of semi-isolated
pavilions, all connecting with a main corridor for medium-sized hospitals,
or connecting direct with an administration building in the case of smaller
hospitals. Such a system is well suited to cities where the cost of land is
usually a consideration. Such semi-block system, however, is more or less
adaptable to hospitals of all sizes, and one which I would recommend for
any hospital over thirty beds, for the reason that just as American designers are going more and more for semi-private wards of two, three or
four beds, in lieu of the old general ward, with the object of isolation and
classification of patients, for the same reason I incline to the system of
more units in lieu of this old style of one large block. Such semi-block
designs may be constructed for two or more units and at the same time allowing for unlimited addition.
3. Designing the Unit—The requirements of each unit will naturally
vary according to the size of the hospital, but a typical unit should contain
a general ward or wards, private ward or wards, toilet and baths for patients and staff, diet kitchen, utility or sink room, office for nurse, and cabinets for linen, medicine and housekeeping utensils. Where units are duplicated or repeated, the cost naturally decreases proportionately, illustrative
of which assertion I might mention the Military Annex Building at the Vancouver General Hospital; each unit is exactly one-eighth of the whole building and was so designed to accelerate construction and afford economy.
4. Size of Wards—The size of wards generally is regulated in most
cities by regulations providing for the minimum area and cubic feet of air
space per patient, as 80 sq. ft. and 800 cu. ft. respectively. Other useful
figures quoted by authorities are 8 ft. froril centre to centre of beds for
single wards and in the case of double wards, also 8 ft. from sentre to centre
and 8 ft. between the row of beds, which after allowing 6Yz .feet for each
bed and the head of the bed 18 inches off the wall, gives a total width of
ward, 24 ft. Such dimensions are, I maintain, too liberal and extravagant.
5. Administration Unit—In smaller hospitals the administrative unit
would naturally provide for admitting and discharging, and examining offices for superintendent and staff, all on the ground floor, while the kitchen
service, staff, dining rooms, etc., are oftentimes placed in the basement, but
in my opinion, are better in a separate unit and above ground. The upper
floor of an administrative unit is the logical place for operating room suites,
dressing and sterilizing departments. Naturally, in a cottage hospital, all
these requirements have to be condensed, both as to number and size.
6. Construction—Regarding construction generally, I will exhibit for
your information a few scale drawings, showing some modern forms and
details of construction and finish all on the latest lines of modern hospital
construction, all of which are along the lines of profiles or forms so designed as to give a minimum chance for germs and a maximum chance for
the house cleaners.
7. Cost Data—As to cost data. I know you are all well aware that
prices at the moment are all more or less abnormal, but in my opinion, high
prices are likely to prevail for some years after the war.
Architects  and others  accustomed to  estimating the  cost of buildings
have adopted the unit prices per cubic foot of building as a basis of comparative costs based on past examples, but these have to be applied in the
full light of experience, knowledge of local conditions, and with the judgment of one knowing the state of the material and labor markets.   With
this word of warning I might quote you the following approximate costs
as a guide to cost of construction in British Columbia:
For small hospitals of frame construction,
plain   detail,   lath   and   plastered   interior ;   shingle  exterior 20c
For semi-fire proof buildings, that is brick
exterior, but mill construction interior,  well  finished 30c  to  35c
For Class A. constructions, fireproof building; well, but not elaborately finished 45c to  50c per cu.
33
to  25c  per   cu.   ft.
per  cu.
ft.
ft. Costs in pre-war days would be reduced from 25 per cent, to 50 per
cent, less than the above figures, such trades as plumbing and heating being largely responsible for the present high costs. Plumbing and heating
in normal times should run each about 2jl per cent, to 3 per cent, of the
total cost of the building, but today they run very much above that. I have
had cases lately where plumbing and heating combined ran to 30 per cent,
of th whole building, but this was in the case where the building was of
the cheaper class, whereas the plumbing and heating were of good standard.
Cost of equipment may be computed at approximately 25 per cent, of the
cost of the building.
The cost of hospital buildings fully equipped may be calculated in round
figures as from $1,000.00 to $1,500.00 per patient for the less expensive construction, and from $1,500.00 to $2,500.00 for the better class of fireproof
construction.
Before concluding, I might say I have tried to deal with the subject from
your point of view, that is, from the medical viewpoint, more than from a
strictly architectural one. Not that Art should have no place in hospital
architecture—far from it, for as I have said in dealing with the choosing
of a site, that which is beautiful and restful is all important in the upbuilding
of the patient; therefore let your hospital building be not only restful and
beautiful in their spirit of rendering, but inviting and dignified in their
massing and composition, and the small outlay thereby caused will be amply
justified in the years to follow.
DISCUSSION.
DR. MacEACHERN—
If the architect desires to get a good institution and a good result he
must consult not only the superintendent but also the heads of the various
departments who have to work therein, and who through their actual years
of experience can give good suggestions. He must confer with the superintendent of nurses, supervisors of the different departments, the dietitian
and other officials, and take into consultation various members of the Board
of Directors.
The infectious block plans shown by Mr. Benzie were intended more to
demonstrate to you a practical observation block which all hospitals should
have. It is needless to mention the advantage of an observation section for
any hospital, where cases with doubtful diagnoses and possibly of an infectious nature can be temporarily detained.
MAYOR GRAY—
The next on the programme is a paper by Mr. R. B. Leders,
Purchasing Agent for the Vancouver General Hospital, on
"Standardization of Hospital Equipment and Supplies."
"STANDARDIZATION OF HOSPITAL EUIPMENT AND
SUPPLIES."
By R. B. Leders,
Purchasing Agent for the Vancouver General Hospital.
Many points of material interest could be dwelt upon to great advantage
on an occasion such as this. Although only a limited time may be spent in
considering this question of standardizing equipment and supplies, still here
we may look closely into the most essential points as we proceed.
It has been thought it would be very beneficial on the part of hospital
superintendents and boards of management to consider carefully and
seriously the advisability of establishing a Central Bureau of Purchase and
Supply in the most convenient centre, there being, I understand, some one
hundred hospitals throughout this Province (large and small). If an
arrangement such as this were made, supplies of all kinds could be purchased
to great advantage—more especially if discounts could be taken, e.g.:   on
34 dry goods, a cash discount of 4 per cent, could be obtained; groceries, 2 per
cent.;   surgical instruments, 2 per cent., and in some cases 5 per cent.
CENTRAL BUREAU.
I have read in the publication, "The Modern Hospital, July, 1915 issue,
of such an arrangement being in force in the State of Maryland, U. S. A.
I quote an extract from same:—
"An excellent feature of the methods of purchase adopted by the
co-operative purchasing committee of the State of Maryland consists in
the fact that the superintendents of the various institutions form the
purchasing committee and are held responsible by their respective boards
for the careful and economical purchasing of Supplies. Supplies are
purchased quarterly, with the exception of coal, which is purchased
during the month of April for the ensuing year.
"The following schedule has been arranged as being the most convenient way for grouping the supplies for quarterly purchasing:
"For the quarters beginning June, September, December, March—
groceries, laundry supplies, paints and oils, rubber goods, curled hair,
tobacco, cigars and pipes.
■ "For the quarters beginning July, October, January, April—dry
goods, house furnishings, drugs and chemicals, tin shop supplies,
engineers' supplies, broom shop supplies, furniture.
"For the quarters beginning August, November, February, May—
notions, blacksmiths' supplies, hardware and carpenters' supplies, clothing, boots and shoes, leather and shoe findings.
"In November Christmas supplies also are purchased.
"Requisitions for articles included in any of the above classifications
required for the quarter are sent to the office of the purchasing committee on the fifth of each month. Upon the receipt of these requisitions
from each institution, a total sheet is prepared, on which are entered all
the different articles (by specification numbers) for convenience and
accuracy, the amount required by each hospital and the total of each
item estimated. From this total sheet there is then prepared on Form 3
a request to bidders containing the items upon which the firms are to
bid, giving the specification number and the name of the article in
brackets, but without a full description, and the total quantity wanted,
with the unit to be used. The name of the institution does not appear
on this sheet.
"For the purpose of illustration, a few items of groceries may be
considered. Printed specification sheets have been prepared and placed
in the hands of the bidders, which describe fully each article, in order
that the bidder may know exactly what he is to bid on. Each article
is given a specification number. For instance, under Groceries, No. la
refers to 'Sugar (fine granulated)'; No. 2a, 'Coffee (Bourbon Santos),'
etc.
"Each institution is furnished from this office with a full set of
specification sheets covering every classification, and is always required
to order articles by specification numbers, which greatly expedites
matters and insures uniformity. Each institution also has a copy of the
schedule governing the purchase of supplies; and each month, upon a
given date, it must send to the co-operative purchasing committee a list
of the articles required as supplies for the next three months. The list
of articles under the different classifications is very large, and is intended to cover every supply that has been used or will be required in
the hospitals. If, however, an article is wanted by the hospital which
does not appear on the specification sheets, such articles may be described
fully on the requisition blank, in a column for the purpose, the specification number being left blank, for the specification number to be supplied
in the office and added to the specifications."
35 Items of most vital importance as follows:—
HOSPITAL GAUZE.
If a standard quality of, say, 21x12 threads were decided upon by a
committee of supervision, the head of the Bureau could in all probability
get in direct communication with the manufacturers and arrange for one
plant to supply the total requirements and make a direct shipment to the
various hospitals at intervals to be arranged. This would also apply to
bandage rolls, cotton batting, absorbent cotton, sheet wadding, sheeting,
sheets, pillow-slips, quilts, blankets, patients' gowns, convalescent suits,
and many other articles, too numerous to give in detail just now.
WARD STANDARD.
Here is a supply standard for a ward of forty beds worked out, showing
how many sheets, blankets, etc., down to kitchen equipment, which I would
like those interested to look at. It is well known that efficient work cannot
be done unless the nurses of a ward are supplied with the necessary articles
and sufficient of them.   There should be a ward standard.
STANDARD WARD EQUIPMENT FOR FORTY BEDS.
Linen.
Draw Sheets     80
Sheets   160
Spreads ~iSi    80
Pillow Gases  160
Blankets, White   ...Jj.;  120
Grey      6
Towels, Bath  _   80
Face   160
"        Doctors      80
Glass       20
Towels,   Tea    20
Roller   10
Nightshirts    80
Tray  Covers    80
Napkins    80
Toilet Bags   40
H. W. B. Covers  30
B. P. Covers  40
Bath Mats   4
Washcloths   80
Rubberware.
Rectal Tubes ...
Catheters 	
Rubber Aprons
Sheets
      6
      6
2
(large)    40
(small)    12
Pillow Cases _      6
Kelly Pad 	
Hot Water Bottles
Ice Caps 	
Lavage Tubes	
Biers Bandage 	
1
18
18
2
2
Enamelware.
Pitchers (large)  6
"       (small)  6
Trays ....:  12
Irrigating Cans   4
Wash Basins   12
Foot Tubs   4
Kidney Basins   18
Instrument Pans   2
Solution Basins   12
Bed Pans   18
Douche Pans —'  2
Urinals ....  16
Glassware.
Catheters 	
Douche Nossels	
Glass Syringes .~	
"     Jars 	
Thermometers, Bath 	
Clinical, Mouth..
Rectal....
Glass Graduates, 500 cc	
10
10
2
2
2
10
2
3
Glass Graduates, 250 cc  2
Minim Glasses   20
Medicine Glasses   20
Alcohol Lamp  1
Connecting Tips   10
Irrigating Tips   10
Medicine Droppers  4
Atomizers ^  3
36 Instruments, Etc.
Scissors, Suture     10
Bandage  2
Artery Forceps  4
Tissue         "       10
Probes  10
Mouth Gags   2
Head Mirrors  2
Throat Mirrors   2
Scalpel    2
Razors ,  3
Hypodermics     • 3
Ear Speculum   2
Tape Measure   2
Drop Lights   10
Stethescope   2
Aspirating Sets   ?
Tycos B. P. Sets  2
Furniture.
Beds   	
Tables, Enamel
Chairs 	
Wheel Chairs 	
Wooden Tables .
40
40
40
3
3
Screens 	
Irrigating Poles"
Mattresses 	
Pillows 	
16
40
80
Cleaning Gear.
Brooms, Hair 	
"       Corn 	
Whisk   	
Brushes, Radiator	
Long Handle Wall	
Dust  _	
Hair	
Scrubbing         2
Stove       2
Brushes, Sink   2
Hopper   3
Urinal   2
O-Cedar Mops   2
Mop Pails    3
"    Handles    2
Garbage Tins   3
Dust Pans   3
Step Ladders   2
Dishes and Silverware.
Cups	
Saucers	
Large Plates   	
Bread and Butter Plates..
Sauce Dishes 	
Soup Bowls	
Drinking Cups  _	
40
40
40
40
40
40
40
Salts  	
Peppers	
Knives	
Forks   	
Teaspoons  	
Dessertspoons
Pitchers  	
40
40
40
40
40
40
10
Kitchen Utensils.
Granite Pitchers   3
Milk Pails   2
Soup Ladles   2
Carving Forks   2
Knives   2
Bread Knives   2
Can Openers  2
Egg Beaters
Lemon Squeezers   .
Strainers, large 	
small	
Double Boiler 	
Frying Pan, large
Gas Range ....
Steam Table
Tray Rack ....
Refrigerator
Frying  Pan,  small    2
Nutmeg Graters   2
Corkscrews   2
Ice Pick   2
"  Mallet   2
Drinking Tubes     10
Metal Trays   16
Wooden Trays   40
Granite Spoons, large  2
Egg Lifter  2
Tea "Kettle   2
Potato Masher  2
Serving Kitchen.
      1     Garbage Tins   2
      1     Serving Table   2
      1     Dish Cupboard   1
      1     Food Carrier   1
Nurses' Office.
Desk      1     Small Tables       2
Desk Chair       1     Medicine Cupboard       1
Office Chairs       2 Utility Room.
Ward Sterilizer       1     Dressing Table
Dressing Carriages       2
Desk  	
Desk Chair
Doctors' Room.
      1     Examining Table
      1     Office Chairs	
Ward Dressings Used.
Large
Medium
Small
Four Gauze Pads (four in a packet)
Cotton Balls
Sponges
Rolls
White Packing, y2", 1", 2", 4"     «
Iodoform Packing, Y*", 1", 2", 4"
Mastoid Packing (Iodoform), %"
Perineal Pads (12 in roll)
Lint
Double T. Binders
Many Tailed Binders
Straight Abdominal Binders
Gloves
Gauze Bandages
Cotton Bandages
Woollen Bandages
Miscellaneous.
Mouth Wash Cups    20
Mortuary Basket	
Dressing Baskets 	
Vases	
Waste Baskets	
Pen Holders  _	
1
2
20
2
10
Rulers   2
Ink. Wells   2
Brushes     2
Combs   2
Bed-rollers, Sets   2
Shock Blocks, Sets   2
A ward is stocked (as mentioned before) from sheets to knives and
forks. An inventory book is provided, and stock taken and checked each
month; on a given date, breakages and worn-out articles are replaced. Here
I might mention that part of the nurses' training should be "Economics."
Many of these breakages are due to some careless person, who, at the time,
does not think whether the article can be replaced or not. It is then up to
the steward or buyer to spend valuable time hunting, sometimes in vain, to
secure something that is now off the market, or provide a substitute. This
latter condition would, of course, not exist if all articles were standardized.
The following is a linen standard:—
LINEN.
Drawsheets are made from 8/4 (meaning 36 inches wide) unbleached
twill cloth.
Sheets, from 8/4 best plain bleached, heavy quality.
Spreads—Dimity Searsucker, 82"x90".
Pillow Cases—Heavy Indian Head.
Blankets, White—Wool. 6 lbs., 56"x76".
Grey—Wool, 7 lbs., 60"x80".
Towels, Bath—No. 60, 23"x45", Plain (no fringe).
Face—18"x36", Cotton Huck.
"       Doctors'—15"x27", Union unbleached.
"       Glass—18"x36". Linen.
Tea—18"x36", Linen.
Roller—18" x 2% yds., Scotch Linen Crash.
Nightshirts—Middy Twill.
Tray Covers—20"x23", Indian Head.
Napkins—12"xl2", remnants of above.
Toilet Bags—A. C B. Ticking.
Clothes Bags—12 oz. Duck.
H. W. B. Covers—A. C. B. Ticking.
B. P. Covers—A. C B. Ticking.
Wash Cloths—Turkish Toweling.
38 Serving Kitchen.
We are in the enviable position of having a Superintendent of Works,
who is an expert on woodwork, having been a carpenter and afterwards superintendent of a woodworking plant. He therefore is in a position to supervise the putting together of a great deal of our ward furnishings. For
instance, patients trays, serving tables, dish, utility and medicine cupboards, tray racks, small tables, bed screens, splints, nurses' desks, samples
of which are on exhibition and have been adopted as our standard, are all
assembled in our own work shop. A considerable saving is made by cutting out the manufacturer's profit.
Ward Food Carrier.
About a year ago a change in the system of serving the patients was
adopted, which proved to be a saving. A platform wagon was provided
each ward, on a plan suggested by our then Lady, Superintendent, which
has provision for four containers for soup, meat and two vegetables.
Formerly the trays were made up in the ward kitchen, each plate was
fixed up in the same manner, a like quantity of meat or fish, potatoes and
vegetables, whatever was provided according to the menu for the day. There
was then considerable waste because patient A did not wish any meat, potatoes or other vegetables, as the case may be. This was then consigned
to the garbage can. Not so now. This wagon is wheeled around from bed
to bed, patient A is served with just what he cares for, probably a small
portion of meat and no potato or vegetable.
Catgut.
Recently we had a great deal of trouble with the catgut provided. Considerable difficulty was experienced for some time in the preparation of the
raw material which was on the market, the alcohol being of a very inferior
quality, it was therefore decided to purchase what is known as "Perfection,"
prepared by the makers all ready for use, in glass tubes. This change
proved very beneficial, both from the economic side as well as the satisfactory work. It is also wise to arrange a supply for a certain, length of
time, so that the supply house may protect themselves against any possible
shortage, if an estimate of monthly or quarterly requirements were provided.
Food Stuffs.
Now to touch on the supply of food stuffs Previous to this year the
Vancouver General Hospital has made yearly contracts for supply of meat,
fish, milk, ice, bread, but owing to conditions which exist today this arrangement could not be entered into, but as a general rule this is a wise
procedure.
Groceries are bought monthly by tender, procedure as follows:
Requisition of requirements as Exhibit No. 2, is mailed to the wholesalers on or about the 26th of each month, being returned in tender form
about two days later. Figures, quality and quantity are then checked and
contract awarded.
I have chosen a few items for explanation, as the question might arise,
"Why do you buy prunes of forty to fifty size? The reason for thiss is—the
stone is much the same size and there is more meat, and cooks up to better
advantage.
Sago and tapioca are specified by second grade, namely—Fancy, because
of price, and quality is good enough for use in large quantities.
Canned Goods—Goods packed in British Columbia are specified whenever possible.
Coffee—Combination of Bourbon Santos, Guatamala and Bogota is used,
the first named as a filler, second for acidity and body and the latter for the
fine flavor and also adds to the body. This blend gives quality equal to
price which I have set.
Tea—A blend of Ceylon and Java so as to keep within price and secure
about two hundred cups per pound.
39 Stationery.
I have provided a complete file of forms in use at the Vancouver General Hospital, which are on exhibition.
A few words about the system of dealing out supplies of all kinds might
be of interest.
Staple articles for ward use from the store are given out every morning
at eleven o'clock.
Form No. 3 is filled in, in duplicate, by the head nurse each morning, first
sent to the Lady Superintendent's office for checking and signature, passed
on to the Dietitian, in order that she may make a list of special diets, if any,
dictated by the doctor; the book is then sent to the store room. Each ward
is provided with a large tray and containers. These are taken to the store
room by the ward helper (not the orderly) and at the time as arranged,
namely, eleven o'clock, this helper returns, checks the quantities with the
clerk and then takes these supplies to his ward. On Friday he returns his
tray again, in order that cleaning supplies may be given out.
Form No. 58 is used for extra supplies when needed, also for stationery
which is given on Saturdays.
Form 3
WARD.
DATE 191.
REQUIREMENTS
Bread, White - (loaves)
Brown-
|      French
Butter    -      - lbs.
Tea
Coffee     -      - "
Cocoa     -      - "
Biscuits -      - '-
Graham Wafers    -
Oranges -
Lemons -      -       -      -
Eggs      -
Sugar, White-
"     Brown-
Jam-      -
Marmalade    -
Requested by
Approved by-
Checked by	
HEAD NURSE
SUPT. OF NURSES
HOUSEKEEPER
Filled by	
40 Form 58
REQUISITION
-191.
The following supplies are required for :
Ward	
Two Branches.
We have also our two branches, namely, Marpole Annex and the Infants' Department, to provision. As soon after the first of each month as
convenient, a monthly supply of groceries, cleaning supplies are sent to each
place, and daily trips are made by a small delivery car with the more perishable articles, such as meat, fish, butter, bread, etc.
Dishes.
To provide against the possibility of wards using dining-room dishes,
a system of colors is carried out Public Wards are provided with what is
known as Green band, heavy.
Private Wards—Blue band.
Isolation Wards—Plain White.
Doctors' and Nurses' Dining-rooms—Brown or Key Pattern.
Military Annex—White and Gold (Shamrock Pattern.)
Marked Dishes—White and Gold (Plain).
In conclusion, I regret that time is so limited for this big subject—and
one I am sure you are all interested in. I hope this paper may arouse more
interest and more serious consideration to this very important matter which
confronts all hospitals, and that at present requires such attention as it
involves many economic problems.
DISCUSSION.
DR. MacEACHERN—
A central purchasing bureau for the hospitals of British Columbia
would be a distinct advantage to all, but something that we cannot expect
to have for a while yet in so young an Association. However, if we had
such a bureau, all supplies could be standardized and you could at all times
get the proper kind at the best price, and such lines as the large dealers
throughout the Province could keep. There would be a distinct economy in
such an arrangement.
MAYOR GRAY—
The meeting- will now resolve itself into round table conferences, which will be conducted by Miss McKenzie and Miss Sinclair.
41 ROUND  TABLE  CONFERENCES.
Conducted by Miss McKenzie and Miss Sinclair.
A B. C. Hospital Produce Day for the donation of fruits, produce and other
food supplies, together with the collection and distribution of same on a pro rata basis.
MR. DEVINE—
This is a subject that I am deeply interested in and, I dare say, every
person connected with hospital work. The suggestion is to have one day
a year for the giving of produce to the hospital. In some cases possibly
the patient who has not the means for paying his bill, for instance, might
grow some little thing in his garden, giving to the hospital possibly say a
bunch of onions, a few pounds of potatoes, some plums, or any kind of fruit,
and increasing the amount as the case might be; in fact, the well-to-do
farmers might give a ton of potatoes. In this way a large amount of produce
can be donated.
The collection of these foods might be arranged for and brought to centres from which they could be distributed pro rata. In cases where such
fruit was given in large quantities, arrangements could be made whereby
the women helpers would come in and can the fruit that could not be used
by eating right away, and so with many other things.
In this way we could give the general public a chance to give something other than money, which they may not have, and each hospital throughout the Province I feel sure would get enough of the stable commodity to
last them the entire season.
I feel confident that the railroads and the different transportation companies, even to the automobiles, could be secured and used almost free of
cost for this undertaking.
It appears to me that if a good live committee were formed at this Convention and means to develop this scheme were arrived at, that it could be
put in force this autumn. We all who are connected with hospitals in one
way or another know that vegetables and fruit enter more and more, especially under the food conservation, into our dietary and that of the hospital.
MAYOR  GRAY—
There' is a good deal in what Mr. Devine has said. The only thing I
don't agree with is that the patient should pay his bill in trade. The hospital has power to collect from the municipality for the case. I think we
should have a day or probably a week in which we would receive donations
for the hospital; particularly in the Fraser Valley, as the amount of fruit
that goes to waste each year throughout the Valley is something tremendous. I know of whole orchards where they don't attempt to pick the fruit
at all.
MR. DEVINE—
It was only a matter from a gratuitous standpoint. We want the money,
and the patients must know that they have had more than money can repay, and from that point they cannot give any more except a gift in kind
MISS   ANDREWS—
I do think that sometimes people do not appreciate all that is done for
them in the hospital.   Sometimes they are able to pay and sometimes they
are not, and I think Mr. Devine is quite right.    Possibly they may be able
to pay in produce when they cannot pay all in money.
MR. MORDY—
I am quite in favor of the remarks and think a great deal can be done for
the maintenance of the hospital by this hospital day once a year.
We are in the centre of a mining district where there is a small farming
centre a few miles out, and during the past year we have had an experience in that regard. There was a campaign for raising funds for our hospital and a canvass made of the district. A number of the farmers were
not supplied with ready cash but gave very generously of farm produce.   I
42 do not think there would be any difficulty in getting a very substantial donation in this way and the scheme is very practical and sensible.
DR.  WRINCH—
We can do very nicely with apples at Hazelton, but do not know whether
the transportation companies would assist. I gather that the' proposal is the
collecting of all this produce into different centres from which distribution
would be made to the different districts.
MR.  GRAHAM—
In mining communities where there is little produce, the question of distribution would enter into this to a great degree. It seems to me it would
be rather a difficult matter to distribute throughout the various places so
that it could be done on a fair and reasonable basis. It looks more like a
local proposition.
MR.  MORDY—
I might say that it strikes me as rather a difficult matter to handle a
large quantity of fruit and vegetables in such a way that they could be conserved for future use. If you have a donation day for produce you might
get such a quantity of fruit and vegetables donated which, no doubt, in the
case of Vancouver, could be utilized, but in the case of small hospitals
would be impossible to utilize. This proposition might be handled by the
Women's Auxiliary in many cases.
MISS  AITCHESON—
I have been requested to mention that in Summerland we have an Egg
Day.   The people are requested to bring eggs to the hospital.
MRS.   BROOM—
In Montreal we had a Pound Day and it was a very profitable one, indeed.
We would accept a pound of butter, a pound of bacon or anything like that.
DR. MacEACHERN—
I suppose in Vancouver we would have to have a Fish Day. We have
had considerable discussion on this now and I think it is a proposition
which possibly could be referred by our Association to a committee to see
if it could be worked out from a practical standpoint.
Increasing the public ward rate from $1.00 per day to $1.50 per day throughout the Province.
MISS McKENZIE—
I think the hospital rate should be raised from $1.00 to $1.50 per day.
This cannot be done without special legislation, and I think our organization could appoint a committee to interview the Government on this point.
DR.  WRINCH—
Where did the rate of $1.00 per day originate for public wards ?
MISS McKENZIE—
This rate is fixed by the Government and is all you can charge. There
was no co-operative action in this matter in approaching the Government
last year during session. I know that the Vancouver General Hospital approached the Government with a view to getting an increased grant and we
also approached them on certain matters, but in my opinion all hospitals
should unite and take up this question. The question has not been raised
as to whether or not we should unite to ask the Government for an increased grant. Last year the only increase made by the Provincial Government was increasing the rate for tuberculosis patients to $1.00 per day.
This was an excellent move. I think we should have an increased per capita
rate from the Government rather than permission to charge a greater rate
to the public. Our public cannot stand a greater rate than we have
charged. I think we are charging the public as much as we can, and I doubt
if an increased ward rate will bring us in any more revenue, but if we can
get the Government to pay a little more, it would be certain. I hope when
this question comes up it will be entered into thoroughly.
43 All hospitals receiving Government aid are now required to take in Tubercular cases, incipient or advanced.   Would it not be best
to have compulsory segregation of all, or
at least, advanced cases?
DR. ROGERS—
If a hospital is in a position to build a ward to segregate these cases, it
should be done.   If they are not in a position to do it, I suppose the Provincial Government could be called upon to help.
DR.  MacEACHERN—
Every hospital receiving Government aid has to provide ten per cent, of
its accommodation for tubercular cases. If you cannot afford to make this
extra accommodation, I suppose then the Government should assist. However, apart from all this, tubercular cases should be segregated and very
especially the advanced cases who are constantly disseminating bacteria.
What is the best and most economical way for a fifty-bed hospital to
sterilize pillows and mattresses?
DR.   WILKES—
In Nanaimo we recognize that the only efficient way to sterilize these
was to get a sterilizer, which is rather an expensive outlay for a small hospital. We would like to hear discussion on the kind of sterilizers that are
to be obtained and also discussion on how this problem has been solved in
other small hospitals.
DR.  MacEACHERN—
Every hospital with high pressure sterilizers and live steam can do this
effectually. Therefore, in the smaller hospitals where such is not obtainable, more difficulty will be encountered. The only dependable way is by
heat sterilization.
(This question will be taken up later.)
The affiliation of small hospitals with large ones for the purpose of giving
a   short   course   in   the   nursing   of
Infectious Diseases,
MISS  FORSHAW—
Speaking from a graduate's point of view, I do not believe that there
is any place in British Columbia that offers a thorough post-graduate course
in infectious diseases.   If there is any such place, I would like to know.
DR.  MacEACHERN—
We do give post-graduate and affiliated courses in the Vancouver
General Hospital. We have a great number of patients in the various infectious wards during the year, but we regret to say that our buildings are
not modern and therefore we felt that we could not give as good accommodation and possibly as up-to-date experience in this line as we could in
other lines, and we have accordingly not encouraged it.
Certain training schools throughout the Province are affiliated with
us. Nurses come here after they have spent two years in their own hospital, and finish up their third year. They graduate, however, from their
own hospital. Two or three hospitals have taken advantage of this privilege, Chemainus having sent us several nurses'. We find this works out very
well in many cases.
In infectious diseases, a course which we could give should be good,
but the number of patients varies as low as one and two at times, up to
a large number during epidemics.
In addition to our affiliation course we have the regular post-graduate
work in" every line.    Personally, now that it has been brought up, I think
possibly a post-graduate course could be arranged.
MISS   McKENZIE—
In Victoria we have nothing to do with this department, as it is under
the City Health Department. I understand Seattle can give a good course
in infectious diseases. I do not know of any hospitals in British Columbia
who are ready to give a post-graduate course in this work if the Vancouver
General Hospital cannot.
44 MR. STEWART—
Has it ever occurred to you, Dr. MacEachern, to establish a school at
the Vancouver General Hospital for nurses, like a normal school?
DR.  MacEACHERN—
It has occurred to me that the University of British Columbia should
establish a chair for nursing and that the hospitals throughout this entire
Province could affiliate their training schools with the University and the
University see that the hospitals were supplied with capable teachers in
different places. In this way a uniform standard course could be given to
all nurses in the various hospitals where they receive the practical experience necessary. When you analyze the ability and efficiency of different
nurses from different schools, you cannot help but feel that there is something wrong, and there is need for more uniformity, standardization or centralization of training.
In Montreal I had charge of a hospital where we received nurses for
maternity training from four or five different institutions. Here you saw
quite a difference in their training, all other things being equal.
For efficiency, therefore, if we in British Columbia want to come to our
own in short time on this question, we must get our training schools on a
jjroper standardized basis as will be explained to you tomorrow, and we must
get a uniformity of teaching, whether it be through the University or otherwise.
I am not satisfied with the way in which these questions are being taken
up and discussed. It seems to me that you are not prepared to lead the discussion on the various questions, and I would like suggestions as to what
is the best way of handling this, to be taken up at a later session.
Moved by Miss McKenzie, seconded by Miss Sinclair:
THAT Mr. Mordy, Mr. Stewart and Mrs. M. E. Johnston be a committee to take up the various questions, classify them and assign them to
various members of the Convention to discuss on the following day.
Carried.
MAYOR GRAY—
This brings our programme for the afternoon to a close.    We
trust that you and all your friends will be back tonight to hear
the four addresses which will be given and which are of great importance to this Province.
Meeting adjourned.
EVENING   SESSION—Wednesday, June 26th, 1918.
DR.   GATEWOOD—
I am going to request our good friend Mr. Grimmett to take
the meeting tonight.
MR.   GRIMMETT—
As the addresses tonight are all along similar lines, I would
suggest that we hear them first and have the discussion after.
(This was agreed to.)
I will now call on Dr. H. E. Young, Secretary of the Provincial Board of Health for British Columbia, for his paper, "The
Hospital as a Community Service."
"THE HOSPITAL AS A COMMUNITY SERVICE."
By Dr. H. E. Young, Secretary Provincial Board of Health.
The object of this Convention might be called a great get-together affair
of people interested in hospital management. I am a very firm believer in
Conventions of this kind. A great many people in the country are imbued
with the same idea of being a help to their fellow citizens in some measure
45 and as a result we have men and women who are willing to devote a portion
of their time and to give their services freely towards the advancement of
the common interests of the municipalities, and willingly serve as
school trustees, municipal councillors, or on hospital boards. Very
often their zeal and their willingness outruns their knowledge of the best
way to obtain the results which they have vaguely formulated in their own
minds. There is no one in their communities who has any greater knowledge
of the subject with whom they can consult and as a result they grope along
learning by experience but, unfortunately, the knowledge they are acquiring
in this way is at the expense of real efficiency in the management of the
institution with which they are connected. They have not the opportunity,
very often, of meeting others engaged in similar work in other parts of the
Province, much as they may desire to talk over the knotty points that arise,
and I think that we are to be congratulated that those, in charge of this Convention, have given us the opportunity to meet and to discuss questions of
mutual interest, to present our individual ideas, to listen to the presentation of those of others, and to meet, face to face, with those who are actuated by the same motives. The questions that present themselves to those
who are connected with hospital work are complicated and varied. They
cover a wide range of subjects and one has only to glance at our programme
to appreciate the fact that the term "hospital" embraces many, and on the
face of it, divergant interests, yet all interlocking and all aiming for the
ultimate result we all desire, viz., a well equipped and efficiently managed
hospital. This is an age of specialization and we find, especially in medicine, that as our knowledge increases that the term "medicine" means something made up of many branches, each in itself requiring special training
and a life devotion in work to carrying it out. The results obtained in the
work in each branch must be corelative with that of others and the knowledge
gained weighed, compared and balanced with others in order that we can
arrive at a definite conclusion in the understanding, management and treatment of disease.
The primary idea of a hospital was that it was a place to go when one
was sick, a place to be dreaded, and people avoided it if possible. It was
looked upon as a reflection upon the ability of people to look after their own
sick when it was said that one of the family had gone to the hospital. With
the great adyances that are being made this idea is being eliminated from
the lay mind and people are beginning to understand that the hospital has
become a community centre, supervised and officered by persons skilled in
the treatment of all forms of disease. So much so, that instead of being
avoided we are willing to take the opportunity of going to the hospital when
necessary, and the laity are progressing so far now as to demand that hospital accommodation shall be provided for each and every one of us. They
are recognizing the fact that in the development of medical science the sociological side has become really the most important. They are realizing that
by the development in medicine we are increasing our knowledge of how
diseases are spread and are realizing more and more that the mode of our
daily life and our environment has such a bearing on disease that they are
demanding protection from the inroads of disease. They are demanding that
the knowledge that we are learning in the laboratory and in the wards of
the hospitals and by the investigations carried on by our boards of health,
shall be given practical application in the protection of the health of the
public.   In other words, they are demanding prevention of disease.
Since the outbreak of the war in 1914, conditions in the nation have
been such that we never dreamed of. Demands have been made upon our
resources that has taught us that rich and prosperous as we are, we have
not been able to meet the demand without economizing, and we have been
taught by bitter experience that the slipshod, hand-to-mouth existence that
we were leading is not such as lends itself to the preservation of what we
had, nor did it show that we were equal to meet the enormous demands that*
have been made- upon us. Fortunately, we are of a race that has in its
history met emergencies and we are meeting them today conscious of our
effort to win and with that as our first consideration we have also made up
46 our minds to do what stern necessity has taught us, that it shall be a lesson
for the future and we will not be caught napping again, that our line shall
be so ordered that conservation of resources will become one of the first of
the nation's duties and conservation of resources means to us, more particularly connected with medical and hospital work, the conservation of the
man power of the Empire. We have been taught the great value of cooperation as shown by the work done by the co-operation of our own armies
with that of the Allies. This idea is bearing fruit and bringing forth cooperation in everything else, and we believe that for the future co-operation
in our hospital work will be one of the outstanding results of the present
war. It is said that in medicine the best service can only be obtained by
millionaires or by the very poor in the cities. The millionaires get it by
paying for the service of experts. The very poor get it gratis in the hospitals of our cities which are manned by these same specialists, but the great
mass of the people are not able to avail themselves of these privileges. At
the same time it is the great mass of the people who, through their taxes,
are keeping up our institutions and are paying the cost, and it is beginning
to dawn upon everyone that they are entitled to an equal service with their
fellow citizens of any class. The idea has germinated that will result in an
impetus in the movement towards establishing hospitals that will be at the
service of everyone. Not a hospital in the old acceptation of the term as
meaning a place that you would only go to when you were too sick to do
anything else, but a hospital in the sense of the application of the services
of an institution to which you could go for advice and service that would
lead to the prevention of sickness, and not a place that you will wait until
you are sick before you will go. It will not be an institution where the
patient will come in for a cursory examination, given a bottle of medicine
by an overworked doctor, and told to come back in a week. It will be an
institution that will be the centre of the medical activities of the district;
it will be an institution whose greatest benefit will be derived from the development of the sociological side; it will be an institution to which when a
patient comes he will not only be given every consideration and advice, but
officers connected with the institution will follow up that case to the home,
will find what the environment of the patient is, what his family circumstances, what observance he is giving to the ordinary rules of health. He
will be advised on these subjects, and the doctor also will be advised in
order that he may take into account in his diagnosis all of the circumstances
connected with the case. It may be said that this is an ideal picture. Ideals
presented to the people in an attractive form stimulates them to an effort
to bring about the realization of their views and to make practical and an
every-day occurence of these ideals.
Co-operation is one of the first steps that is necessary. We must get
away from the idea of local jealousies. We must get away from the idea
that a small community must possess a hospital because some other hamlet,
which is its rival some few miles distant, has already started one.
A few years ago when, during the boom and the period of railroad construction in the province, town planning was the favorite diversion of the
real estate dealer, and the pretty picture he drew of his townsite invariably
showed the proposed site of his hospital. This, with the sites for the schools
and the town hall, being used as sugar for the bait in his lot-selling game.
Many of these towns have not yet even got beyond the picture stage, but
others progressed so far as to justify, in the opinion of the promoters, the
beginning of the hospital. Local enthusiasm was aroused, money raised,
and this, with financial assistance from the government, provided for the
building. Unfortunately, the population fell and the prospects for the immediate future of an increase are, to say the least, not very rosy. But the hospital remains with no diminuation of the fixed charges for maintenance and
with recurring annual deficiencies in the revenue. I am not criticizing the
hospitals, or the present management of the smaller institutions. The fact
that they have been able to continue at all, speaks volumes for the zeal and
devotion of those who have voluntarily assumed the responsibility of carrying on the work. But, nevertheless, the present financial conditions of many
of the smaller institutions is a cause of worry and anxiety to those in charge
47 and the prospects for the immediate future for any improvements are, to
say the least, not very encouraging. We are, however, in this province, not
alone as regards this condition of affairs. The western provinces have gone
through the same experience. Our province is very large in extent. Our
population is scattered. The depression following the collapse of the speculative period, coupled with the large drain on our population that has been
made by the war, is bringing the condition home so forcibly in the provinces
of the west that they have adopted a scheme for the solution which appears,
in the case of Alberta and Saskatchewan, to be meeting the difficulties. They
have recognized the fact that in the sparsely settled districts the maintenance
of the smaller hospitals was impracticable. They recognized the absolute
necessity of having hospital accommodation, and as a result they have
passed an Act which makes provision whereby groups of municipalities and
urban centres may co-operate in the organization and maintenance of hospitals to serve their people. It provides that two or more rural municipalities may co-operate with one or more urban centres in the establishment of
a municipality hospital. The Act provides that each municipality concerned
has the power to levy a rate, not exceeding two mills on the dollar, on all
assessable property within its boundaries for hospital purposes. The managing boards are composed of representatives of the councils of the cooperated municipalities. It has struck me that it would be an excellent idea
if the members of this convention were to take under consideration the adoption of something similar in British Columbia. They are getting back to
the idea of co-operation. They are adopting the principle which, in the
Education Departments of the different provinces, is being found to be of
great advantage, that is, the centralization of school work by the establishing of graded schools at some central point, providing for transportation of
pupils to that school, and doing away with small schools. In the establishing of the graded school the child has the benefit of the co-operation of a
number of teachers, they can follow out their course from grade to grade;
whereas in our isolated schools, there is a limit not only to how far they
can go, but there is a limit to the best efforts of the teacher when the teacher
has to teach all the subjects from the A B C's to Euclid. Now if it works
so well in the schools, why cannot this same principle work out in our hospitals? I pointed out in the beginning of my remarks, that it has been said
that in medicine only the best services can be obtained by the millionaires
or by the very poor in the cities. By this is meant, that in the larger institutions the facilities provided for the treatment of the sick are available in
a way that we can never hope to obtain in small institutions, but if two or
three or more adjoining municipalities were to co-operate and found an hospital that would receive the financial assistance of the municipalities, we
would be taking a step in the same direction that the school authorities have
taken, and we would be able to get correspondingly good results. In these
days of easy transportation with the increasingly large number of motors,
with the establishment of good roads, what, a few years ago would have
■been a day or two days' journey may be done now in an hour or two, that
now we may say a centrally located hospital is in direct and easy touch
with the territory within a radius of fifty miles. It would mean, on the
basis of the taxation adopted in Saskatchewan, a very low charge upon the
municipality. It would have a financial grant from the government, and
between'the two would be a free hospital for the people. It would mean
co-operation amongst the medical men, and it would mean that such an institution would become a community centre, not for the sick alone, but would
be the hub from which would radiate the efforts and endeavours that are
being put forth today in what we know as preventive medicine.
Sometimes a suggestion of this nature seems to be radical because at
the first offering of the suggestion those whose interests are affected are
most apt to object. I know, and I am speaking as a medical man, that it is
very convenient for a doctor to have his hospital next door, especially when
the population is a scattered one, because with a trained nurse in charge he
feels much safer with his patient immediately under his supervision than if
he has to make a visit every day, and probably have a trip of ten or twenty
miles to do so. On second thought that same medical men would know that
in a larger institution with a larger staff of trained nurses, with the advan-
48 tage of consultation with other medical men, with possibly laboratory facilities, that he's going to do far better work and get better results, and that
his patient is going to be much better off than if the old condition were to
be continued. As for the institution itself, the maintenance charges of two
or three or half-a-dozen smaller institutions would be done away with, economies would be practised and training schools for nurses could be maintained that would be training schools in fact as well as in name.
In speaking of the training of nurses, the development of a community hospital, such as I have outlined, would result in a broader training
for nurses, and a larger field for their work. It would mean the training of
some of the nurses more along the lines of health-work and result in the
development of a system of district nurses whose duty it would be not only
to visit the country schools, but to give pre-natal instructions to expectant
mothers, and to act as a link between the hospital centres and the people
in the outlying districts. In other words, we would be carrying a gospel of
health to the people. She would be able to personally advise in matters
affecting the health of the home, and it is time for a body of workers^
mainly concerned in health missionary work, among the people, to appear.
They would be able to co-operate with the laity in initiating and furthering
all movements that would tend to prevent disease. They would be foremost
in the work for child welfare organizations, for propagandas against venereal diseases and tuberculosis, for all public health work arid of other educative schemes. Many years ago Florence Nightingale said that there could
be no health of a community without health of the individual. The fundamental means of success in health of people is by education, and while our
health department and our health officials throughout the province are working along the lines of education,- yet the great difficulty that they find is in
reaching a sufficient number of the people. We publish bulletins and distribute them as widely as we can, but the great drawback of this method is
the fact that these, as a rule, fall into the hands of those already interested
and do not reach those who should know the facts that we are trying to
convey.
Experience has taught us that it is only when an epidemic of some sort
arises that the interest of the people is aroused. Talk of an epidemic of
Smallpox will result in a great many people wishing to be vaccinated. You
could frighten people with press reports of Infantile Paralysis, but you cannot rouse them to the danger that arises from epidemics of Measles or
Whooping Cough. They do not recognize the fact that probably there are
more deaths from Measles, or from the troubles that follow Measles, than
from almost any other disease. The Provincial Board of Health is something that they hear about occasionally, but in which they are not interested. Its headquarters are far away from them and there is not that personal touch which is so essential in the work of health education. With
our local hospitals as centres, with workers from these hospitals radiating
throughout the districts, the personal touch is established and people begin
to recognize that the health visitor is one who is not an officer of red tape,
but a human being, well versed in the subject, and may meet them on common ground with heart-to-heart talks, explain to them the meaning of the
"don'ts" and also explain to them the meaning of the "why" they should
follow out certain lines of conduct in their personal habits and in their family life. The Board of Health can, and does, direct the medical examination of the school children. Defects are discovered and the parents are
notified of the defects, which, if attended to at the time, means that the
child will not be handicapped by physical defects in after life. When the
notifications are sent home to the parents, while in many cases they are
attended to, yet in many others the importance is not understood and attention to the matter is put off to a more convenient time. Whereas if the
follow-up work were adopted, explanations given to the parents of what the
results to the child would be of neglect, action would be taken, but it would
be taken simply because the parents would understand. In other words;
they would be interested in health matters.
We have made a start in this in the province in regard to tuberculosis.
We have a splendid sanatorium, but it is crowded with advanced cases.
The cases we want to reach are those in the incipiency stage that we can
49 cure. We are asking that these cases be reported. We are asking that the
local hospitals set aside ten per cent, of their bed accommodation for tuberculosis cases, and we are appointing a medical man to go round the province, not with the idea of looking after the advanced cases in the hospitals,
but to take the names and addresses of those who have been reported in the
early stages of the disease and to follow them up and bring directly to them
the knowledge of how to take care of themselves, and particularly the knowledge of how to guard against infecting others. This is our work at present,
and we intend to enlarge it, but we must secure the co-operation of those
interested in the work in the smaller centres, and we hope in time to develop
this scheme whereby the hospital will become a community health centre
of its district working in conjunction with the Provincial Board of Health
as the administrative body, and we hope to secure the services of the laboratories of the University to do the necessary health work that would be required of a laboratory. The University laboratories could provide experts
who would visit the districts and would give an opinion of water supplies,
sewerage disposal, and questions of paramount importance from a health
point of view in smaller districts where facilities for handling these things
are not as great as in cities. They would be able to advise directly with
municipal bodies who are installing water supplies, and to advise generally
on questions of health as affecting the community. Lectures would be delivered on health matters either at the hospital or by someone connected with
the hospital, at different points in the district.
My presentation of the subject may appear as a description of an ideal
condition, especially so when one looks over the programme and notes the
subjects which have been set for the different papers to be read before the
convention. But I feel that I have outlined in a general way the natural
growth of the hospital. We are coming to the days of state control of medical service in the country. Health insurance, old age pensions and the care
of the sick are not subjects of probability, but are something that is being
given effect to in other countries. Under our democratic form of government we will have to work the general application of these principles out
gradually, but those who have given any attention to the subject recognize
the fact that all governments will have a department, presided over by, a
Minister of Health; that medical attention of the people will be a function
of the state, and that hospital accornmodation, in the broad sense of the
word, will be free and. available to every citizen. - Standardization in all
branches will be brought about, and while your own immediate problems for
the management and maintenance of your hospital are engrossing your attention, still those who are interested in these subjects and are giving them
thought, recognize that the people are going to demand, and they are entitled to equality of service, no matter in what part of the country they live.
The war is not over, nor can we even begin to count what effect the loss
of our men is going to have upon our national life. When we begin to
realize what a halt this loss is going to cause in our productive life as a
nation, and when we begin to realize how even our national existence will
be threatened, we are going to insist upon steps being taken to conserve
our assets, and particularly the asset of human life. Our mortality tables,
which are at present simply records of our incompetence, will be studied
with a full knowledge of what they mean and with an appreciation of that
knowledge will come an insistence by the people for different methods in
the ordering of our lives. Not only will we insist that as far as humanly
possible that the span of life shall be lengthened, but that during that span
of life an individual shall stand for one with fully developed mental and
physical powers, that shall be utilized to the best of their capacity for the
advancement of the nation as a whole.
MR. GRIMMETT—
I will now call on Mr. J. J. Banfield for his paper on "The
Duty of the State to the Individual."
50 "THE DUTY OF THE STATE TO THE INDIVIDUAL."
By Mr. J. J. Banfield, Director of The Vancouver General Hospital.
As a Director of The Vancouver General Hospital for several years,
and noting the growth and also the change in public sentiment towards hospitals, I am convinced that these institutions require to be placed upon a
different footing financially. Their usefulness and necessity are a proven
part of the municipal and state life.
We live today in an organized community where the value of the individual to the state is recognized. While, however, with us, the individual
does not exist for the state, there are acknowledged duties as between the
one and the other, and my thought is that along certain lines especially
interesting to us, the state might extend more liberally its support and
activities in the preservation of public health and so enhance the value of
the individual for the well-being of himself and the community; as his productive abilities in all branches of life are in direct ratio to the condition
of his health. You cannot'secure a 100% production with a 50% health. My
connection with our own splendidly equipped hospital has given me both the
pleasure and the privilege of discussing with business and professional men
the relation that should exist between such institutions as our and the people; also the duty of the state to the individual and the institution. There
has been a favorable change in public sentiment towards hospitals within
the last twenty-five years. The demand for expensive equipment necessary
to effectively carry on the work cannot depend for support on individual
endowments and charity, but require to be financed by organizations who
are in a position to raise the required money through taxation, thus reaching the individual members of the community. (Only in this way shall our
full duty be realized by not only the individual but by the state.)
FUNCTIONS.
The functions of a hospital are: First, the care of the sick; second,
educational;   third,  investigation and research.
FIRST.—Dealing with the first, the care of the sjck, this calls for
various departments, medicine, surgery, and research, all manned by experts and equipped with the most modern appliances so that they may be
ready for any contingency that might arise during a medical or surgical
investigation. The nurse is a trained woman and expert in departmental
management, which with all other preparations are made in order that the
individual shall be able to obtain the best possible medical and surgical
advice and care if his welfare in time of sickness is to be considered. All
of these advantages, advice and treatment, are within the reach of the
wealthy, as they possess the money required to avail themselves of the best
to be had. Then again, all the privileges, with the best treatment of the
hospital, are placed at the disposal of the poor by the assistance of the
state and the generosity of many philanthropic individuals. There is a worthy self-respecting class of people that come in between the two first mentioned, and my plea is for them. They are ignored or regarded indifferently.
They represent the mass of taxpayers, and should receive a greater consideration from the state. In many instances the demands on this class of
people are greater than their financial ability can bear, and consequently
the medical requirements of themselves and their children are neglected,
owing to the cost of medical and surgical treatment. To the bread winner
there is a loss of time, and the children's future health is impaired, and
both become a charge upon the state at a time when they should be most
useful to it.
I maintain that all should have the inalienable right to a free diagnosis
and should then have the option of receiving treatment in a state ward free
of charge or accept other hospital accommodation for which they would
be required to pay. Free diagnosis is the special point I desire to make
here, and my contention is that it is prevention and would lessen not only
the future work of the hospital, but other departments of the state life that
have to be maintained at great cost.
As to free treatment, I will deal with this at a later period.
51 SECOND.—Regarding the second function, namely, the educational,
patients admitted to hospitals cannot help but absorb a great deal of information during the periods of their treatment, and the general public, when
they become visitors, carry away a respect for organization and system.
But to those who go into these institutions to study and train themselves
for lifework great opportunities are shown. They receive a degree of training that fits them for the care of the sick which is necessary for the public
and themselves, while the medical and surgical practitioner come into a
more practical exercise of his work than can be taken up in theory at the
University.
THIRD.—Finally investigation, this branch is beginning to be appreciated and should be, in a state department, extended to medical science.
It demands special trained workers who cannot be expected to make their
departments pay and at the same time continue their research work. In
the ordinary institution this branch is a financial burden.
I have merely referred to these ideas that I might lead up by logical
deduction to the principal idea of my paper. The state being composed of
individuals, it naturally follows that the welfare and condition of its component parts makes for success or failure as the parts are strong or weak.
The cycle of life that begins with the birth of an infant does not end with
the death of that body, but must be carried on through its life to that of
another. The part the' child plays as a member of the community will either
be well done or badly done just to the extent that it is equipped. Our experience during the past few years with the Better Babies Contest has
proved the value of a really free clinic or diagnosis of the little 'ones
brought for examination; many a mother came not once but twice and three
times, just to see how her little one fared physically. The actual benefits
derived were made use of by them. Medical statistics show that 80% of
the children that die within the first few months after birth die from preventable  diseases.
We are making an effort to stop this loss of life. The United States
people realize the importance of child life to such an extent that an aggressive campaign has been inaugurated under the Department of Labor and
the Society for the Prevention of Infant Mortality to save 100,000 babies in
the year 1918, having in view of making good their loss during the war.
This is prevention. If we link up to the prevention that is now being made
in our schools, the child life on the one side and the matured life on the
other by the same system of diagnosis and treating, we shall have a great
waste of human life. The state has assumed the care for the education of
the children, and this work is being well done. The doctors and thai nurses
not only guard against epidemics, but see that the children are kept as far
as possible in good health. A step further covers a large percentage of
people who need and should have advice and treatment for ailments, not
always the result of some inherent weakness or aggregation of circumstances or conditions. We are justly proud of our own country and boast
of its wealth of resources, but to hold this wonderful country we must have
a robust manhood and womanhood to people it. Given a healthy population with a proper understanding of themselves and their relations to each
other and to the state, we need have no anxiety for the future. A decadent people is one which through neglect of body has been unable to keep
up with the race for existence; whose mental strength cannot keep pace with
that of others. Many who have, what seems to be to them a slight ailment, for lack of sufficient money, cannot receive the care they should have,
and who transmit to their children a weakness that may result in an early
death or may cause a miserable existence, which they in turn pass along
to the next generation. Philip Brooks said many years ago: "It is the
right of every child to be born healthy." Should there be established a
state-supported clinic, with the privileges of treatment added such as I have
briefly mentioned, I am firmly convinced the necessity for such elaborate
institutions as now exist for the care of the diseased would be decreased
very materially.
I advocate prevention in place of cure. From a financial point of view
this is necessary. Should we continue in the present condition, numerous
hospitals and mental institutions will be required to meet the demands of the people, and consequently a drain on the public exchequer for the care
of the individuals that might have been prevented by timely treatment during the early period of their lives. In my judgment prevention is the crux
not' only as applied to tubercular cases, but also to the majority of those
commonly treated in our hospitals. If we switch our system, and starting
with the child, carry it along through the school period, then on to manhood and womanhood, we shall produce a better race and one that will not
call for the demands now made upon our hospital work. These institutions today are not only a financial burden upon the community in which
they are located, but also upon the state. If we are to continue our present
system in order to lessen the financial burden upon the institution, the state
and the community will be required to pay the full cost of looking after
the deserving poor. This the institutions can no longer do. The constant
deficits in hospital work are tiring to the Directorate, who endeavor to
maintain a state of efficiency that causes a financial burden that cannot be
continued except with increased state assistance. We recognize fully the
great financial demands made to maintain the work, but under the present
system no other method can be adopted than that which is at work. Relief
will be required from the state as people of means during a period such as
we are in, are financially unable to assist in continuing the operations as
at present.
The details of my suggestions herein outlined can be easily and profitably carried out, and I appeal to you that they are worthy of at least consideration on the part of people in authority.
MR. GRIMMETT—
I will now call on Dr. R. H. Mullin, Director of Laboratories,
The Vancouver General Hospital, to give his paper on "The Public Health Problem of this Province."
"THE  PUBLIC  HEALTH  PROBLEM  IN  BRITISH  COLUMBIA."
By Dr. R. H. Mullin, Director of Laboratories, Vancouver General Hospital*
and Director of Bacteriology for the University of British Columbia.
At the first glance it would not appear that a subject dealing essentially with community health would .be of interest to a gathering consisting of those interested primarily in the various phases of the treatment and
cure of individuals. However, in certain lines of public health activities,
the hospitals are being recognized as a very essential factor, especially in
the control of communicable diseases. Moreover, physicians are looked
upon by the laity as being familiar with all of the phases of problems concerning health. It is therefore seemly that physicians and hospital administrators have an accurate knowledge concerning the principles which underlie the practises in the science of public health. The principles of public
health do not vary with different communities. It is true in some communities, greater emphasis may be properly laid upon some branches than
on others, but the principles are always the same. The public health movement is a conscious and co-operative effort on the part of all, or at least
the majority, of the individuals of a community to promote as much as
possible their own bodily comfort and well-being, to prevent as far as possible their own sickness, and to postpone as long as possible their own
death. In this movement there are three prominent, essential factors. The
effort must be conscious on the part of the community; 'it must be cooperative among all the individuals in the community; and it must be continuous. The goal of the moyement is to increase community and national
efficiency by increasing individual efficiency. It is therefore a true symbiosis where all are living together for their individual and combined welfare. The ability to live a continuous community life of this kind is one
of the markings which distinguishes men from lower animals. Among the
latter a continuous community life as such does not exist, since it is limited
to a family life, lasting for the most part only until the young can originate
a new family.
53 There is no such thing as complete independence. The world is composed of nations all more or less inter-dependent. The success and relative
position of any nation is determined by the ability of that nation and its
component people to successfully compete, individually and collectively,
with other nations. The public health problem is to produce a nation that
is adequately prepared from both a quantitative and qualitative standpoint
for the continuous competition, national and international, which constitutes this world.
The practice of public health, while resembling the practice of medicine
in some respects, differs from it sharply in others. For a clear conception
of the former it might be well to sharply differentiate between it and the
latter. Private health or private medicine is essentially individualistic and
selfish. The parties concerned are interested primarily for their own particular good. As a general rule the relation which this may have to the
community as a whole is seldom thought of. Public health, on the other
hand, is essentially communistic and philanthropic. The interests of the
community as a whole are predominant, compelling, in certain instances,
the apparent interests of an individual to give way to and be superceded by
those of the common welfare. In private medicine the cure of the disease
is a most essential factor; prevention occupying a very secondary position.
In public medicine, on the other hand, prevention is the key-note; the cure
in individual cases being frequently left to the individuals themselves. Private medicine ranks amongst the oldest of the sciences, dating from antiquity. Public medicine, on the other hand, is a science of comparatively
recent development. Especially is this true when one takes into consideration the various specialties, which taken together, constitute the science as
a whole. These two sciences resemble one another in that both are more
or less related to disease, and they are both sciences in the true sense of the
term. They both depend upon accurate observation and experimentation.
They are both coming in their practises to be divided into various specialties, so that no longer is it expected of any one individual that he should
be entirely familiar with the whole subject of either science.
A knowledge of the character and aims of these specialties in public
health and their relations to the whole, is necessary for a correct appreciation of the science. They naturally fall into groups more or less related.
One group consists of the accurate recording of all health activities; another is related to disease; a third to conditions connected with environment and development of individuals; and a fourth to the factors which
make for the comfort and convenience of the people.
Vital Statistics.
Vital Statistics play a very important and prominent part in all public
health activities. It has well been called the "bookkeeping of the science,"
since it records all of the items concerning the health and numbers of the
community. Too frequently in the minds of many people, vital statistics,
or demography, is thought to be limited to the mere collection of data
regarding births, deaths and marriages. This should not be so, for there
should be collected in addition accurate information concerning the prevalence of diseases, the conditions under which it is occurring and numerous
other factors, all of which are essential in any accurate determination of
the health index of a given community. It is only by a careful analysis of
such records, accurately kept, that an adequate idea can be obtained concerning the advancement or retardation, from a community health standpoint, of any particular locality. Furthermore, proper and reasonable deductions should be drawn, not from individual cases, but from a collection of
data from large numbers of similar cases. Such are obtainable only when
an accurate and complete system of compiling Vital Statistics obtains in a
community.
There are two branches of the science which deal more or less directly
and entirely with disease and the effect it has on the community, namely,
Communicable Diseases, and Infant and Maternal Welfare. These two
constitute a very important division and are of importance, since through
them it can be determined easily how the scientific application of the principles of the science are related to the economic and- social advantage of
any community.
54 Communicable Diseases.
Development here has been very rapid in recent years, due to a large
extent to the fact that familiar as some of these diseases are, their scientific
control is comparatively new and that, with the development of bacteriology
and more accurate deductions drawn from closer observation of facts enabling the control of communicable diseases to be more easily effected,
many of the older theories are being rapidly discarded. Some claim that
the pendulum has swung too far. The old voluntary cry of the leper, "Unclean, unclean," has been replaced by compulsory and iron-bound confinement of dangerous individuals. It is being appreciated that complete success can be obtained only when the combination of these two principles are
employed, so that now there is sought a maximum amount of voluntary
assistance from the afflicted, together with just sufficient confinement of
their activities to produce the maximum amount of safety to the community.
The old idea that each individual infectious disease follows rules of its
own in the matter of spread and so forth, is now lost. It is known that
the control of all such diseases follows certain fundamental principles, although of course variations may occur in any one. Success in control depends on knowing when, where, and under what conditions such diseases
exist, and of being able to prevent infectious material from the infected
(usually found in their discharges) reaching the healthy. That much-abused
term "common sense" (which, from the frequency of its occurrence, might
better be called "uncommon sense") is a factor which is rapidly replacing
iron-bound rules. More than in any other branch of public health, in- communicable diseases there is found a number of paradoxes which are difficult
to explain. It is a fact that people fear and dread the unknown to a very
much greater extent than they do the known, so there is found an almost
hysterical state of mind on the part of the public regarding such diseases
as leprosy, and infantile paralysis—diseases which cause a comparatively
limited number of deaths—while there is an apathy and indifference to the
commoner diseases, such as measles, whooping cough, etc., which in bulk
cause a comparatively great number oE deaths. People will go blocks to
avoid passing a practically non-infectious leper on the street, but will hold
most intimate social intercourse with a highly infectious syphilitic.
Infant and Maternal Welfare.
These two branches are usually grouped together since it has been
found that many of the factors which operate in producing high infant mortality are to be found where there is a high maternal mortality. Usually
remedial measures taken to reduce infant mortality will have a decidedly
beneficial result in reducing maternal mortality. This is a natural consequence of the observation that many of the deaths of infants one month old
and under are due to ante-natal causes. For the correction of these defects
the education of the prospective mother is necessary. This education naturally is of considerable advantage, not alone to the child, but to the mother.
Few of those who have not given special attention to the matter realize
the seriousness of the present condition of affairs. It has been determined
by reliable and accurate statistics that nearly one-fourth of babies born
never reach the productive age—productive either from an economic or
procreative viewpoint. Most of these deaths occur during the first year.
Of these that occur during the first year, twenty-five per cent, occur on the
first day, thirty-eight per cent, in the first week, and fifty per cent, in the
first month. Four-fifths of these are preventable. In spite of the wonderful
advances that have been made in other branches of medical science, such as
surgery, internal medicine, etc., the fact remains that, during the child-
bearing period, more women die from accidents connected with child-birth
than from any other disease, except tuberculosis. Fifty per cent, of maternal deaths incident to child-birth are caused by sepsis. In the United States
one woman dies in child-birth for every 145 living children born, so that
one might almost say that it is more dangerous for a woman to have a
baby in the United States than to pass through the submarine zone. Without a doubt, many of the maternal mishaps of child-birth are due to improper preparations and insufficient care before, during and after confinement.
It is found that conditions are much better where hospital facilities are
55 available than where they are lacking, so that the saying has arisen that
while the country may be a fine place to .live in, it is a poor place to be
born in. Undoubtedly economic factors play a very important part in the
birth rate. It has been found in England on two occasions, that legislation
restricting child-labor has been followed by a sharp and unprecedented fall
in the birth rate. To compensate for these untoward factors, mechanisms
must be devised for state assistance before and during child-birth and until
the children shall have reached a self-supporting age. In more advanced
countries, this has been taken care of in part, by education, by the institution of maternal benefits, and by providing day nurseries, public playgrounds,
etc., where the family can be relieved in cases of necessity from the immediate care of their children, and so be released for productive work.
School Hygiene.
The supervision begun at an early age, even before the child is born,
is now being maintained during the course of the educational period. Public school education is an effort on the part of the community to increase
the economic value of individuals during their formative period by community-supported efforts. The inutility of pushing education without at the
same time supervising the health of the pupils, is clear to all. School supervision, or school hygiene, has therefore grown to be a factor of considerable
importance in most enlightened communities. This medical supervision allows the proper relationship to be established and maintained between the
physical and mental development of the children. It affords a means of
devising special mechanisms to meet certain physical defects, and permits
of corrective efforts being begun before too much damage has occurred and
perhaps before the damage may have become permanent. It is the aim to
turn out a product that is both mentally and physically at its highest point
of efficiency for each individual. As a very important factor in physical
education which is becoming so prominent in schools and colleges, the value
of public playgrounds and recreation periods is being appreciated. It has
been found that not only do children have to be taught to work, but they
also have to be taught to play. To attain the best results of recreation it
must have an adequate and intelligent supervision. School hygiene plays
a very important part in the control of the ordinary infectious diseases,
since most of these diseases occur sometime during the school period, and
undoubtedly many of the infections are acquired during attendance at
school, either in the class-room itself, or in the journeys to and from the
building.
Industrial Hygiene.
In all productive industries a number of elements, will enter into the
productive efficiency of all employed. The sanitary arrangements of the
factory, such as proper heating, ventilating and lighting, are of the very
greatest importance. Proper intervals between periods of work have been
found to increase the capacity of the workmen. There have arisen certain
legal mechanisms for the compulsory inspection of factories and the prohibition, except in cases of necessity, of over-time labor. Another glaring
defect in previous economic theories has been rectified. It is recognized
that the product, and not the employer or the employee, should bear the
expense of the hazards of production. On this the so-called "Workmen's
Compensation Acts" are based, and they have been found to work out advantageously in more directions than one. Not only is the employee protected against accidents, but the employer also is given an opportunity to
more or less select his workmen, after a consideration of their physical
capacities. In many of the larger industries physical examination of applicants and social service activities among their employees, have been adopted
as a means of increasing the efficiency of the employees. Employers have
found that frequent changes in the personnel of their workmen entails always an economic loss, since the new man must be trained to the particular
job of the man he is replacing. Voluntary efforts to prevent this loss to
employers all point in the direction of attempting to keep the employees
happy and well, so that their services may be retained. Greater and greater
provision is being insisted upon by various governments to prevent the so-
called "trade diseases" arising from handling dangerous metals, such as
56 lead, phosphorus, arsenic, etc.    These occupational diseases are receiving
in many places adequate legal supervision.
Housing and Town Planning.
Closely allied with hygienic conditions at the factory are hygienic conditions in the home. It has been found that physically defective employees
are not as productive as those in the best of health. Undoubtedly, home
surroundings will influence to a certain extent all employees. It is just as
important to have hygienic conditions in the home as at the factory. With
this idea in mind, the modern efforts at town planning have produced wonderful results. The principal idea has been to substitute well-lighted and
well-ventilated small houses properly equipped, for the old-fashioned tenement houses where the laboring classes were formerly boused. The value
of these "garden cities" where each house has light and air and sufficient
garden facilities to produce not only flowers for beauty, but food for consumption, can be readily determined by a comparison of the physical condition of their inhabitants with those of others, and by comparison of the
efficiency of these happy garden-city dwellers with that of their more
poorly housed  companions.
Social Hygiene.
Closely allied to both industrial hygiene and to the housing problem is
a newer branch of the science, designated, for want of a better name, as
"social hygiene." This is an attempt to co-relate the economic and social
aspects of the individuals of a community. Efforts are made to establish
what relation, if any, exists between the wage and the birth and death rates
and disease incidence. This is an aspect of the science that has only recently come into prominence, so that it is too early to hazard an opinion
as to the direction in which this branch will ultimately go.
Food and Drugs.
This department has to do with the supervision of foods, so as to
ensure their suitability for consumption, and the examination of drugs to
determine their purity.
For a considerable time most of the energies spent on foods were
directed towards our commonest articles of diet, namely, milk and water.
Both of these problems are very extensive since constant supervision in
each is necessary. Milk supplies are always a source of gravest concern,
since milk itself is an excellent food for bacteria, which will multiply with
great rapidity. The damage to milk may be of two kinds. Either the milk
will become rotten, or it may become infected with some organism pathogenic to man, either tubercule bacillus from the cow, or some other organism, usually derived from a healthy carrier who is handling the milk.-
The danger in public water supplies lies in the fact that some people
insist on using the same source as a means of disposing of sewage and a
water supply. This is always dangerous; and never pleasant, if one is
aware of it.
One common factor between these two problems is the number of people who are apt to be involved if infection with a disease-producing organism occurs. Milk and water born epidemics are usually explosive in character, a comparatively large proportion of the population becoming infected
at or about the same time. On account of this explosive nature of the
epidemic, the dangers and the necessity for supervision are easily apparent,
but for some peculiar reason many communities will delay this supervision
until after a lesson has been brought home by some large, disastrous epidemic. More recently the necessity of supervision of other foods has become recognized, so that there is federal inspection of packing plants, the
oyster industry, and so forth.
The supervision of the drug industry is more or less an economical
problem, being an effort to protect the public against impurities. This
search for impurities is not limited to drugs alone, but has extended to
foods. The effort is chiefly to assure the consumer that he is obtaining
that for which he pays, and not some cheaper adulterant which may appear
the same, but lacks the essential value desired. Enough has been said to indicate the size of the public health problem
and the great variety of directions in which this problem leads. No matter
whether one considers the problem as a whole, or in one of its divisions,
the community aspect of the problem is predominant. Different units of
communities exist. The smallest community is the family, which in reality
is the unit of civil life, no matter what the size of the family'may be. For
economic and other reasons, families may group themselves in municipalities of greater or smaller size. Such municipalities, with the surrounding
rural country, for the purposes of government are grouped into townships,
counties, and so forth. These counties are collected into a province, and
the provinces into the Dominion. The health problem is related directly to
each community, no matter which one of these divisions is concerned. All
these divisions of civil life are inter-related, so that there is a corresponding
inter-relation of health problems as between these Various communities.
The inutility of one community having an excellent health service, while
the one immediately adjacent is neglected in toto, is at once apparent, since
social intercourse is not as a rule limited by geographical boundaries. Unfortunately, in this country there is not even a pretence at the maintenance
of a federal department of health. The provinces are organized with a
degree of efficiency varying from none at all to comparatively efficient. The
question naturally arises: What is required for an adequate and efficient
health service in a community? There are three factors which are of paramount importance. First, there must be a demand on the part of the individuals in the community; second, there must be an organization to perform the public service; and third, there must be an adequate budget to
support the activities of the service.
It is a fact that more and more, both medicine as a profession and
public health as a science are being robbed of the mysticism in which they
were at one time more or less enshrouded. People are beginning to want
to know. They desire to have things explained in ordinary every-day terms
which they can understand, and it is usually found that when once the people appreciate the problem, they are anxious and willing for its solution,
even if it entails a considerable amount of expense. The comparative ease
with which the Rotary Clinic was established in this city, and the generous
response made to a voluntary call, is good evidence of this. However, if
the problem as a whole is to be successfully met, the demand for its solution must be generalized, insistent and continuous, instead of localized, very
faint and spasmodic.
To accomplish this end, education of the people in health lines is most
essential. A leaf should be taken from the book of the patent medicine man.
Their profits depend, not on the value of their product, but upon the publicity, frequently mendacious, for which they pay. It has been found that
such publicitj', even for a worthless product, will bring fortunes to the proprietors. Surely the same wealth can be conserved to the community if a
valuable effort were to receive the same publicity.
This education may be undertaken through the public press or any of
the ordinary avenues by which publicity is attained. There should also be
a systematic education in our school system, beginning in public schools and
ending in the university. This educational factor links the public health
movement to the educational institutions of the community. It would seem
that those who are actually concerned in the public health service should
be the best to take part in the education of the community. This of necessity belongs to the highest type of education, whether or not a medical
school exists in the community. Therefore, trie Provincial University should
be intensely interested in health activities and should form a prominent part
in any provincial health service.
It might well be that the technical work of routine, service, investigation and research, should be established as a department of the university,
thereby making the university as the highest educational institution in the
state, the technical advisers of the Provincial Government in health matters. By such a mechanism, the benefits of having the technical workers
and instructors composed of the same body of men would accrue to both
the university and the service.
58 The organization of a health service is of the very greatest importance,
since the success and value of the service will depend to a very considerable
extent upon the efficiency with which it is organized. Since any community
health service involves the principle of compelling individuals to do certain
things for the good of the community, it follows that the health service
must be a governmental institution. It is not meant by this that the service should be a political institution, for nothing will kill a health service
more quickly and more completely than making it subservient in any way
to the so-called "party politics." Legal machinery and police power is always required, since no community action can be taken until legal means
are provided. An administrator is therefore required to see that all the
laws, rules and regulations, and so forth, related to the health service, are
enforced in the different communities within the province. His position as
an executive is not necessarily a highly technical one. Extreme tact, and
the ability to receive with a smiling face the abuse of anyone who fancies
himself injured, together with fearlessness in administrating the law, are
the essential characteristics required in a successful administrator.
A technical staff is required composed of men who have been specially
trained in the particular branches of the science to which they are assigned.
It is becoming more and more appreciated that training over and above that
received in the medical school or engineering college, is required and demanded in technical workers in health services. This demand is being met
in part by institutions of learning providing the necessary facilities and
instruction, so that a worker can get his training there, rather than by
practising upon the community which he is supposed to serve."
Needless to say, such highly specialized experts demand and should
receive compensation in proportion to the amount of time which has been
spent in preparing themselves for their work. They should receive a wage
sufficient to enable them to occupy their proper place in the social life of
the community; they should have a reasonable tenure of office, if health
positions are to attract men of the proper type. They should have the
assurance of freedom from political interference, so that their positions are
not held at the pleasure of the low type of politician which is sometimes
met; and they should have sufficient time for study and research, so as to
enable them to add to the information that others may desire.
The organization itself should be made after a careful study of the
necessities of the particular community. A definite and well-thought out
plan for each community should be prepared, obviating the hit or miss
method of meeting emergencies as they arise, which always governs an
organization composed of elements almost impossible of co-relation. This
organization should be capable of meeting the immediate necessities and
at the same time should permit of future expansion or alteration as changed
■Conditions arise, without having to go through the disrupting influence of
complete reorganization at more or less indefinite intervals.
The provincial organization should be centrally placed, with branches
if required by geographical necessities. The staff should be of such numbers as to allow of extreme mobility, enabling them to obtain direct, firsthand information from the scene at which any problem may occur.
Budget.
It would be folly to pretend that any such health service can be maintained on a small budget. For its success adequate monetary provision is
an absolute essential. Too many people distinguish sharply between economy and efficiency, applying to the term "economy" a meaning which entails
refusal to spend money. That economy is best which will give the highest
efficiency, and can only be obtained with spending a proper quid pro quo.
The relation between the budget and results can be determined by observation. It has been found in actual practice that the health efficiency of
any community will vary directly with the amount of funds that are appropriated for the health department. This has been determined in a very
interesting manner. It has been found that the typhoid_ death rate may be
taken as a gross means of estimating health efficiency; this, of course, in
communities where typhoid has  existed.    In  recent investigations  it has
59 been determined that the typhoid death rate in a community will always
bear a direct proportion to the budget of the health department.
Does expenditure on legitimate public health problems pay? "An
ounce of prevention is worth a pound of cure" is as true in health problems
as anywhere else. To be concrete: is it cheaper and more efficient to do a
■Wassermann test, and if necessary adequately treat with Salvarsan, say
100 individuals, at the current rates in British Columbia, or to maintain one
individual at the Mental Hospital for a varying number of years as the
result of an improperly treated previous syphilitic infection? It would
probably be found that the amount of money spent annually in maintenance
of the syphilitic insane would go a good way towards paying for the total
suppression of venereal diseases, so that any other good derived could be
listed as clear profit. In the State of California it has been determined
that the amount of money saved in the prevention of typhoid deaths, the
number of which can be accurately and readily computed, is more than
sufficient to cover the total appropriation of the health department, so that
practically all of their many other activities are done without expense.
In the minds of some people the war seems to be a sufficient excuse
for refusing any additional expenditure, no matter how great the benefits
to be derived may be. The question would naturally arise: is this a good
time to begin a conscious, co-operative and continuous effort for the public
welfare? It must be remembered that there is at present a period of very
great wastage of adult productive man-power, undertaken to preserve and
maintain national honor. It would seem that every possible step should be
taken to compensate for this wastage, which can never entirely be replaced;
the very fact of the wastage demands a compensatory effort unless the resources are of such magnitude as to render the wastage comparatively small.
Moreover, people generally are beginning to demand reliable and accurate information concerning health subjects, and to look for protection in
health matters as a right to be expected from the governing bodies. The
people themselves have already shown that when they become familiar with '
such problems, they are ready and willing to pay the cost when the need
develops.
The state has already shown itself ready to make demands upon its
citizens for the protection of the community. The assumption of the right
to make demands lays upon the state obligations to afford adequate protection to the individuals in the community. Governments are supposed in
theory to carry out the mandates of the people whom they govern, but it is
a wise government that can foresee and foretell the pressing needs of the
community and give a proper protection to the economic and physical welfare of their electors.
It would seem that immediate action along these lines is eminently
necessary in order to have proper and adequate plans prepared and in operation before the great period of reconstruction begins, in order to simplify so far as possible that reconstructional period. There should therefore be no hesitancy in the government undertaking, or in the people urging
the government to undertake, the immediate installation in British Columbia
of an adequate and energetic health service.
MR. GRIMMETT—
I will now call on Dr. A. P. Procter for his address on "The
Tuberculosis Problem of the Province."
"THE   TUBERCULOSIS   PROBLEM   OF   THE   PROVINCE."
By Dr. A. P. Procter, Major C. A. M. C.
I believe I am acting as a stop gap for Dr. Vrooman, of Tranquille,
who was to have addressed you on this subject. The only thing I can
promise to lessen your disappointment is to be .brief.
I was asked to speak on the problem of tuberculosis in this Province.
It is easy today to speak of tuberculosis, because every man, woman and
child knows something about this disease and its symptoms. It was not,
I remember, so many years ago when we took charge of the ranch that is
now Tranquille Sanatorium—how I met the owner, a farmer, who said to
60 me in broad Yorkshire:   "Doctor, do you think that that there consumption
is catching?"    I said that I rather thought it was.    He replied, "I don't
believe you."   Not very long after that, when we were cleaning and fumigating the old farm house where many consumptives had been staying, this
same man's wife was very indignant because, in the process, we tore many '
covers off the sofas and chairs.   "They talk about germs," she said.   "I have
been here over thirty years and I have never seen one." Almost the youngest
child knows something about this disease and its cause.   One thing about
this War, with all its tragedies (and I suppose there never has been such
a universal tragedy as this War), it has done more to bring home to our
people the value of physically fit people than years of peace might have
done.   I don't know what you think about alcohol;   but it seems that it
almost took the great War to banish the bar.   I believe that the bar has at
least gone out forever, and so with tuberculosis.   It used to discourage those
of us who tried to wake our people up on the subject of tuberculosis, but
the War has done more to bring home to our people this awful loss of young
manhood and womanhood.   Every year in this Province (Dr. Young may
correct me if I am- wrong), you lose approximately four hundred of your
citizens, men and women, from tuberculosis.   It seems that in' the city of
Vancouver last year you lost one hundred and fifty-eight of your citizens
from the same cause.   Dr. Philip, of Edinburgh, tells us that if you multiply
the number that die by five or ten you will get approximately an estimate
of people in your country that are victims of this disease, because a certain
portion only of those affected die each year. Do you know what the economic
loss means to this Province and to this city?    Well, political economists
place various figures upon the value of the wage-earning life,—anywhere
from two to ten thousand dollars, and if you multiply the total that die by
that figure you will get in dollars what this Province is losing every year
from tuberculosis.    It seems that at the  lowest figure this  city is  losing
something like $300,000.00 a year from this disease, the Province $1,000,000.00.
When I was down at the City Hall a short time ago discussing whether
after the first year the Rotary Clinic should be supported by the city, how
little the city fathers seemed to realize what this city was losing in dollars
and cents, and how little they realize how much in dollars and cents they
ought to spend to stem that loss, apart from the human suffering that this
disease means.    Have any of you been told that you have tuberculosis?
How would it feel to be told that you had that disease?   I remember some
years ago, a great picture, exhibited in the city of London, a picture known
as "The Death Sentence," which created quite a sensation—the picture of a
young man at the one side of the table and his physician at the other. The
physician had told him as gently as these things can be told, that he had
tuberculosis of an advanced type, with all that that means.    Out ot that
young man's eyes all hope of life goes.   Love of life is a very natural
thing;  and particularly true of youth.   Think of the beauties of this country;   no wonder that people love life.   The tragedy of this disease is that
it kills largely in the period of youth, in the valuable time of life.    Tuberculosis, while it is not a respecter of any age, of course, chiefly attacks and
kills in the valued period of life, the wage-earning period.   That is what
the problem of tuberculosis is today in our country.   Don't you wonder when
we think over the facts and see them as other physicians see them and as
other nurses see them, don't you wonder that it should have been difficult
to arouse people out of the apattry that seemed io exist some years ago,—to
do something to stem this awful disease in our midst?   What are we doing
about it now?   Happily a great deal more is done than twenty years ago.
Municipal responsibility is at last being recognized.    A civic conscience is
being awakened.   I venture to say that the response to the Rotary Clinic
shows what the general public feel about this question today.   What is the
answer to this problem?   The answer is easj-.   First of all, it divides itself
into two definite lines :  first, the cure or the care of those who already have
this disease;   second,  and  last, the prevention.    I  don't need to tell you,
although it is a very fine thing to be able to cure disease, it is very much
finer to be able to prevent it.   We have at the present time two sanatoria
for the treatment of tuberculosis.   Up to one year ago we had only one, at
Tranquille, capacity of one hundred and forty beds.   We have another now
61 at Balfour, a purely military institution, taken over for the soldiers, with
a capacity of about ninety beds. Those of you who have been reading the
journals lately may have noticed"a somewhat pessimistic note with regard
to sanatorium treatment. I think that that largely arises from a misconception of what the sanatorium starts out to do. Some people appear to have
looked upon the sanatorium as the beginning and the end of the tuberculosis
problem. The sanatorium is only one very small link of a very general
crusade against tuberculosis. Unfortunately, as has been explained before,
we have been obliged to take at Tranquille a large number of advanced
cases with little hope; these cases will ultimately die and injure the
statistics of the sanatorium, and they unfortunately take up beds which are
badly needed for cases which do have a reasonable hope of getting better.
A certain number of cases that go to a sanatorium will not do well, but a
very large proportion do excellently, which all points to the value of sanatorium work when cases are properly selected. Somebody asked some time
ago whether it paid to cure tuberculosis. In spite of having taken so many
advanced cases into our institution at Tranquille, we have a record of cases
cured or arrested which is not discreditable. One series of twenty-five cases
that had been arrested or cured has been kept track of, which cost some
$6,000.00 to look after and treat and finally turn out as arrested. When they
were last traced, these same people had earned $65,000.00 since their discharge. Not a bad answer whether it paid to cure tuberculosis. Besides,
looking after these people was a very proper and very humane thing to do.
From the standpoint of education, the sanatorium is splendid. These
people come back to their homes as missionaries and they spread the good
work to others; because you would be absolutely amazed if you knew how
many people who have tuberculosis, have not apparently been told one thing
about how to take care of themselves or about the prevention of this disease.
The Government is coming to the rescue by making it necessary for the
general hospitals to take in the advanced cases. I know that certain districts and certain hospitals rather resent having the advanced cases of
tuberculosis forced upon them; but if we are to fight this thing properly,
if we are to stop this awful toll, this awful loss of our best young manhood
and womanhood, we must take care of the advanced cases and prevent these
infectious cases becoming centres of infection for the outside world. What
I would like to see the Government of our Province do is to appoint a
committee to make it possible for us to confine certain advanced cases in an
institution where they "would have to stay. I am not speaking of the man
or woman who is decent and who will try to* protect others, but there is a
type of tubercular person who does not care at all. They expectorate on
our streets, and these are the people that by some kind of legislation ought
to be confined if they won't play the game.   Here are a few illustrations:
A case in Ward "O"—a man insisted on leaving the hospital—that man
spent his summer as a waiter in one of your restaurants down town, an
advanced case of tuberculosis, and we have at present no legislation to cope
with that type of case. We should have the power to keep them in the
hospital for their own sakes, but chiefly for the sake of others.
Methods of prevention. I have spoken first of the care of the advanced
cases, which is one of the most important parts of the campaign. We should
prosecute those who continue to expectorate on our streets.
At a meeting held at the B. C. E. R. Co., some years ago, to protest
against the dirty condition of the street cars, the general manager at that
time got up and actually said in cold blood that the dirty condition of the
street cars was due to the way the people expectorated in the street cars.
When you realize that the danger of infection from tuberculosis is in the
expectoration, you will realize the criminality of that sort of thing if
allowed.
Then the testing of cattle,—we now know that bovine tuberculosis is
communicable to people. 1 have talked with people, and it is rather annoying, you have to be very good natured, who come up to you in a superior
manner and suggest that we doctors are simply enthusiastic faddists. I
' would like to be able to show men and women of that type a few facts. I
should like to give you a case that came under my own observation. I was
called in to see a child with an obscure fever.   After watching the child for
62 a day or two I could find nothing definite and finally the child got better.
About the same time the mother got ill, was ill for weeks. We found that
they had been taking milk from private people who had had two cows die.
The mother was operated on and found to have 'tubercular peritonitis." In
this case I have not the slightest doubt what the child was suffering from.
I know what the woman was suffering from because I saw it.
We want a campaign of education. We want our physicians to notify
whenever they run across a case of tuberculosis. The health authorities
cannot fight this disease unless they know where this disease exists. I
want to say one word about this Rotary Clinic. Nothing can be of greater
value to a city than the establishment of the clinic that has just been made
possible by the splendid campaign of the Rotary Club. They will have a
nurse who will follow up suspicious people who come down from the
sanatoria as arrested or cured cases and who come in and have their chest
gone over. We shall have our fingers on the active cases; we shall be able
to check it, know where it is and fight it. That is the value of a clinic.
. There will be -a laboratory, there will be an X-ray. Most of you know that
we are getting a tremendous amount of aid today from the use of the
X-ray.
I have tried to speak to you for a few moments on the problem of tuberculosis, and what I consider to be the answer to the problem. The subject
is huge. It is very inspiring to have you gathered together discussing these
health problems and trying to make this a better country for people to live
in. I don't think it takes very much imagination for us to realize that we
are standing on the threshold of a great nation. We can almost hear the
footsteps of those who are to come after us, and surely it depends very
largely on the foundation we may lay, socially and morally, what the kind
of people who come after tis will be.
DISCUSSION.
MR. MORDY—
Dr. Procter stated, if I am not mistaken, that we have on an average
a loss of young men and young women, of four hundred in the province
annually; but he only reckons the loss for one year. If you take the working life of an individual from twenty years to fifty years, that is thirty
years of work, and at the rate of $2,000.00 per annum, and four hundred
being the loss this year and four hundred next year, and so on, for each of
those thirty years, it adds up to the enormous loss of $24,000,000.00 to this
province in an ordinary working life.
MR. SUTTON—
In order to produce a thing you have got to have it.    It reminds rne
of a story I heard.    A man said to his wife, "I have made $50.00 today.
I spat on the sidewalk and they didn't see me."
MR. DAY—
While some of the views put forward regarding the provision that
should be made by the state for the maintenance of hospitals, might be considered Utopian, it is certain that the trend of thought amongst those intimately connected with hospitals is largely along lines similar to those laid
down in the papers read this evening. In Sir Thomas More's "Utopia,"
published at Louvain in 1516, the following passage occurs :—
"The hospitals are furnished and stored with all things that are
convenient for the ease and recovery of the sick; and those that are
put in them are looked after with such tender and watchful care, and
are so constantly attended by their skilful physicians, that as none are
sent to them against their will, so there is scarce one in.a whole town
that, if he should fall ill, would not choose rather to go thither than
lie sick at home."
The vision of three hundred years ago is a fact today, and as the social
world is moving rapidly, the vision of today will probably be seen translated with fact by our young men before they have reached the age of those
who have so ably dealt with the subjects of the community and the state
this evening.
Today hospital boards have four sources of income—Dominion, Provincial, Municipal, and Individual.    With the Dominion, twenty years ago
63 we had only to consider the question of caring for a few Indians. Then
with the taking over of the defence of Canada from the Imperial Government, came the care of sailors and soldiers, and with the abolishment of
the Marine Hospital the care of ocean-going merchant seamen. Now the
returned soldier problem has come, and we in Victoria consider the rate
allowed for their treatment is inadequate for the wards of a general hospital. It never covered more than actual cost, and now with the high prices
of all food and supplies, it is inadequate. The Provincial Government and
the municipality have noted this and are watching it with some concern.
The Provincial Government grant is admittedly liberal when compared
with the grants made to hospitals by the prairie provinces, and the Minister
of Health has not failed to tell us so. In his opinion the further burden of
support should fall upon the municipality, while the latter is firmly of the
opinion that it is easier for the government to help than for them. We
have, therefore, some way to go before we can bring these opposing forces
into line. Hitherto each hospital board has gone to the government and
made its request, some on one ground, some on another ground, and possibly some divergence of opinion has been shown. This convention should
appoint a representative committee to consider the requirements of the
hospitals, and. formulate a definite income-raising scheme. Then we can
go to the government as a unit and make the weight of our case felt. Inasmuch as now we have to deal with three bodies (Dominion, provincial, municipal) we should endeavor to determine what proportion of cost should
fairly fall upon each, and we should keep at the work until we have accomplished a satisfactory result. Fuller control by the state as a corollary of
full support would follow. Hospital boards would not be allowed to run
up heavy bills for the community to pay. Thus state would control all
expenditure, especially capital expenditure, and decide what equipment is
necessary for each hospital, so that it would have all reasonably adequate
accessories for the treatment of the general run of patients likely to be
found within its walls.
MR. SUTTON—
Dr. Young mentioned the need of a co-operative spirit between municipalities for the formation of community centre hospitals—that is, the smaller
places would get together and link up with the larger centres—making this
the community centre. He suggests this be run by the councillors. Does
he think that such a body would be a suitable one to maintain and manage
a hospital, in view of* the fact that in many places they are not able to
manage their own municipalities?
Does the Provincial Government think time opportune that tuberculosis
should be tagged in the same manner that any infectious disease is at the
present time? In case of scarlet fever, diphtheria, smallpox, for instance,
no one is allowed to enter or come out, yet a person suffering from tuberculosis is allowed to come and go anywhere. Do you not think that this is
an opportune time to placard the house or take that man away from the
place, where he can be looked after without coming into contact with the
people ?
DR. YOUNG—
The contributing source and the revenue of the hospital would naturally
want some representation on the management of that hospital. The direct
management of the hospital would not be vested in a board that would be
of such representatives. There should be selected for that active management of the hospital superintendents and others who would understand the
management of a hospital, they would be concerned in the management of
the hospital. If the co-operative scheme was carried out the Provincial
Government should also desire representation on account of its contribution. I would not suggest that we pick up a board haphazard throughout
the province. The question with most of our hospitals, unfortunately, is
management. I would suggest boards of men and women who are voluntarily giving their services because they "are interested and love the work.
There would have to be some scheme for representation of municipalities.
The government would ask that one or two members of the board should
be appointed by the government.
64 As regards the question of tuberculosis and the question of treating it
as an infectious disease—1 am very glad that you wish to see that carried
out and enforced, but while we may place this upon the Statutes, and while
we may enact regulations under the authorities of those Statutes, we cannot succeed in enforcing them unless we proceed to the extremity of prosecution, and if so, we raise a storm of protest, and we are finding out by
experience that until the people are educated, it is almost an impossible
task to enforce. The public are admitting in some places that they are afraid
of being disfigured by smallpox—of the terrible effects of infantile paralysis,
because the lay press will always feature the horrible side. There are
hundreds of thousands of other cases fill up our deaf mute asylums and fill
our cemeteries with bronchial pneumonia, etc., following measles. 'We need
to educate the public opinion that the public health officials know what they
are talking about, and it will come to the time, as Dr. Mullin pointed out
tonight, where the community, which is constituted by the family, becomes
a menace to the community at large, drastic measures will be adopted, and
when a tubercular patient will go forth to spread the disease, then the State
must step in and say to that patient, "You are a menace to the community,
you will have to be confined," just as we say to a scarlet fever or smallpox
patient—but they do not know the deadly effect of tuberculosis.
I cannot conscientiously congratulate the medical men for the enthusiasm they have shown in co-operating with the Government in regard to
the reporting of tuberculosis cases.
At the last session of Parliament a Bill was passed providing for a
Uniform Training School for Nurses for outlying districts. I was not
opposed to this Act, and advocate a broader training and a wider field of
work.
I would have them engage in general health work in the nature of
District Nurses, carrying the gospel of health to the people; visit the schools
for hygienic instruction and give parental lessons where they are needed.
Co-operation with the public for all its health and educational needs
along health lines, I advocate as a nurse's work. Nothing short of an
epidemic arouses public interest to real health matters, and the health
department headquarters, unfortunately, are too far removed from the
people to accomplish all the beneficial work it should be able to do to have
the direct effect.
But in order that a nurse may give her best to further her profession,
it is very necessary that she should have proper accommodation. If she
is put into a hot, stuffy room, with bare walls and no comforts, she cannot
be expected to accomplish as much, or to do as much good, as if she were
quartered in bright, comfortable rooms, with plenty of air and sunshine.
I therefore strongly advocate better accommodation for our nurses. Also,
I say that provision be made for a Nurses' Training School in small hospitals. This is essential, and I trust it will not be long until this is
established.
MISS COLE—
I was in a land where the law was made, where it was compulsory for
a tuberculosis patient to be removed from the house, and certainly the people
were not educated up to it in any form or way, but I can strongly say there
was no opposition. I was working myself and had to do with a great deal
of tuberculosis. Proper isolation had to be insured and proper care, and
there was no opposition. It answered very well, but I cannot see, that with
all the great work the Rotary Clinic is going to do in the next year, how
they can succeed without having some compulsory law attached to it. In
these days you may wait and wait for people to be educated, but until a
strict measure is taken you will not get a very good effect,
MRS. CURRIE—
I would suggest a $50.00 fine for people who expectorate on the street,
as in Banff.
MR. GRIMMETT—
A man suffering from tuberculosis, may be for years, bis isolation may
continue for years, whereas in a case of measles or smallpox, only a few
65 weeks at the most.   Is not that the reason for this apparent apathy in regard
to isolation of tuberculosis cases?
DR.  YOUNG—
I do not think that is the apathy, but the fact of the long existence of
the disease. Smallpox comes on in a very acute maimer and it appeals immediately to those who are in contact. It is only within the last few years
that those interested have determined upon the contagiousness of the disease. As you know, probably—anybody here can remember, it isn't so very
many years ago—to tell a man that he had consumption was simply to
condemn him to death. There was no hope for that man, but as our studies
progressed we have learned that we can cure tuberculosis.
Education of the public on this particular subject is needed, and when
they become educated to the fact that if the disease is taken at the right
time we can cure it—then we can control it better. We can at least teach
them such rules of procedure that will put them on the road to cure; but
where the real danger lies is when the expectoration is loaded with the
bacilli: it is then that they become a menace and should be confined, just
as strictly as a smallpox case; at least they should be under such supervision that there would be no danger of affecting other people.  -
The building of sanatoria is necessary, and we must have them. These
patients must be taken charge of and the Government proposes to do it.
We ask the co-operation of all the medical men to report the cases. If we
have an exact knowledge of the existence of the cases we will be able to
deal more directly with the subject, and. as I pointed out when I was speaking tonight, we are appointing a man who will take supervision of that
work. No doubt we will ask and hope to get the co-operation of the
Victorian Nurses in this scheme; but we want to carry the work into the
homes, to educate the people to the danger; and we hope that when that
point is reached, when we reach such a storm of protest, we will go into
the homes and say, "For the benefit of the community you must do so and
so." We have the idea, we are trying to instill it into the minds of the
public, and eventually, not in the distant future, we propose handling these
cases which have been shunned heretofore—handling them as contagious
diseases. The same remarks will apply to the venereal diseases. The public
realize the fact, and we will, we hope, in the very near future, publish
regulations which will apply to this disease. You cannot convince the
public of what the medical men know in regard to this. It certainly was
enlightening to listen to Dr. Mullin tonight on what it costs to support a
syphilitic patient in the Mental Hospital at New Westminster, but you don't
hear any outcry about intimate social intercourse amongst people who medical
men know are syphilitic, but people are beginning to realize the seriousness
of the case. The public will demand that the authorities who are in charge
of this work shall protect their health and it will be done.
DR. RIGGS—
We hope that this thing will go on until the whole country will be well
organized to deal with all these questions, not only contagious diseases but
all the questions of public health; but I would like to just draw the attention of the Convention back to the question of State control of hospital
work, and the question as raised by the gentleman from Victoria as to cost.
We cannot, probably/get the Government to take over hospitals all at once,
to bear the whole expenses of the hospital all at once, but I would like to
emphasize what Mr. Banfield said—making a certain part of the work of
the hospital available for everybody. It seems to me that while the rich
man and the pauper are treated the very best, that we should, make these
means available to the poor part of the population with the same readiness.
That means that the hospital cannot support laboratories and X-ray, clinical,
bacteriological, pathological and X-ray laboratories and do this work for
nothing. The expense is too great, and yet that is necessary if these people
with moderate means are going to be treated as well as the pauper.
Therefore I would suggest to this committee to see that they have the same
line of argument to put to the Government—ask the Government to continue
the work they are doing, and to stand the expense of every hospital in the
Province to furnish the means of diagnosis, free.   It would mean in the
66 small hospital that it could be arranged that a clinical and bacteriological
laboratory on a small scale could be instituted in every hospital, also an
X-ray, and that all these means would be available to everyone and would
be supported by the Government. That would materially help, and I believe
that it would not only be an economic thing from the standpoint of preserving those who are already badly diseased, but that we could get many of
those cases early, and therefore should be able to prevent much of the
trouble that arises from either lack of diagnosis or a wrong diagnosis, as
at present.
MR. GRIMMETT—
If there is no further discussion, I will declare the meeting
adjourned, to meet to-morrow morning at 10 a.m.
We will close by singing the National Anthem, "God Save
the King."
MORNING SESSION—Thursday, June 27th, 1918.
DR. GATEWOOD—
I am going to ask Mr. R. S. Day to take the chair this morning.
MR. DAY—
I will now call upon Dr. Milton Jones for his paper on "The
Elimination of Chronic Hospital Cases by Proper Dental Diagnosis and Treatment."
"THE ELIMINATION OF CHRONIC HOSPITAL CASES BY PROPER
DENTAL DIAGNOSIS AND TREATMENT."
By Dr. Milton Jones, Vancouver, B. C.
The discovery of a relationship between defective teeth and ill health is
not recent. It has been recognized for centuries by practitioners of dentistry
and medicine, but only within the last decade has it received the attention it
has deserved. Benjamin Rush, one of America's most noted physicians,
began observations along this line as early as 1801. He says, "I have been
made happy by discovery that I have only added to the observations of other
physicians in pointing out a connection between the extraction of decayed
teeth and the cure of general diseases." The early writers attributed the
relationship to dental caries. Doubtless the swallowing of poorly masticated
food, putrid material and even pus has an untoward effect upon digestion.
It does not seem probable, however, that it has an important bearing upon
the many systemic ills for which the teeth are now thought to be responsible.
The healthy mucous membrane of the gastro-intestinal tract can tolerate
much abuse and can even destroy septic material when ingested. Pyorrhoea
is a frequent source of chronic infection distributed by the blood to remote
organs; so also alveolar abscesses and granulomata are known to be a
source of ill health and are of greater pathological import than is pyorrhoea,
for two reasons :—
First—They lack drainage, are confined in bony walls and contra-
distinct to the infected areas of pyorrhoea where expansion is possible.
Secondly—Pyorrhoea gives rise to symptoms which are apparent to both
patient and dentist; whereas chronic granulomata at the root apices do not,
as a rule, give rise to a single disagreeable symptom which could arouse
suspicion.
Pyorrhoea is easily diagnosed by ocular and digital examination, its
essential symptom being the exudation of pus on pressure being applied to
the gums. Yet many physicians have erred in the diagnosis of this malady.
They have diagnosed pyorrhoea where only an accumulation of tartar and
the consequent gum recession was present. One case came under the writer's
observation recently where a prominent surgeon had diagnosed pyorrhoea in
67 a patient whose only dental trouble was a series of erosion cayities at the
necks of the teeth, due to a vicious secretion of the mucous glands.
The diagnosis of the blind abscess or granuloma is a more difficult
matter inasmuch as it can be made only with the aid of the X-ray. Should
the infection be of the hemolytic type, of high virulence, the abscess will be
acute and the casual symptoms of acute inflammation in evidence; whereas
if the infection be of the vividans type, of low virulence, the inflammatory
reaction is likely to be chronic, giving rise to little disturbance, but slowly
progressive in nature. The acute form leaves very little trace of its activities
from a radiographic standpoint, there not having been time for dissolution
of the lime salts to occur. On the other hand, a chronic abscess, having
dissolved out the lime salts, will allow of the free passage of the rays and
show up as a dark area on the film.
At this point it is well to observe that the X-ray, while an important
and indispensible means of diagnosis, is not without its limitations and can
never be relied upon as the sole means of diagnosis. Not. every dark area
on the film is evidence of infection, and many an infected area shows normal
on the film. The roentgenographic evidence must invariably be weighed
along with the history and the clinical manifestations if a correct diagnosis
is to be made. Often a small granuloma may be entirely obscured by being
located directly behind a dense root. On the other hand some dark areas
on the film represent cavities which are sterile, having been rendered so by
previous treatment. This observation, however, we believe applies only
where treatment has been recent; for if treatment had been made several
months previously, there ought to be evidence of new bone formation if the
treatment was effective.
There are> other anatomical conditions which are sure to mislead the
unwary. Often the shadows of the nasal fossae are projected at such an
angle that they show an apparently rarefied area at the apices of the central
incisors. One instance came under our observation where a physician had
ordered the extraction of the two centrals because of this shadow which he
saw on the film. Fortunately, the dentist knowing the teeth to be vital,
checked up what might have been a serious blunder. The shadow of the
anterior palatine foramen may often be mistaken for a rarefied, infected area
in the same region, just as occasionally the shadow of the posterior palatine
foramen may be projected at the apex of the palatine root of one of the
molars, and be misread as an area of infection. The shadow of the antrum
often leads to complications of diagnosis in the upper molar region especially
as the roots of the molars often lie in the walls of the antrum or project
abnormally above its floor. The mental foramen may also be mistaken for
an infected area inasmuch as the shadow is frequently cast over the apex
of the lower bicuspids. Even the inferior dental canal itself may cast a
shadow so close to the root apices as to lead to a hasty diagnosis of rarefica-
tion. Then, too, the uncalcified tissues at the apices of erupting or recently
erupted teeth may be misread as an infected area. These citations are made
to show the many pitfalls into which one may -fall in an attempt at a
diagnosis of a roentgenogram without the aid of clinical evidence. The use
of the Faradic current is an excellent aid in diagnosis. By it one can
determine the vitality of a pulp and in this way often settle a doubt or even
avoid the necessity of an X-ray exposure for any particular tooth.
The stages of periapical disease may be summed up as follows:—
1. Chronic pericementitis, shown on the film as an increase in thickness
of the normal dark line between the apical portion of the tooth root and the
bone.
2. Chronic rarefying osteitis with granuloma, and a disintegration ot
bone takes place in a circumscribed area, the bone cells being replaced by
granulation tissue. The tooth apex may project into the bone cavity, may
be roughened from irregular absorption or may be enlarged from hyper-
cementosis. In the film there appears a clearly defined area surrounding
the diseased root apex.
3. Chronic rarefying osteitis with suppuration. The area is pus soaked
and shows on the film as a blurred area of somewhat lessened density, with
irregular and ill-defined margins into which the roughened tooth apex
projects.
68 4. . ChfBhic rarefying osteitis with cyst formation. This stage succeeds
that of granuloma, the cavity being filled with clear fluid and often little
soft tissue except a thin fibrous sac. In the film there appears a very
clearly defined dark area involving the apices of one or more teeth.
In dental X-ray diagnosis two points of practical utility are worth
noting: First, where shadows are superimposed, as of one root over another, the more clearly defined shadow is that of the root nearest the film.
Second, when a shadow of a foramen or other cavity is shown projected
over a root apex, try to follow the light line of the stratum durum around
the root apex. If you can, the tissues are norfnal. This will be better understood when a slide is thrown on the screen.
So much for diagnosis. Let us assume that a correct diagnosis of
infection has been made. What is the treatment? One of three methods is
to be considered:
(1) Treatment through the root canal;
(2) Surgical removal of the diseased condition by root resection and
curettement;
(3) Extraction and curettement.
Often teeth are condemned to extraction which could safely be retained
by proper treatment, owing to lack of discrimination on the part of the
physician. On the other hand the training of the average dentist does not
permit him to grasp the broad pathological aspect of the question and he
often attempts to save teeth which may be a menace to the life of the patient. Much depends on the dentist as to whether conservative or operative
measures are to be advised. Unless the dentist is familiar with modern
methods of aseptic root canal work and is guided in his operations by the
X-ray, by far the safest procedure in the extraction of any tooth whose pulp
chamber is entered by decay. If the patient is in the hands of a competent
dentist with a sense of surgical asepsis and familiar with modern accessories, much can be done in saving many teeth which show evidences of
infection. In this connection, I may say the method of treatment by ionization promises much but is yet too little used to warrant conclusions. The
question of conservation or radical treatment should first be decided by the
health of the patient. Often a tooth may be recommended for treatment in
a healthy individual where in an invalid it would be extracted without hesitation. My one admonition in regard to a decision as to conserving or extracting an offending tooth is this, "When in doubt, extract." The risk of
sacrificing a harmless tooth is a small matter when weighed in the balance
against the life of the patient.
As regards the treatment of teeth involved in pyorrhoea, the following
rules may be made:
Teeth, where the surrounding destruction involves more than one-half its
support, should be extracted.
Multirooted teeth, in which the destruction has extended to the bifurcation of the roots, should be extracted.
Teeth, in which the suppuration from pyorrhoeal pockets resists persistent attempts at conservative treatment, should be exracted.
It is felt that practitioners carrying out the above line of treatment will
escape the charge of ultra-conservation on the one hand and ultra-radicalism
on the other, and will be following a sane middle course.
The treatment of maxillary infections is largely a dental problem and
is at present the subject of much interesting study. Several factors must
be considered in the choice of method, viz., adequacy and permanency of
the result, the possibility of restoring masticating surfaces, and the time
and expense to the patient. Time and expense often make extraction of
teeth with infected roots the method of preference. Moreover, it is the
safest and surest method of removing sepsis. Frequently, however, conservative treatment is justified, especially if the resulting systematic diseases
are not serious and there exists no constitutional disorder such as diabetes,
&neniia, etc., which .may lower resistance to infection and decrease the likelihood of success. The question of the best method of treatment might yet be
considered an open one, and for the present at least, the method in each
individual  case might be based  in  part upon  the  apparent  possibility of
69 eradicating sepsis by conservative means and in part upon the gravity of
the systematic ill for which the teeth might appear to have been the contributing cause.
So fa'r, we have considered the treatment of existing sepsis. We must
not overlook the importance of treating defective teeth with a view of preventing sepsis. Let this also be remembered, that so long as a tooth remains vital it cannot become the seat of an apical abscess. It i s a real
calamity when dental caries is allowed to progress to the stage of pulp exposure. It is usually the beginning of a chain of troubles often culminating
in the death of the individual. Many a death certificate is registered as
nephritis, myocarditis, cholecystitis or arthritis, which would be more truthfully recorded as "death from an exposed dental pulp." Under ideal conditions prophylaxis should begin in early childhood and should include the
proper handling of every abnormal condition of the mouth, throat and nose
which may give rise to mouth breathing, debility, infection, etc., and, in
this way, interfere with the proper development of the architecture of the
throat, nose, jaws and teeth. If the public, as well as physicians and dentists, were aware of the serious influence which defective teeth have on the
development and health of the average individual, oral prophylaxis would
hold the important place in preventive medicine that it so richly deserves
and the result would be economy in time and expense to the patient, increased physical and mental efficiency, a greater average duration of life,
better preservation of the tissues in old age and fewer chronic diseases.
Rosenow, of the Mayo Clinic says, "The relationship between dental infections and various systematic diseases is demonstrated The eradication of these foci of infection, often symptomless, is indicated. The exact
methods of ridding patients of existing dental foci of infection must be
decided in each individual case. A closer affiliation of the medical and
dental professions is called for. The dentist of the future should not be
isolated in a small office over a drug store, his chief work being to devitalize and fill teeth without regard to the general health. Properly trained
dentists should be a part of the public school system and hospitals. The
dentist should be closely associated with a group of phyicians so that patients may be given the benefit of a co-ordinate group of specialists with a
minimum loss of time and money. Moreover, it seems to me there should be
started a public health propoganda so that the people may be fully informed of the dangers, to their continued health, that arise from infected
teeth and how to avoid them.    Prophylaxis should be the watchword" !
The bearing of all this on the management of hospital cases is evident.
Many a chronic case of rheumatism, heart disease, kidney disease or ulcer
of the stomach is lying in the public wards, a charge on the institution, and
a burden to themselves and their relatives, which could be sent out cured or
greatly benefited if they were to have their teeth X-rayed for the discovery
of focal infections at the root apices, and these foci of infection properly removed. No modern internest considers his diagnosis complete in such
cases until the hidden lesions, brought to light by the X-ray are carefully
examined by a competent dentist specially trained in the interpretation
of the shadows cast on the films. This is not a simple matter and must be
done by one familiar not only with the technique of making the radiograms, but quite conversant with the special anatomy, physiology and pathology of the teeth and jaws. This specialist should consult freely with the
general pathologist in an effort to arrive at a correct diagnosis of the patient's ills. The sooner hospital trustees and superintendents recognize the
necessity of employing a scientific dentist with what we might call a pathological sense, as a regular member of the staff, the sooner will be cleared
up a multitude of the chronic ills with which the patients are affected.
MR. DAY—
I am sure we all have enjoyed Dr. Jones' paper, and thank
him for the enlightenment he has given us on this subject. If
there is any discussion we would like to hear it now.
70 If there is no discussion, I will now call on Mr. Grimmett
for his paper on "Financing the Hospital."
"FINANCING  THE  HOSPITAL."
By Mr. M. L. Grimmett, Merritt, B. C.
In speaking to you this morning on this subject I wish you to bear in
mind that I am speaking from a very limited experience—that comes from
my connection during the last two or three years with the hospital at Merritt. I am here to learn rather than teach. At the same time I feel that the
duty is incumbent upon me to convey to you whatever knowledge I may have
derived from my experience. It is a trite saying that financial questions are
trying, but the great importance of this subject should make it intensely interesting to those of us who have upon our shoulders the financing of the
hospitals. I take it that I am to deal with the financing of hospitals as they
exist at the present time.
The future of hospitals lies, in my opinion, in the direction of individual
or municipal ownership and management. You heard last night about the
Government of Alberta and Saskatchewan. I did not know that Saskatchewan
had also legislated on the subject. I knew that Alberta had, and I have
possession of a copy of the Act. Dr. Young told us that Alberta had already
passed an Act making it possible for municipalities to maintain hospitals,
a step that I am sure is in the right direction. I feel that in the near future
British Columbia will have legislation of the same kind.
I will tell you what we do in Merritt. I have no new theories to advance as to hospital financing, but I can tell you how we are doing up there
if I may be permitted, and it may add something to the meeting.
It is only the last few months that the hospital at Merritt has been on
a paying basis. For years we were carrying a heavy debt there, for months
the chairman went without his outlay being paid, even, the staff had to wait
for their salaries. I wish to say today, notwithstanding the high cost of
living, notwithstanding the larger salaries we are paying there today, I am
proud to say that the hospital at Merritt is paying its way, and if in the
near future we can get a further grant from the Government, we should not
only be able to pay our way but to improve our grounds and buildings,
which is very necessary.
I want first to deal with our sources of income, then in the second place,
deal with the collection and getfing in of that income.
We have what is called the "contract system" in connection with men
working in the mines, in the sawmills and in the logging camps. This system, I believe, is not in vogue in some hospitals. Men there pay us seventy-
five cents a month for hospital treatment, but according to calculations, we
find that at present we are just about breaking even along this line. We are
seriously considering whether we shall not abolish this system entirely.
We think that our income would be increased should we do so. However,
the subject is just under consideration. Until the last three months we were
receiving only fifty cents a month from these men. We found it entirely
insufficient. We increased to seventy-five cents, realizing the large wages
they were making, the increased cost upon every line, and they arose to the
occasion and made no objection. We have what you all have—income from
private source. We were charging up till recently $1.50 per day for the
public ward, and perhaps it would be advisable for me at this stage to correct a wrong impression that was conveyed yesterday, namely, that we were
limited to $1.00 a day for public patients. It is quite correct partially; in
another way it is incorrect. Municipalities under the law can be made to
pay for indigent patients. Under the Act that man is limited to $1.00 per
day. That is the only instance that the Government has said we can only
collect $1.00 per day. There is no limitation on the hospital in regard to
fees, what they will charge. Recently we raised our rates from $1.50 to $1.75
for the public ward.   Our rates now are:
$1.75 per day in the public ward, or $12.00 per week, to patients who
are there longer than a few days;
Semi-private cases, $2.00 per day;
71 Maternity cases, $3.00 per day until treatment, after treatment, $3.75;
Private, $3.50 per day;
Operating room, $5.00;
X-ray, first plate $5.00, two or more plates of the same patient, $10.00.
We find that those rates are being cheerfully met by the patients, no objections'raised whatever.
Now I come to the much talked of question of the Government grant.
Unfortunately, our failure is one of lack of co-operation along this line.
We are all of the opinion that the present grant in aid is not sufficient. The
present grant was fixed some years ago. Again referring to the high cost
of living and of labor, if that was a fair and equitable amount to grant us
then, I say it is unfair under present conditions, and we have every reason
for going to the Government and saying, give us an increase of twenty-five
or fifty per cent, on your present grant, to meet conditions that exist now,
that did not exist when that legislation was passed. We must make an effort
along this line.
I want to refer to another source of income that we have, that is-^we sell
tickets, $12.00 per year, entitling the holder to certain privileges. We found
that some persons were so generous toward the hospital that they came generously forward when they knew one of their family was to be ill, and purchased a ticket. Now we sell tickets only once a year, during the first week
in July. However, we are continuing that privilege, and we are ready to
grant it to those who appreciate it, but we do not like them to appreciate it in
the way I have mentioned.
With reference to Indians, we have a number of Indian Reserves in
our community. We get $1.00 per day for the treatment of those Indians
from the Government. At the same time it was costing us $2.00 to $2.25 a
day to treat these Indians. The Dominion Government did not give us a
cent towards the maintenance of our hospital and the Board naturally asked
the question, "Why should we treat Indians who are wards of the Dominion
Government, without receiving any aid from the Dominion Government?"
Under the regulations passed by the Lieutenant-Governor-in-Council we are
entitled to receive no aid from the Provincial Government in regard to Indians, so that you can see how unjustly the hospitals in this country have
been treated. The Indians have to be treated. We took the matter up with
the Indian Agent in that district, and he agreed to pay us the actual cost of
Indian patients, and we treat our Indian patients the same way we treat
the white ones. We have never heard one protest about the admission of
the Indian in the public ward, so they get the same treatment. We took
up the question with the Agent, who agreed to allow us the actual cost, so
we sent in one bill based on a cost of $2.12 a day. It was paid. We sent
in the next bill and it was refused and certain correspondence took place.
(Read letter from Indian Agent.) Now, you can see how very unjust it is
that we should be asked to treat Indians at less than it is costing us per
day. We are pleased to treat these Indians, we have a duty toward those
Indian patients, a duty we are going to discharge to the best of our ability,
but we have a right to be paid what it is going to cost us; consequently there
should be united effort on the part of all of us, no matter what your cost
in Vancouver, Kamloops or Salmon Arm, we should at least get from the
Dominion Government the actual cost of keeping the Indians.
We have received aid, and I cannot speak too highly of the aid we have
received from the Ladies' Auxiliary. These ladies have given devoted service; I need not explain what that service has been in regard to supplying
linen for the hospital—in holding at Easter a public ball, giving them a great
deal of trouble. We cannot speak too highly of the aid they have given
us. I am pleased to say that we are getting into a position where our demands upon the ladies are not going to be so heavy, and the ladies have
given the last Easter ball to the Red Cross. I would like to thank the
ladies for their devoted work. They are now devoting their energies to
another sacred and high cause—the aiding of our lads at the Front. God
bless the ladies for their work!
Mr. Chairman, do you have any difficulty in collecting your bills in
Victoria, or Dr. Gatewood, do you in Vancouver?   There are some people who are quite willing to leave their hospital bills unpaid, to leave their
physicians bills Unpaid, yet if yon were to niake' them a direct offer of charity, they would feel insulted. Indirectly, they are ready to receive charity
from the hospital and physician. Now, our finance committee meets once
a month, they closely scan the current accounts and if they feel that there
is a man on that list who is able to pay and won't pay, the account is at
once placed in the hands of a solicitor. You have got to do this to educate the people that an hospital account should be paid as soon as the
grocer's bill. The result is we are getting our bills in much better than we
used to. We have $2,000.00 owing to us on open accounts but our collections have been increasing steadily. Those who are unable to pay we mark
off our books. We find that it is necessary to present our accounts regularly to the patients. I understand some hospitals present their accounts
evSry two weeks. I think that is right. If upon leaving the hospital the
patient cannot pay, or if the patient be a lady, and her husband is not able
to pay, get some acknowledgement of the debt, take a three months' note,
take some evidence in writing of the debt, so that in future, if you have to
put it in the hands of the solicitor, there can be no dispute. Be sure and follow out that principle of taking notes.
We have two committees in our hospital, a Finance Committee and a
House Committee. In this connection there should be the closest co-operation between those two committees. The House Committee should not enter upon any expenditure of any magnitude without the approval of the
Finance Committee. There must not be unlimited power placed in the
hands of the House Committee with regard to buying.
In conclusion, let me say that this is the most important branch of our
discussions, and consequently, I would like to hear a full and free discussion of this subject. I am here to learn and very anxious to find out what is
being done in other hospitals. Any questions I shall be very pleased to
answer, if I can.
DISCUSSION.
MR.   MORDY—
I would like to know, Mr. Grimmett, before you raised your rates in
the public ward or the contract rate to seventy-five cents per man, what
was the actual loss per patient per day at fifty cents, and also I would Hke
to know with regard to collection of accounts—what is the method of charging these accounts—are they payable week by week in the private wards,
and are there any stipulations made as to the payment in the public wards
on presentation of accounts? In Cumberland, we have a Finance Committee, Supply Committee and a House Committee, which
general welfare of the hospital. These three committees
hand.
MR. DAY—
We collect all our bills in advance. If you go into a pay room in
Jnbilee Hospital you will pay one week in advance, and you must pay
weekly thereafter; unless you go into a public-ward.
The address to follow by Mr. Haddon is so much along the
same line that I think we should have it before any further discussion. I will now call on Mr. Haddon for his address, "Hospital Accounting."
"HOSPITAL ACCOUNTING."
By Mr. Geo. S. Haddon, Managing Secretary of the Vancouver General
Hospital.
One of the problems in all hospitals, however large or small, is that of
providing a system of bookkeeping that will enable the directors and management to have at all times a simple but yet complete and comprehensive'
statement of the hospital's financial condition.
The importance of up-to-date accounting, as applied to hospitals, is becoming more and more apparent every day, and while I think that this important branch of hospital work has been somewhat overlooked, 6t possibly
73
look after the
work  hand   in neglected, in the past, nevertheless, it is pleasing and interesting to note
that at most of the large hospital conventions held within recent years, particular mention has been made of the great need of more careful attention to
the study of hospital accounting.
Many hospitals no doubt are handicapped to a certain extent through
lack of staff, or otherwise, in having their statements and reports prepared
in a way such as they would desire, and perhaps feel that is unnecessary
from their point of view of keeping the detail necessary to permit of the
publication of an annual report. This is unfortunate, for if the statements
were published in a clear and understandable form, they would become of
real and lasting benefit, not only to the hospital authorities, but also of great
interest to the public and to other hospitals for the purpose of comparison.
The object of this paper, therefore, is not so much to elaborate upon a
system of bookkeeping, but to outline as briefly as possible the headings that
might be used in the hospital books, viz:—Cash Book, Voucher Journal and
Ledger, as will permit of the preparation of a monthly statement so much
desired and along the lines of that shown later in detail. And further, to
offer a suggestion relative to the inauguration of a uniform system of hospital accounting as applicable to hospitals, not only in British Columbia, but
preferably for the whole of Canada.
It is needless to say that if this were accomplished much benefit would
result, as all hospitals using the system would be in a position to intelligently compare figures of cost of operating or otherwise, which is not possible at the present time.
Naturally, there are obstacles that would be encountered in devising
such a uniform system to suit all hospitals, on account of the different conditions under which they operate. There is no doubt, however, in my mind
but that any such difficulty could be overcome.
How much more interesting it would be to compare your own with other
institutions from published yearly reports made out along similar lines. You
all know how unsatisfactory it is to attempt to compare figures today. The
expense headings in practically all hospitals are totally different. Capital
charges in some cases are mixed with operating expenses and so on. In fact,
there is no set rule, as there should be, to govern or guide in the distribution of all items of expense under their correct headings. A classification
of all articles used in hospitals would tend towards overcoming this difficulty
and would ensure that each item of expense is charged to its proper section.
A large number of hospitals make it a practice of showing the operation of their work in the form of Receipts and Disbursements. This is not
so complete or so interesting as showing a statement of Income and Expenses. The former does not show the true state of the hospital's business
for the year. For instance, very often considerable income is derived, such
as Government and Municipal grants or otherwise, which is not received
until after the close of the year, and further, disbursements are more frequently not made until several months after the accounts are incurred, and
so on. It can therefore be seen how much more satisfactory it would be to
show the income as against the actual receipts, and the expenses as against
the actual disbursements or bills paid, which in the case of Income and Expenses will show any surplus earned or deficit suffered during that period,
while that of Receipts and Expenses, the Cash Book Balance only.
This is mentioned for the purpose of showing the need of a uniform
system of hospital accounting.
The Cash Book, Voucher Journal and Ledger headings which are detailed herewith, and the General Statement of Income & Expenses, more
tully described, are, with slight modifications, similar to the system at present
in use in the Vancouver General Hospital, and which have been found to
work extremely well. With slight changes in the headings these can be
adapted to any hospital and might be used as a suggestion or as a basis to
form a uniform system of accounting.
Cash Book.
The Cash Book shall,' of course, contain the various headings of possible
revenue as shown on the General Statement form, and also the customary
74 columns for disbursements made. The disbursements need not necessarily be
posted in the ledger to individual accounts, but as a lump sum to a
ledger heading of Accounts Payable or other suitable wording. This
will show, after making the postings from the Voucher Journal, the amount
actually owing from time to time, saving as it does the time necessary to
make a list of the balances of the individual accounts. A suggestion is offered which will considerably reduce the time necessary to post the individual receipts from the Receipt Book to the Cash Book. In the case of
the Vancouver General Hospital, the number of receipts issued each day
became so large (unfortunately the expenses increased to a like extent) that
it was found necessary to make provision for a distribution of the receipts in
a special place provided in the Receipt Book for the purpose, and posting
to the Cash Book the total only of the distribution of the day's work, in
place of the amount of each separate receipt. This proved a great factor in
the saving of time and extra labor, but it is not particularly recommended,
only when the separate posting of receipts becomes too heavy a task that
it is necessary to inaugurate time and labor-saving schemes.
Voucher Journal.
The Journal or Voucher Journal shall contain a record of all accounts
passed for payment by the hospital board. All vouchers or disbursement
warrants when drawn up and so approved, must be entered in the Journal,
given a consecutive number and distributed to the various departments to
which they are chargeable.
A special combination voucher form and cheque is shown herewith and
in actual practice has proven entirely satisfactory. The voucher is permanently retained in the office, the cheque only, which contains a record of
the invoices called for in the voucher, being forwarded to the payee. The
voucher form itself contains a complete record of the various headings of expense for distribution purposes before transferring to the Journal. All
danger of losing the voucher, which very often happened under the old system
of mailing the original voucher to the payee, is entirely eliminated.
THE VANCOUVER GENERAL HOSPITAL
Dr. To     v
Cheque is void if detached from statement of account or altered in any way.
No	
Vancouver, B. C, 191	
PAY TO THE ORDER OF	
  Dollars, $	
in full settlement of account as per statement above.
THE VANCOUVER GENERAL HOSPITAL
To the 	
BANK OF MONTREAL Chairman
Vancouver, B. C. 	
Treasurer
Endorsement of this  cheque by payee is  sufficient  receipt,  none other  is
necessary.
Ledger.
The Ledger, of course, is drawn up to conform to the headings in the
' Cash Book and the Voucher Journal, with the customary Bank Accounts,
Profit and Loss account and so on. The double entry system of bookkeeping
is recommended, viz.—Debiting and Crediting all entries passing through the
Ledger. This permits of a closer check on all entries and at the same time
assists in proving the Trial Balance when taken at the close of the month.
75 General Statement of Income & Expense.
The Statement of Income and Expenses is made up monthly arid will
show the deficit or surplus (if any) covering that period.
The Statement should be drawn up somewhat along the following lines.
with any changes in the headings to suit, viz.:
For the month of ,191	
Income.
1. Grants—
Government
Municipal
Other
2. Donations—
Annual
Special
Other
3. Fees from Patients-
Private     wards
Maternity
Semi-private
Infectious
Public
(Other)
4. Special Departments—
e-g.
X-ray
Laboratories
Etc.
5. Other or Miscellaneous-
Expense.
1. Administration—
(Salaries, Telephones, Printing, Stationery, Postage, Miscellaneous)
2. Medical & Surgical—
(Salaries, Drugs, Medical Supplies & Renewals, Surgical
Supplies & Renewals, Gauze,
Dressings, "Bandage Rolls,
Rubber Goods, Wines & Liquors, Thermometers, Miscellaneous)
3. Nursing—
(Salaries, Uniforms, Text
Books, Diplomas, Pins, Miscellaneous)
4. Stores—
(Salaries, Meats & Fish, Poultry, Eggs, Ham & Bacon, Butter, Bread, Milk & Cream,
Fruit, Vegetables, Ice, Groceries, Miscellaneous)
5. Kitchen & Household—
(Salaries, Hardware, Crockery, Dry Goods, Brooms &
Brushes, Cleaning Compounds,
Furniture Repairs, Renewals,
Miscellaneous)
6. Engineering & Mechanical—
(Salaries, Fuel, Gas, Plumbing
Supplies, Repairs, etc., Electric Supplies, Repairs, etc., Elevators, Supplies & Renewals,
Machinery, Boilers & Renewals, Lubricating Oils, Miscellaneous)
(If power plant is not in connection with hospital, use heading of "Fuel & Light" (only)
7. Laundry—
(Salaries, Gas, Supplies, Repairs & Renewals, Miscellaneous)
(If in connection with hospital
use these sub-headings)
8. Buildings & Grounds—
(Salaries, Supplies, Repairs &
Alterations, Miscellaneous)
9. Special Departments (e.g.)—
X-ray,
Laboratories
10.   Miscellaneous—
Rent
Taxes
Water
Etc.
76 The above style might very easily be used by the majority of hospitals,
alter making slight additions or changes in the sub-headings to meet changed
condjtjp^s. The consolidation of the monthly statement for the twelve
months will give the yearly statement of Income & Expenses for incorporation in the annual report.
Per Capita Cost Per Patient.
The per capita cost per diem is the familiar and usual way of learning
the cost of caring for a patient. It is not an entirely satisfactory manner of
comparing one hospital with another unless it is known that both hospitals are
operating under similar conditions. Some institutions, for instance, are
exempt from Uxation. water rates and the like, while others are burdened
with these heavy charges. On the other hand, theie are hospitals that may
only treat public, ward patients as against those treating all classes of patients. This has quite a bearing when using per capita costs for co-npara-
tive purposes. Under a uniform system of accounting, this wo I'd be properly taken care of. The per capita cost per diem is arrived at by dividing
the total monthly or yearly expenses by the total day's treatment of patients
during the same period.
Patients Record and Ledger Book.
A perm?nent consecutive recoid of the admission and discharge of patients treated must at all times be available. The draft shown herewith
provides also lor the entry of payments received from patienrs and is a combination Patients' Record and Ledger.
The details should give:
Rate p_r day charged
Ext* a charges, e.g.
Operating Room
Anaesthetics
Special Medicine
X-ray
Laboratory
Etc., etc.
Total amount of account
Payments  made   (under  12  monthly
headings)
Remarks Column
Date of aomission
Name
Age
Nationality
Peligior.
Address
Occupa"ion
Where employed
Member of Lodges
Address of relatives or friends
Doctor in attendance
Date of discharge
Number of days stay
Collections.
As to a collecting system, I think it can be said that the collecting of
outstanding patients' accounts causes more worry to those in charge and at
the same time, more adverse criticism of a hospital than positively anything
else. It is therefore a question as to what is the best system to use or course
to pursue in the collection of accounts without receiving the abuse that very
often results from an attempt to collect a hospital bill.
The Vancouver General Hospital has tried several schemes, with more
or less success, and is at present experimenting further in this direction,
which promises to be even more successful. Before any results can be obtained, however, and before any definite recommendation can be offered, the
publiG must first be educated to feel that obligations incurred at a hospital
are justly in line with any other debt.
In conclusion, I have much pleasure in moving the following resolution :
THAT a Committee be appointed by this Convention for the purpose of considering and devising a system, if possible, tending towards
the uniformity of Hospital Accounting, and to report at the next meeting of this Convention.
Seconded by Mr. T. Mordys.
Motion Carried.
(Meeting adjourned to have group photo.)
(Discussion resumed.)
77 MR.  GRIMMETT—
With reference to contract patients, as to whether they paid at fifty-
cents a month—according to the best calculations we could make, we found
that they were not paying and that was why we raised the contribution to
seventy-five cents. We made calculations during the last few months and
we find that at the increased rate of seventy-five cents a month, they are
just about paying. We do not collect in advance, probably we should. That
is a matter that I will take up with the Board when I go back. Of course,
there are cases where you cannot do that, but collection should be made in
advance, if at all possible.
MR.   GRAHAM—
With reference to this question of financing, I think that we all pretty
well agree that it is one of the most important problems, if not the most important problem, that is,—financing the hospitals in British Columbia today.
Now, I heard Mr. Grimmett's explanation in regard to the question of the
hospital rates and public rates as provided by the Act, and I might say
that that was also my interpretation—that you .were at liberty to collect
all you could from the patient. I must say that at the Cumberland Hospital, that is one thing that we have been up against there—the question of
finances. I think I am safe in saying that the rates in Cumberland have
been the lowest in British Columbia. We found that the rates being charged
generally were higher, and the highest rate charged in -our hospital was $2.00.
We have made changes which are effective on the 1st of July; still our rates
do not come up to the rates quoted by Mr. Grimmett.
With regard to contracts, practically ninety-five per cent, of our patients are employed in mining, and therefore, a contract would be a very
good thing from our point of view. That method might not be suited to
a city hospital, but in a community such as ours where we have on the payrolls of the coal companies fourteen hundred men, we figure if we could
estimate the expenses of our hospital to a fairly close rate, that we would be
able to \get from these men a sum of money per month which would enable
us to carry on the work. We had in mind seventy-five cents. We figured
it out—the cost of operating this coming year and the number of patients
on the average that we have been having (we have allowed for a slight increase), we figure that the sum of seventy-five cents per month would be
sufficient. With regard to that, I am rather surprised at Mr. Grimmett
stating that he didn't think that seventy-cents would be sufficient, and he
was considering abolishing the contract. We have also under consideration the question of hospital tickets and we were rather doubtful about it.
We have not done anything.
Financing in general—I think it is necessary for the Provincial Government or Municipality to come forward and do something towards financing
the hospitals in general. It is only by the Provincial Government and the
communities themselves coming through with the necessary amount that a
hospital can be run efficiently, and it is absolutely necessary that it should
be kept going in that manner.
I think this Convention will achieve a great deal of good if they will
appoint a committee to meet representatives of the Provincial Government
and take it up with the representatives from all the hospitals in British Columbia, and that is the only way in which the matter can be handled.
If we go there one at a time asking for assistance, we will not get it, but
if we go unitedly, I think that the chances of getting it are good.
DR.  HENDERSON—
In regard to fifty cents per month, I would like to know what the individual gets for that—whether simply hospital treatment, or medical services as well.
In regard to the contract work, so far as Powell River is concerned, the
men prefer that and would be sorry to see it changed to any other system.
However, the contract system is .liable to receive a severe jolt owing to
conditions of the Workmen's Compensation Act. That part of the Act which
refers to the supplying of artificial limbs and artificial eyes to any individual
who may require them—that Act provides that these will be supplied to
the patient.   Either the company or the surgeon has got to comply with that
78 Act. For my part, I should be loath to contract with that individual for
the rest of his natural life; such a contract would be a very poor asset to
my heirs if they had to incur such a liability. I should refuse to enter
into such a contract. The companies are loath also to enter into it. Companies such as the Powell River Company could hardly assume such a" contract. The result is that the Board of Compensation would likely annul all
the contracts and compel us to adopt the system as it is indicated in the
Compensation Act, that is,—charging them one cent a day for treatment of
injuries incurred only while they are ■ at work. So far as we are concerned, I get the dollar per man and I think that is little enough, and I do
not see how any institution can afford to take care of the men at the rate
Mr. Grimmett suggests.
MR.  GRAHAM—
The Compensation Act provides artificial limbs.
DR.  HENDERSON—
The Compensation Act does not supply artificial limbs.
MR.  GRIMMETT—
The Compensation Act does supply artificial limbs.
Replying to Dr. Henderson, I beg to say that in my desire to be brief
I omitted any reference to the Workmen's Compensation Act. Our arrangement between the Merritt Hospital and the Board is that we get $1.50 per
day. I think that the whole question should be taken up with the Board
We might discuss it tomorrow when the Chairman of the Board is here
1o address us. Seventy-five cents a month entitles patient to contract treatment. He is entitled to free use of the operating room and has other privileges. As to his medical attention, he pays $1.00 per month for that to the
doctor. I may perhaps have left a false impression on Mr. Graham's mind;
I perhaps went too far when I said we were considering abolishing it. We
are considering the whole question. It may be that our considerations may
result in feeling that our arrangement is an excellent one. I am sure that
at seventy-five cents a month, we are getting value received.
MR. MORDY—
What was the amount of loss which the hospital found themselves involved in under the old rate of fifty cents? We propose to enter into a
contract at seventy-five cents at Cumberland, and as a member of the Medical Board at Cumberland, I find there is a considerable amount of opposition to seventy-five cents, and a feeling that fifty cents ought to be sufficient. Therefore, I would like to hear from Mr. Grimmett just how- much
they were actually in the hole.
MR. .GRIMMETT—
So far as we have been able to ascertain, the fifty cents a month was
not paying. The last three months have shown that the seventy-five cents
per month is paying. Now to the credit of the men working in our mines and
logging camps, there was not a single objection to this raise of fifty per
cent, in the amount that they were paying, and Mr. Mordy may take that
back to Cumberland—that the men in the mines at Merritt feel it their duty
to pay this additional amount.
MR.  WALTERS—
I was not clear with regard to the way in which to deal with the Indian
question. I want to ask if it is not a fact that the Indians are supplied with
hospitals in the district, but if they go into the public hospitals it is because
they don't either like the hospital or the doctor. Doesn't the doctor in
charge of the Indian Hospital receive a per capita grant for each patient?
Does he receive a per capita grant from the Provincial or Dominion Government ?
MR.   GRIMMETT—
Mr. Walters has reference to a small hospital for Indians in the Nicola
Valley. This hospital is not a public hospital, as we understand it was
established by the Anglican Church. It is entirely under their management. Probably they have done good in the past but their means are limited. There is a feeling among the Indians that they receive better treatment in the Nicola Valley General Hospital.   The Dominion Government
79 pays ft physician there a small monthly salary for looking after the Indians. That does not in any way do away with the duty of our hospital
as a public hospital to receive these Indians, and we have so far never refused admission to Indians applying. The Provincial Government, as I
stated this morning, under the Act is not supposed to make any per capita
trant for Indian patients. Of course, as I said before, the Dominion Government pay u§ nptljjng. However, we are doing the best we can to make
the Government pay the cost of treating their wards.
MR.   WALTERS—
With regard to indigent cases, I would like to know how the medical
men treat these cases.   Do they receive any remuneration for treating indigent cases?   If a medical  man treats an indigent case, does he send
his account in to the Provincial Government and receive pay?
DR.  MacEACHERN—
The medical man does not get anything from the indigent case, nor from
the hospital, nor the Provincial Government.
MR. R. S. DAY—
Now, when the Government passed that Act brought in by Dr. Young,
under which public hospitals can charge any municipality $1.00 per day for
any patient, we were very grateful for it, but we recognized that it was not
enough to cover the cost of the patient. We receive patients from Victoria.
Esquimalt, Saanich and Oak Bay, and we asked them to give us $1.50 per
day and they all cheerfully consented to that, and since that Act those municipalities have paid us $1.50 per day. Previously, they were treated and
fell as a burden on the hospital, and eventually had to be paid for by the
City of Victoria. We have waited upon them this year and have asked
them to icrease that to $2.25 and it has been favorably received, and while
no definite reply has come, we have every reason to believe that they will
pay us $2.25.
There was another point that struck me during the conversation here.
I lived some twenty-five years ago on the Diamond fields in South Africa.
They had a system in force, helping hospitals. If I engaged a native, he
was under contract system at once, he was contracted to me for a certain
number of months; I had to take him down to the Government office; he paid
a small fee, one shilling per month, to the Government for that contract,
and that money went to the hospital and the native was entitled to free
treatment in the hospital. It seems to me that the Government ought to
make some arrangement with the Chinese for free hospital treatment, and'
we would reap a very large revenue from it.
MR. DAY—
I am sorry we have to stop this interesting discussion. Ow-
uig to an engagement which he cannot alternate, Dr. Carder has
asked that his paper be deferred till to-morrow morning. I am
therefore going to call on Dr. W. B. Burnett. Obstetrician to The
Vancouver General Hospital, for his paper entitled "Maternity
Work in the Small Hospital."
"MATERNITY   WORK   IN  THE   SMALL   HOSPITAL."
By Dr. W.  B.  Burnett, Obstetrician to the Vancouver General  Hospital.
In a country like British Columbia where distance is much more evi«-
dent than population, and where what population there is is very largely at
the reproductive period of life, we have some problem in Midwifery, not so
common in the more thickly populated district where nearly everyone is
within a very few hours of a large hospital or a nurse's registry. Truly
our grandmothers got along mostly without a doctor, and were made very
comfortable by some kind hearted old lady who took naturally to nursing
maybe, or more likely by force of circumstances, and being considered qualified by having raised a large family herself when she was young. But, if
we cannot do a little better than our forbears, then t'were appropriate that
we should see Dr. Osier and receive the painless exit, making room for a
80 . more progressive generation. However, without any doubt, the results of our
maternity work are certainly a great improvement on that of a generation
or two ago. The great war with its problems has rather supplanted that
maddening motto, "Do it now," with the banner, "Efficiency," and if in our
maternity work we are to give the greatest number of women the best
care, then we must centralize and concentrate. Maternity work is surgical
work with all its problems of asepsis and emergencies, with the same frequent surprises requiring the correction of diagnosis and reversal of treatment, calling for equipment and assistance not always obtainable in the
home, and here is the opportunity for the small hospital. Every doctor, I
believe, is a good maternity doctor because of the excellent practical training he received in this department as a student, and by dint of the two cases
he handled all by himself while "Interne" in the surgical ward afterwards.
But, unfortunately, not every good nurse is a good maternity nurse. A good
maternity nurse any doctor will tell you is one who knows enough to call
him always just in time that he may get his gloves to hold the head back
a little, the last two pains. There are other qualifications also in which, in
the few days allowed for special training in this"" department, in many of our
large hospitals, no nurse could be expected to become proficient. Fortunately, special opportunities and inclination give certain nurses the experience to make them very expert. But if the community is to receive the
most from them, then the patients must come to them at the centre rather
than having them go out to scattered units on a wide periphery. That
centre should be the hospital and the hospital should see that it has that
kind of a nurse. By a hospital we mean a place equipped to care for the
sick. As you have heard, we are coming to classify hospitals very rigidly,
according to the degree of that equipment, and there seems almost no end
to the requirements in a large general hospital today. The smaller and
private institutions are nearly all likely to have more maternity cases than
any other single class, and ought, if they take such work at all, to be thoroughly equipped to afford the attending physician every opportunity to do
his best work, as he cannot always in the patient's home. Caesarean Section is not always a formidable operation, but the bed in the carpeted and
curtained room is not the place to do it, and there is no reason in the world
why the small hospital with anything worthy the name operating room
should not, by affording the facilities in this line, become the savior of one,
or perhaps two lives in many cases of Eclampsia, Placenta-Praevia, Contracted Pelvis, etc.
In the country districts more than in the cities no doubt cases will
arise when the doctor is not called until the women is exhausted by prolonged labor, and already the child is dead. What a Godsend if she can
be removed on spring and mattress in an express wagon to the hospital,
where he can do a Craniotomy or other appropriate operative delivery and
feel sure that she will have proper care thereafter.
Those of us who treat our Eclamptic cases only in hospital where noting
the blood pressure, stomach lavage, phlebotomy, intravenous saline, etc., are
convenient and instantly obtainable, where expert attendants can tell us by
'phone as we make our rounds just how the patient is doing, know little of
the difficulties of treating these cases in the home, with no nurse and no
'phone.
Even in normal labor the birth of the first child is a matter of anxiety
and it is not always easy to foresee just what circumstances may arise,
calling for some extra help immediately. In the home the call is vain, you
must do the best you can, but it is remarkable how .busy these nurses can
be kept, each at her own essential part, for a short time about as the baby
is born.
The multipara when it comes to indicating the exact moment she intends to deliver that child, is a delusion and a snare. I have heard that
good doctors, even after vaginal examination and close questioning of the
patient as to how she feels, have gone away leaving a list of places where
they could be found, but assuring the nurse that hours must elapse before
they would be needed. Nevertheless he had not yet arrived at the first call
when the baby was born.   This I could hardly believe except for personal
81 experience. But if such a mistake must occur it might better be with a
nurse in much experience, where at least she has some assistance, than in
the home with the excited mother and husband giving advice to a nurse not
too expert in the work.
You will have gathered that I approve of my patients going to a good
hospital to be confined. I do, because I feel sure they will then receive
much better nursing than is reasonably possible at home. Day and night
the nurse is always awake and watchful, with every facility to give the best
of care. If complications arise at any stage we can have at once sufficient
help and all means of treatment.
In case the mother is unable to nurse her baby, skilled nurses enable
us to get settled on a suitable modification of milk for the baby before the
mother has it alone at home. Even the so-called easy labor is a severe
physical and nervous strain, and the freedom from home worries (because
truly "out of sight is out of mind" to a very large extent) is most desirable.
And financially it is very much more economical.
These are good reasons, I think, why the maternity hospital or department of a general hospital should exist, and at the same time carry with
them the demand that the hospital should supply the very best of equipment
and nursing for this work.
Are there any objections? Many, by both doctor and patient. First
comes the greater risks of infection in the hospital. With equal care I
grant you that the hospital affords much the greater opportunity of infecting
the patient with something other than what we might call an autogenous
vaccine. Any hospital worthy the name always admits this danger and
expects to get the full share of blame if trouble occurs. If the staff is competent then I believe that the extra care and means of guarding against
infection by abundance of sterile swabs, towels, sheets, etc., etc., much more
than compensate for the extra risk But you must have the technic and
the facilities which, unfortunately, are not found in every small hospital,
whereas there is no excuse for the smallest place essaying to do this work
being one whit behind the largest and most elaborate institution.
Next comes the risk to the baby from infectious disease. This is a real
difficulty, rare, but much harder to overcome. Particularly does this apply
to infection which, if it starts at all, is apt to spread even before the danger
is recognized. The common bath tub is here, I believe, the greatest source
of danger.
The patient's objections come chiefly from the very natural inclination
to be at home when ill, and to the rapidly disappearing prejudice against
the hospital as a very dangerous place full of groans and lamentations,
and where many people die.
I believe then that one of the most important responsibilities in the
small hospital, especially in outlying districts, is to supply the best of care
for maternity cases. This means at least one head nurse of sufficient training and experience to give her dependable judgment as to the progress of
labor, and as to what is normal and what is not, during the puerperium.
he should be able to administer ordinary obstetric anaesthesia in an ordinary
case, and be familiar with the ordinary technic of delivery in the normal
birth. Those hospitals of fair size may also train up a good practical
maternity nurse to fill in until the happy time when all cases go to the
hospital and doctors have an eight-hour day.
It is the duty of the small hospital to equip itself to handle any
obstetrical operation or complication, and as a teaching centre of artificial
infant feeding. When this ideal cannot be reasonably approached, I doubt
if the maternity hospital is an unmixed blessing.
MR. DAY—
I am sure this is a very interesting and practical paper.
I will now call on Dr. R. H. Mullin, Director of Laboratories,
The Vancouver General Hospital, for a paper on "The Hospital
Laboratory."
82 "THE HOSPITAL LABORATORY."
By Dr. R. H. Mullin, Director of Laboratories, the Vancouver General
Hospital.
To adequately and properly discuss the hospital laboratory and the relation it should bear to the hospital as a whole, is not as simple or easy
a procedure as would appear at first glance. All hospitals are .not alike, so
that it becomes at once apparent that any set type of laboratory will not
necessarily fit all hospitals. To adjust the relationship which should obtain between the hospital and its laboratory it is necessary to thoroughly
understand the kind of hospital and its particular functions.
Hospitals may be grouped into four classes. First, the private hos-
uital of varying capacity, maintained by a practitioner or a group of medical men for their own convenience, and that of the patient. Such institutions are, of course, more or less commercial and, unless of large size and
privately endowed, must be maintained with a keen eye to their financial
aspect. Second, there is the exact opposite of this—a public hospital for
the treatment and care of the sick poor. These are maintained usually by
municipalities or central governments of some sort, for the care of the indigent sick. Naturally, their funds are, to a certain extent, limited by the
generosity of the governing body which supplies the funds. There is a
third group of hospitals, which is in reality the combination of these two,
such as the ordinary municipal hospitals that maintain both public and
private wards with the variations between the two. There is gradually
coming into existence a fourth class of hospital connected with the medical
schools, which have the added function of having their teaching facilities
developed to a considerably greater degree than those hospitals which have
no affiliation with teaching institutions.
Naturally, the functions of these different types of institutions vary to
a considerable degree. In all, however, there is a common function—namely,
the care and treatment of the sick, whether this be done as a commercial
problem, as a charity or as a means of teaching medical students. Too often
this function is developed at the expense, and to the exclusion of other
functions which should obtain in every hospital. Every hospital should
have an educational function and an investigational function, whether the institution is connected with a teaching body or not. Each institution should
endeavor to add something to the sum of knowledge. This educational function should not be limited to the teaching of students. Every institution
should be in a position whereby the attending medical staff, and of even
greater importance, the patients themselves, may obtain an increased knowledge^ with regard to the proper practice of medicine. Likewise too, each
institution should advance the science of medicine by investigation into the
cause, treatment and effects of disease, otherwise they will be losing to a
very great extent one of their very important functions. Unfortunately, the
educational and investigational functions are to a very great extent dependant upon a sufficient budget for their adequate care. This is usually
a matter of some difficulty.
In all of these functions the hospital laboratory plays a very important
part, not only as a means of stimulating the desire for further information
and research, but particularly since it occupies the position of being an instrument of precision. In the treatment of the sick the laboratory is of
greatest importance as an aid in diagnosis, as affording indications concerning treatment and for the purpose of giving a more accurate prognosis
in each case. In all of these, however, the laboratory should serve merely
as an aid and not to be looked to as the sole means of arriving at a conclusion. Frequently in practice, clinical men will forget that they are the
ones who should properly interpret laboratory results, since they are the
ones who come in contact with the patient and are the only ones who can
apply the results to the patient
In recent years, and to an increasingly greater extent, the science of medicine is being divided into its numerous specialties. One of the first divisions is into clinical and laboratory medicines; each of these is further
subdivided, so that we have now the various specialists on the clinical side
83 and—what is going to be recognized more and more—specialists in the
various branches of the laboratory side. It is needless to say that for anyone
specializing in the laboratory branches of medicine, additional training and
experience over and above that ordinarily obtained in a medical school,
is required. This training is becoming more and more differentiated so
that we have pathologists, bacteriologists, serologists and so forth, all of
whose work overlaps to a certain extent. Since all of these must have additional training and experience, it becomes at once apparent that the maintenance of a complete staff in a hospital laboratory is a matter of considerable expense and that such a staff can be maintained only where adequate funds are available.
Although it is impossible for every hospital to maintain a completely
equipped and manned laboratory, nevertheless it is possible for every hospital to provide facilities for a certain amount of necessary laboratory work,
such as is ordinarily undertaken by a few of the more energetic practicing -
physicians in their own office equipment. Often such laboratories are begun in hospitals of the smaller size by enthusiastic individuals, but frequently they drop into disuse, usually because no one is held responsible for
their maintenance. It must be appreciated that laboratory technicians can
be had who will undertake much of the tedious work necessary in the maintenance of laboratory facilities and equipment. This factor has added
greatly to the possibility of having a satisfactorily run laboratory. It is accompanied by the important feature that such technicians can attain a remarkable degree of expertness in different fields and that they will work for
a considerably smaller salary than a fully trained medical man. They
must, of course, work under more or less constant supervision but if they
have been adequately trained, they frequently acquire a dexterity and exactness sufficient to guarantee the accuracy of their results. Such workers can
be advantageously employed by the smaller hospitals and will undoubtedly
give more satisfaction than a recent graduate, who frequently looks upon
laboratory work as more or less of a bore. Such technicians can take care
of the ordinary routine urine analysis, of blood counts, the examination of
stomach contents, the quantitative examination of urine and similar examinations.
It has been found that women will develop remarkably in this particular line; some of them having great adaption and liking for their jvork.
Nurses are gradually taking up this line of work after their graduation
from the training school. If the demand were greater, undoubtedly the
training school would add facilities to their curriculum, so as to turn out
nurses specially qualified for this work. If such an idea were developed,
it might lend an easy solution to an otherwise more or less difficult problem.
Our Province is more or less peculiarly situated. It is hemmed in on the
East by the mountains, on the West by the sea, on the South by an international boundary line and on the North by a very undeveloped country.
For its area it has comparatively small population. Much of this population, however, is condensed into municipalities of larger or smaller size.
It would seem that there is sufficient wealth in the Province foT the maintenance of one or more completely equipped laboratories if the mechanism
for maintenance could be provided. It must be appreciated that in all
cases an immediate diagnosis upon a given specimen is not absolutely essential. Certain specimens, too, readily lend themselves to being transmitted through the mails without damage if they have been properly prepared. This gathering is the beginning of what undoubtedly will become
a permanent organization in British Columbia. Might it not, when its permanent organization is effected, consider the feasibility of establishing a
co-operative system of laboratories, whereby a laboratory system completely
equipped for all classes of examination, for investigation, for education and
for research, might be maintained? The problem is not as difficult, nor as
extensive, as we might at first surmise. It can be taken for granted that in
the not too far distant future the Government of this Province will see the
absolute necessity for establishing an. adequately equipped Bureau of Communicable Diseases, in an effort to control this class of sickness. Such a
Bureau must have as one of its chief agencies excellent laboratory facilities.
84 Although clinical laboratory examinations are not of the same character as
those required in public health methods, yet much of the equipment used
in the one can be applied and is useful for the examinations made in the
other. It might be possible to persuade the Government to undertake not
only the public health examinations necessary, but also the clinical laboratory examinations. The prospects for this are, perhaps, not as bright as
might be desired by some. It would, in effect, be a step towards the socializing of medical practice, and for this reason might not appear desirable
to some, although, undoubtedly, the Government could undertake such examinations at a minimum cost. Failing Governmental support in this regard, it might be possible, and it would certainly be desirable, for the hospitals to attempt a co-operative plan with the Government in establishin
a combined laboratory. Such a plan would mean a considerable economy
in overhead expenses, and in equipment and supplies needed. There should
not be any very great difficulty in arranging for a pro-rated expense to
each hospital which enters into such a co-operative plan. This plan would
not relieve any hospital of all laboratory examinations, but only those in
which specimens can be transmitted through the mails without deterioration, and where the equipment necessary is too expensive for the smaller
hospitals to economically install to take care of the limited amount of work
which they might have. Necessity for increased laboratory facilities in
the Province must be plain to all. Undoubtedly, such increased facilities
would add greatly to the stimulus towards a more scientific practice among
the medical profession.
MR. DAY—
As we are by our time, I will declare the meeting adjourned
till 2:30 p.m.
AFTERNOON SESSION—June 27th, 1918.
(Dr. MacEachern made some announcements about the evening
entertainment.)
DR. GATEWOOD—
I am going to ask Mr. Charles Graham to take the chair this
afternoon.
MR.  GRAHAM—
The next two papers are along similar lines and therefore I
think we had better have all the discussions together.
I will now call on Mrs. M. E. Johnson, Superintendent of the
Bute Street Hospital, for her paper, "The Standardization and Affiliation of Training Schools in British Columbia."
"THE    STANDARDIZATION    AND    AFFILIATION    OF    TRAINING
SCHOOLS IN BRITISH  COLUMBIA."
By Mrs. M. E. Johnson, Superintendent of the Bute Street Hospital.
Sixty years ago training schools for nurses were unknown. The first
training school was established in St. Thomas, London, England. It was
endowed by Florence Nightingale, $200.00 was provided for instruction. The
theoretical work was in the form of lectures and bedside teaching. Twelve
years later the first training school in America was established in the New
England Hospital, Boston, Mass., by Dr. Susan Dimick. The course of
training covered one year, three months medical, three months surgical and
three months obstetrical, one month night duty, two months care of private
patients. Twelve lectures Were given by the medical staff and practical instruction given by Dr. Dimick.
Today there are training schools for nurses in almost every hospital
of fifteen beds and over, but I am sorry to say there are few endowed schools
85 Standard requirements
for Training Schools.
in this country. Almost every training school is carrying out its work
under difficulty for lack of funds. Many of our schools and colleges are
richly endowed, while our training schools for nurses are established by the
hospitals with one main purpose, to carry on the nursing work of the
hospital in return for instruction given to student nurses. The education
of the pupil nurse is a secondary purpose. Is it right? If our boards of
directors and hospital administrators are to have a true conception of the
responsibilities which are assumed in attempting to direct, control and
develop in an adequate way the education of the nurse in the training
school?
If the nursing profession is to occupy the place it rightfully deserves
among the profession, then education must be one of its first considerations; also the building of character and efficiency in the pupil, and creating
a high standard of bedside nursing to the patient.
The Requirements of the Pupil Nurse—The hospital training schools are
dependant, to a large extent, upon the high schools for applicants, some
hospitals require high school graduates. Applicants should at least have one
relationship with the high schools and training schools in the Province so
that the preparatory course of physics, chemistry, biology, bacteriology,
hygiene and dietetics could be taken up in the high schools. Thus fitting
the student nurse to come to our training schools better equipped for practical work, then the training schools would be in a position to give a more
thorough training in general and special work.
In regard to a standard' curriculum for British Columbia. When asked
to write this paper, I wrote to the Provincial Secretary for reports on hospital training school work in British Columbia, and was informed that there
was no government supervision of training schools; so that it is unnecessary
for me to emphasize the need which exists for standardization of training
schools in this Province. Miss Johns, Secretary of the Canadian National
Graduate Nurses Association, in her report last year on national standardization, recommends the following requirements for standard schools:
1. A daily average of patients.
2. A  diversity  of service sufficient  to  give  experience  in  the  main
/ branches of nursing or suitable affiliation with other institutions.
3. A proper and adequate provision for the pupil as regards good lodging.
4. A trained teaching personnel and supply of teaching material.
5. Such regulations of hours off duty as to allow time for theoretical
/work.
6. A standard curriculum.
7. A standardized system of training school records.
8. Standardized admission requirements.
9. Training school  inspection  by a  competent  nurse  inspector  under
/ provincial auspices.
The Graduate Nurses Association of British Columbia have been working for six years to have a provincial nurses registration bill, and I am happy
|  to say it has been passed and made valid at the last session of the legis-
J  iature.   The bill provides for the following essentials :
1. State registration for graduate nurses by Act of Parliament.
2. A three years' term of grace for practicing nurses, already trained,
after the Bill becomes law, during which time they can register without
examination.
3. A uniform curriculum (or course of training) for training schools,
arranged by affiliation if necessary, which already is in force in several
B. C. hospitals.
4. A central examination for all nurses at the expiration of the three
years grace.
5. All nurses graduating from recognized training schools, prior to the
passing of the Act, may be registered without examination.
6. Nurses who are registered as trained nurses in other Provinces or
countries having substantially like requirements for registration, shall be
entitled to register in this Province without examination.
86 7. The Examining Board will be composed of two doctors and four
nurses, graduates of recognized training schools, who have had at least
two years' additional experience in nursing. It is the desire of the Association that the Examining Board be appointed by the Lieutenant-Gov-
ernor-in-Gouncil.
8. If an applicant shall pass a satisfactory examination and have the
necessary qualifications, she shall be entitled to receive a certificate of registration and to append to her name the letters R.N., showing that she has
been registered in accordance with this Act.
9. This Act shall not be construed to apply to the gratuitous nursing
of the sick by friends or members, nor to any persons nursing the sick
who do not in any way assume or pretend to be a registered nurse.
Acts having substantially the same requirements are already in force
in five Provinces and in practically every State of the Union, and this
Act has the endorsation of the Medical Association of British Columbia.
Section 21 of this Bill, in regard to British Columbia hospital training
schools, reads:
"After three years from the passing of this Act the following training schools only shall be approved by the Council as giving to their
graduates sufficient training for registration under this Act, namely,
training schools connected with a general hospital of at least fifteen
beds (or a special hospital which is affiliated with an approved general
hospital). The principal and night superintendent which are registered
nurses or eligible for registration giving a three-year course of instruction and providing general training in the following departments
of nursing: Medical, surgical, obstetrical and pediatric nursing; and
which schools are registered by the Council under this Act as approved
training schools.
"Training schools which do not provide adequate opportunities in
all the above departments shall not be registered as approved training
schools unless they first become affiliated with institutions approved as
giving such opportunities."
Now, if there are training schools in British Columbia which do not
come up to the requirements of this Act, they will have to make the neces-
cary changes in order that the pupils entering their training schools this
year may be able to register when they graduate, three years hence.
In order that this registration bill may, not work a hardship on the
small special hospitals, provision has been made for affiliation, and I am
glad to know that some of the smaller hospitals are already affiliating
with the larger ones. Affiliation is the greatest blessing that ever came to
the trained nurse trained in the small hospital.
In many ways the small hospital adequately equipped can give the
pupil nurse a training specially fitting her for general or private nursing,
but affiliation with the larger ones gives her a broader view point and
a greater variety of experience. Could we not make one large hospital
centre for affiliation with the smaller hospitals? It is practically impossible to suggest a uniform method for practical work of hospitals, but
the same theoretical studies at the same time in the different affiliated
hospitals would be a great advantage. I would like to see affiliation carried on in British Columbia to a large extent.' Training schools in the
mental, tubercular and military hospitals affiliating with a general, thus
giving a good general training and raising the standard of our profession
still higher.
For the small hospital who cannot affiliate, inadequate equipment need
not be a source of discouragement. The minimum requirements for class
work includes a lecture room, laboratory, reference library, inexpensive
models, doll-charts, etc.
In regard to instruction, the superintendent of nurses in most small
hospitals is too busy to do the required teaching, an assistant who has
special training as a teacher would be invaluable. Very few small hospitals can afford a nurse instructor. Co-operation with high schools where
some branches could be taught would be one way to gain instruction. Nurses
who have prepared themselves for teaching might be obtained as visiting
87 xrQ"j."cuu._Lsiue otudie^ j,or
entrance  to Training Schools.
instructors.    One   nurse   in   Massachusetts   has   sent   out   announcements
that she is prepared to teach a course in each of the following:
Anatomy and Physiology ,- 30 Hrs.
Materia   Medica    16
Bacteriology    12
Chemistry  18
Hygiene   6
Municipal Sanitation  10
History of Nursing 10
At four dollars an hour.
Several hospitals in British Columbia might combine to.engage a visiting instructor. University affiliation, when possible, is desirable and increasing. Some hospitals in the United States are combining a University
course and Nursing course of five years. They give a B.A. degree and a
Nurses' Diploma.
The world's upheaval of war is making many new demands in the field
of nursing and our teaching must be directed towards these demands.
In Philadelphia last year the American National Association of Graduate Nurses recommended the following standard of minimum requirements for instruction in schools of nursing:
Recommendation of Legislative Committee.
""Pre-requisite Studies Recommended for Entrance Requirements to Schools
of Nursing.
1. Latin—One year.
2. English—Includes ability to speak the English language correctly
and the power to write English in a correct, orderly and fitting manner.
3. Mathematics—Elementary Algebra (recommended)—Includes ability
to deal with problems including fractions, percentage and the decimal
system.
4. Chemistry—Includes elementary general chemistry with laboratory
practice.    Household Chemistry.
5. Biology—Includes  the study of plant and  animal  biology sufficient
^to provide a foundation for the study of physiology and bacteriology.
6. Home Economics—Includes Domestic Science as cooking and house-
mold management, preparation of meals and food values.
The following graduation of educational requirements is recommended:
From January 1918 to January 1920, evidence of a successful completion of one year of high school work;
From January 1920 to January 1922, evidence of a successful completion of two years of high school work;
After January 1922, evidence of four years of high school work.
Minimum requirements for Theoretical Work.   The following standard
of minimum requirements for instruction in schools of nursing is recommended :
v FIRST YEAR.
First Half.
Subject— Hours
Nursing Technique 32
Bacteriology (Elementary)  _ 16
Anatomy and Physiology 16
Elementary Dietetics  16
Elementary Hygiene  „ 16
Ethics and History of Nursing s-s 16
136
Second Half.
Subject— Hours
Nursing Technique  .-. \(,
Anatomy and Physiology 16
Materia Medica   _16
Bandaging    „...  8
56 SECOND   YEAR.
First Half.
Subject— Hours
Nursing in Medical Diseases  16
Materia Medica and Therapeutics  16
Urinalysis and Laboratory Technique   8
Advanced Dietetics and Laboratory Work 16
Nursing Ethics   8
64
Second Half.
Subject— Hours
Nursing in Surgical Diseases  16
Operating  Room  Technique    8
Orthopedic Nursing  _  8
Obstetrics and Obstetrical Nursing 16
Gynecology   8
Diseases of the Skin and Teeth  8
64
THIRD YEAR.
First Half.
Subject— Hours
Pediatrics and Infant Feeding 16
Communicable Diseases and Preventive Medicine 16
Mental Diseases  16
Eye, Ear, Nose and Throat  8
Hygiene and Sanitation  _  8
64
Second Half.
Subject— Hours
Ethics and Social Problems  16
Instruction in Special Branches of Nursing 16
History of Nursing and Nursing Organizations 16
48
Minimum Requirements for Practical Work—
Medical  6 Months
Surgical  6 Months
Obstetrical  3 Months
(Or care of 10 patients, including labor and care of baby.)
Children  2 Months
Diet Kitchen 2 Months
Night Duty  „ 4 Months
Operating Room  3 Months
Special Duty , 3 Months
Vacation   2 Months
Unspecified Duty 5 Months
MR. GRAHAM—
I will now call on Miss M. McLeod, Superintendent of Nurses,
the Vancouver General Hospital, for her paper, "The Modern
Trained Nurse."
"THE   MODERN  TRAINED   NURSE."
By Miss M. McLeod, Superintendent of Nurses, The Vancouver General
Hospital.
The nursing profession was called into existence by the real needs of
suffering humanity. It is the only profession women can claim as their
own. It is a profession exalted by intellect and culture. Yet we are told
there is something wrong with the training schools of today.
89 The doctors claim that the trained nurse is not efficient. Superintendents of training schools say there is something wrong, and the lay public
finds something radically wrong. If we could come to a satisfactory diagnosis of the case, I am sure among us we could establish a training school
capable of training women such as John Allen described as "not existing on
this side of the pearly gates."
I am not going to inflict upon you a history of the progress and growth
of the nursing profession. Sufficient to say that the Montreal General Hospital can boast of the first training school for nurses in Canada. This
school was opened in 1890, and Dr. R. E. McKechnie of this city, was among
the first to lecture to the nurses. In the United States, the training school
dates back fifty years, and during these years it has made rapid strides. A
number of these schools now have University affiliation, preliminary courses,
and almost all have paid instructors.
The duties of the student nurse in the large general hospital are quite
the same as those in the small general hospital, so that if we have anything to offer for the information of the one, the same would be true
of the other.
We shall consider first the relation of the training school to the hospital. Quite a number of training schools are organized under a separate
charter, and operated under a different board of directors, and kept in
every way completely apart from the hospital, except that the pupils in
the training school are employed by the hospital under certain conditions
to nurse the patients. The Illinois Training School of Chicago is an independent institution. The student nurses get their practical training in
the Cook County Hospital on the basis of affiliation. In this instance, the
plan has proven a success. There are several training schools under university management. In these schools the practical training is given in
the hospital, while the university controls the other educational details, and
the university, not the hospital, authorizes the graduation and issues the
diplomas.
Any connection, however, of a hospital training school with a university, inevitably leads to the addition to the training school curriculum of
an increased amount of purely technical work. This presents a problem of
far-reaching significance. It must be appreciated that in her future profession, the earning capacity of a nurse is limited, and the remuneration
ordinarily received not very high. Too much technical information in the
training school is therefore not warranted by the subsequent remuneration which is to be expected.
Many hospitals are getting away from the ten-hour day which used to
be in vogue. Recent investigation regarding the effect of fatigue upon
efficiency has shown that after a ten-hour day the efficiency of the worker
greatly diminishes. It would seem best, therefore, to reduce the time on
duty per day from ten to eight hours. If this were done, then a sufficient
amount of time would be left available for the increase in technical work
which would be required by university affiliation. More time for the purely
nursing part of the training could also be obtained by eliminating from the
duties of the pupil nurse the ordinary house-keeping duties in connection
with the wards. It has never seemed reasonable to expect pupil nurses to
entirely assume all the housekeeping duties which usually are connected with
hospital wards. These duties might better be undertaken by ward attendants or helpers who would receive adequate remuneration for the work
they did. In this way the pupil nurses would be relieved of the monotony of
doing certain tasks continuously throughout their training, which in reality
have little or no bearing upon the actual teaching or learning of their profession. If such a procedure were adopted, more time would be available
for the proper instruction in the actual principles and practices of nursing,
and the pupil nurse would be in a more receptive mood for study.
Other changes in the curriculum of the training school might be considered. It must be appreciated that this is an age of specialization. The
demand is becoming more and more acute not for the nurse with general
training, but for a nurse who is qualified along special lines. For instance,
it is of no particular value to a surgeon that a nurse is a fairly capable
90 general nurse. What he wants is a nurse who has special training in
surgery. So too with the other specialties in medicine. According to the
methods of training now in vogue, any specialist nurses are developed after
they leave the training school from which they have graduated. All their
■ training, therefore, in their specialty is undertaken without supervision
and at the expense of the practice of their profession. How much better it
would be if the various training schools would undertake to give the course
in the specialty either as a part of the under-graduate course, or as a
distinct graduate school.
If the changes already suggested in relieving the pupil nurse of some of
her arduous work were adopted, it would be possible to find time for a more
or less intensive course in a number of specialties. It must be appreciated that more and more a new field of opportunity is arising not alone
in the special branches of medicine, but in some of the more closely related
sciences, especially those related to public health activities. It might be
possible to give courses which would fairly well qualify nurses to act as
assistants in the X-ray department of the hospital, in the hospital laboratory,
in a training school administration, and in the social service department.
In the majority of Canadian hospitals the student nurses receive no training in the social service department. She gets her practical training in
the wards of the institution, but has no actual knowledge of the conditions
which have placed the ward patient in the hospital. Today all nursing
work points towards educating the public to avoid causes of disease, rather
than alleviating the suffering. This branch of the work should be given a
place in the curriculum of our training schools. The nurses should be
graded in the work, and an examination given. One worker in the social
service department could give eight or ten lectures to the pupil nurse in
her second year, and as well the pupil nurse could spend one or two weeks in
the social service department visiting poor families, thus learning the
causes responsible for sending the patients to the hospital. Other special
branches demanding workers in their particular line are diseases of infants,
infectious diseases, school nurses, visiting nurses, etc. It would seem that
it might be possible to rearrange the work in the training school so as
to allow the pupil nurses to elect any one of the special branches for the
intensive work in the last six months of their training.
In this way, specialist nurses would be developed to meet the demand
which is surely coming in a very urgent manner.
DISCUSSION.
DR.   MacEACHERN—
This Association will find itself in the same position as the International
soon—in which we find that we have to divide it into sections, as—Nursing,
Dietetic, etc., in order to cover the work properly.
In all my hospital administration I have always endeavored, and it
is the duty of every superintendent, to give the superintendent of nurses and
the training school every possible support in the work. One of the pleasures
which I get out of my work is the interest which I take in the training
school. We have seen in our training school here many advances in the
past few years and we are still making advances. We have affiliation and
post graduate courses now here. I also understand the Provincial Jubilee
gives a two-year affiliation. Our affiliation is one year. The nurse from
the smaller hospital may take her final year in the Vancouver General Hospital and finish her course through the special branches as—Operating Room,
Obstetrics, Pediatrics and Dietetics. She may graduate from our platform
but she receives her diploma from the hospital from which she came, and
is recognized as a graduate of her own hospital. The post graduate courses
are in Operating Room Technique, Obstetrics, Dietetics and Pediatrics.
Personally, I feel that the time will come when the University of British Columbia will have a Chair of Nursing and with it all the training
schools in British Columbia will be affiliated. The University will supply
the theoretical teaching and the various hospitals throughout the Province, the practical teaching.
91 MRS. CAMPBELL—
Don't you think it is hard on the small hospital to take the nurse away
in the third year?    We in Vernon object on this ground.
DR.  MacEACHERN—
To the nurses, it is a decided advantage; to the hospitals, I suppose, a
disadvantage. It is too bad we cannot make such an arrangement as would
be advantageous to both. The nurse from the smaller hospital during her
first two years should receive as good training as the nurse from the large
hospital, all other things being equal, and there is the advantage Which
she may have of having had more individual instruction. In the third year,
by affiliation, she gets the advantages of the courses in the large hospital,
which comprises Operating Room Technique, Obstetrics, Pediatrics and
Dietetics, and this gives her a good rounding off for her profession. It is
a question whether we are going to let the nurse or the hospital suffer.
Personally, I do not think we should let either suffer.
DR.  MULLIN —
There are some things in our training schools as they are carried
on today, which are fundamentally wrong from every standpoint excepting
service to the hospital. The nurses used to get all their instructions at night,
after they had completed a day lasting from seven to seven, with a few minutes off, and Sunday morning. If the hospitals are going to occupy a position of more or less public health centres, it seems to me that it is up to
the hospitals to begin the practice right in their own institution.
Another point that Miss McLeod brought out was that the remuneration they are receiving is not very high. In the United States, I think the
most they receive for ordinary cases is $35.00 a week. Perhaps in Canada, it
is not quite as high, perhaps $30.00. Even at $35.00, that gives you a maximum income of $1,800.00 a year. If you work anywhere from twelve to
twenty hours a day for fifty weeks in the year, how much training is allowed, how much training will be justified by the subsequent remuneration? This is something that 1 think needs a certain amount of consideration—that is, we cannot expect the nurses to have a very extreme grade of
efficiency so far as the extensiveness of their course is concerned, under
present conditions. There should be some definite amount of training required and the subsequent remuneration that is to be expected should be
accordingly.
From a laboratory standpoint, we find in laboratory Work that certain types of nurses are specially adapted to undertake some of the technical details of this work, not only in the hospital laboratory but also in the
laboratories of physicians who have offices down town, so that if the training schools could establish a mechanism whereby the nurses could obtain
this information, either during their course or immediately after it. as a
post graduate course, a great need would be fulfilled. I think the want of
this is very keenly felt at present. It is practically impossible to get medical men to stay long at this work; they refuse to work for the salaries which hospitals and others can supply for the work which is demanded.
Something has been said regarding the fact of university affiliation with
training schools for nurses. I was at one time connected with the University of Minnesota where they had this affiliation, and they found it
tc work out excellently. The actual nursing work was taken in the University school, with co-operation between the work of the hospital and the
University.   All the nurses seemed pleased with that course.
Dr. McEachern at this point read the following letter from Dr.
C. H. Vrooman, Medical Superintendent King Edward Sanatorium,
Tranquille, Kanmlops, B. C.:
"Dear Dr. MacEachern :— sSifc-
In connection with the Hospital Convention, there is one subject I
would like to have brought up at the Round Table Conference, this is
giving nurses a training in nursing cases of pulmonary tuberculosis. This
subject was discussed at the recent conference in Toronto and at the Med-
92 ical Meeting in Hamilton. A resolution was passed urging that the general hospitals make arrangements to give nurses in training a course in
sanatorium nursing at the nearest sanatorium available. It was felt that
in general hospitals at the present time they do not get a complete training in
this particular branch. Nurses are largely ignorant of what is meant by
sanatorium treatment and Sanatoria had constant difficulty in securing
nurses for their institutions. There is a prejudice among the nurses to
taking positions which is largely due to ignorance of the life there. The
increasing importance of the Tuberculosis problem makes it necessary
that nurses receive training along thes'e lines, and it was felt by practically
all the superintendents of Sanatoria whom I met, that it would be greatly
in the interest of the Anti-Tuberculosis work if the hospitals could be got
to co-operate with the Sanatoria and send their nurses for a short period
and receive treatment in this important subject.
I am sorry I cannot be there and present the matter, but I hope you
will be able to get someone to do so.
With kind regards,
I remain,
Yours very truly,
C. H. VROOMAN,
Medical   Superintendent."
DR.  MacEACHERN—
Hospitals are compelled to take in tubercular cases.   Would a nurse get
sufficient training during her course for this work ?
MRS.  CURRIE—
Yes, but they are compelled to take in advanced cases. Apparently, the
nursing for the advanced tubercular case is a little different from the incipient. The incipient gets a special line of exercise and treatment. The
advanced case is practically a bed case and treated as an ordinary bed case,
excepting for the fact that it is an infectious case, where she will have to
administer a certain line of technique, which she should know in her -ordinary training course. Our hospital has an exchange—we sent three
nurses up and received three in exchange—and this was mutually advantageous.
DR. MacEACHERN—
Seems to me this is a question for a committee or for future consideration. Possibly we could discuss it at the round table conference tomorrow.
MR. GRAHAM—
If there is no further discussion, I'll call on Miss E. Kinney,
Chief Dietitian to the Vancouver General Hospital, for her paper
on "The Hospital Dietary."
"THE   HOSPITAL   DIETARY."
By Miss E. Kinney, Chief Dietitian to the Vancouver General Hospital.
Today, scientific feeding is being recognized as an important part of
hospital routine, with great co-operation between physicians, hospital superintendents and staff. Four years ago, a prominent medical man, writing
for the Modern Hospital, stated that there were not at that time three
good dietitians in the United States. Three months ago, writing for the
American College of Surgeons, he states that now, "thanks to the co-oper-
ation of physicians, there are fifty good dietitians with many more fully
qualified to take up the hospital training necessary for scientific management of hospital dietaries."
The fault has not all been that of the dietitians, however. For a matter
of some eighteen years Domestic Science has been sending out graduates
well equipped to assume the responsibility of institutional food administration; and for perhaps fifteen years of that time, these girls have been filtering into hospitals; at lftast for the instruction of the nurses in invalid
cookery; later, for the added duty of private tray service; of later years,
working with the physicians in diseased metabolism, and taking from the
93 housekeepers and stewards more and more responsibility until now in many
hospitals the dietitians are taking charge of food, from ordering to final
distribution, conducting the work of instruction along broader lines, utilizing
the preliminary training for work with physicians in diseased metabolism,
and supplying for the hospital staff a standard diet that aims to please, as
well as satisfy.
Considering a hospital dietary, we must think of three phases:
1. Its physiological requirements;
2. Economy;
3. Its educational function;
any one of which would furnish material for many papers. It is our present
purpose to discuss these requirements in general only, and that briefly—
Miss Sinclair will be able to treat at least one of these much more specifically.
A standard hospital dietary must provide meals for at least four classes
of people, all of whose food requirements are radically different,—patients,
doctors, nurses and help.
First for the patients—food for those who are seriously ill is a matter
of vital importance, for the life of the patient often depends upon the maintenance of strength during the acute period of disease—or on the recovery
of power during convalescence. The food must be abundant, plain, simply
prepared, inexpensive.
While it seems impossible even in a moderate sized hospital to plan
dietaries filling the caloric requirements of each patient; yet bearing in
mind that a well man lying quietly in bed, requires from 1,600 to 2,000 calories a day, that if the body is being wasted by disease, he may require
a great deal more—and that during convalescence, if the body has lost
weight, food must be given for rebuilding in addition to the ordinary daily
needs—we can plan a diet which will furnish 2,000—2,200 calories daily average portion; and by judicious variation in portions, and addition of eggs,
etc., as nourishments, adapt this dietary to the individual need.
Caloric needs are not all that a hospital diet should satisfy; we must
supply a well balanced diet which will also please and satisfy capricious
invalid appetites. With a limited variety allowed, this must seem difficult,
but a little time and attention can accomplish wonders. For example, fish
and eggs, staple items of invalid diet, especially of public ward patients,
if served boiled repeatedly, must become unappetizing, and yet there are at
least six simple, digestible ways in which these foods may be prepared
and served at the cost of a little time and attention.
But there can,be no fixed law for details—each locality, each class of
patient is a case by itself; in fact, the person responsible for the hospital
diet should hold herself ready to study the requirements and idiocyncrasies
of the individual—at the same time false ideas as to the character of food
necessary for health should not be encouraged in patients.
Here let us mention that planning a diet and preparation of the food
is the least part of the problem. All is lost if the food service is poor.
Service of food is one of the most important parts of the nurses' training
in dietetics. Fault is often found with the diet; if such complaints were
sifted, a large percentage would be found to relate to the methods of serving food after leaving the kitchen. The old dictum hot's-hot and cold's-cold
cannot be over-emphasized. Too much pains cannot be taken in serving
food. The fact that it is not the quantity or quality of the food which
provoke criticism, but the method in which it is served, should be borne in
mind.
In connection with patients' diet, it is difficult to mention special diets
briefly. Special diet slips, revised yearly by physicians and surgeons, are
doubtless of great help. Yet the day of the standard special diet has undoubtedly passed and the problem of individual metabolism is the one with
which we most commonly have to deal. There are many good special diet
lists easily available, and any one here I might give would be quite superfluous.
The diet for the nurses has been a phase of the hospital dietary often
much neglected. The staff, doctors and internes have usually fared better
—and yet the nurses are daily coming into as close, if not closer, contact
94 with disease; are working hard through long hours. A caloric requirement of at least 2,700 daily does not seem too high; and again too much
emphasis cannot be laid upon variety and good service. The staples—
meat, soups, and the breakfasts cannot be varied greatly; but with the
many appetizing lunch or supper dishes available and a variety of deserts,
an attractive daily menu can be arranged which need not repeat for at
least fifteen days.
The diet for the help is the third big item in the hospital. The employees are usually recruited from people accustomed to a bulk rather than
a variety, who like their "three squares" a day, and view with distrust the
equivalent for a meat dish, or the most appetizing dish made from leftovers. The dinner is not as hard to plan as the supper. A bulky meat
equivalent and a relish, such as pork and beans with pickled beets, seem
to help meet this difficulty. Again comes the need for studying locality.
An Irish-Jewish staff in an Eastern hospital presents a totally different
problem from the Scotch-English staff of a Western Canadian.
The old laborious method of computing caloric values has been much
simplified by the introduction of tables showing hundred calory portions.
I have with me such a table which can be duplicated.
The problem of cost and waste may be divided into two branches:
that connected with the food before it reaches the kitchen, and that connected with its preparation until it reaches the patient.
It is not my purpose to express any opinion as to the former—except
that it is never an economy to buy an inferior grade because the price is
lower; no poor quality should be received is axiomatic. ■ At the same time
the most expensive grade is not always the best. Judicious buying and
careful checking of contracts can save any hospital yearly.
The question of waste in the kitchen is answered by the one word,
"supervision." Constant supervision of preparation, checking of service, and
the careful use of left-overs, can work wonders in saving. This means a
larger staff, but the resultant economy seems to justify the extra salary
expenditure. Women cooks are more economical than men, but we often
hesitate to use them as they are harder to manage.
The question of waste does not end with the kitchen—we come again
to our question of service. It is useless to set portions and send out diets
accordingly—unless the service is followed up and the same portion used
on the ward. To check the return trays of a chartered special diet is an
eye-opener. To inaugurate a system of bedside service, which gives the
patient small portions before him and a return for second service if wished,
is a bigger one. Patients as well as nurses can be taught economic habits
in dealing with food. They should not be allowed to see food wasted. Too
much praise cannot be given to nurses who are careful to conserve food
supply.
An excellent means of reducing the cost of food supply is in standardizing per capita allowances and in following these allowances and a standard
diet carefully in ordering. We have ready a standard per capita allowance
list and a standard diet to submit. I would criticize the diet for patients
as supplying an evening meal which is far too heavy; but an attempt nine
months ago to make this meal lighter resulted in such a clamor of complaints from public ward patients that we have returned to the heavier menu
—trying to achieve the same results by serving light dishes and small
quantity portions.
In conclusion, the training of nurses in dietetics is of the greatest im-.
portance. Most training schools can be criticized that this part of their
training is too short. May I quote from Doctor Joslyn at the American
Hospital Association:—
"Nurses are already given courses in dietetics; but the need for more
instructions is daily apparent, because treatment in hospitals is more and
more based upon quantative variations. Experience alone will enable
nurses to carry out orders properly. Nurses may know more about diet
than the older physicians, but they do not as a rule know as much as the
present younger group of doctors. All nurses working in institutions should
have demonstrated to them the necessity for the avoidance of waste. They
should be familiar with the caloric value of food."
95 In thinking of my subject, "The Hospital Dietary," it has occurred to
me that our experience, with every advantage of equipment and supply,
would be quite aside from that of those working in smaller more isolated
hospitals. With that in mind, I have written only briefly, thinking that it
might be of more profit to you to spend the remainder of my time in trying
to answer your questions.
DISCUSSION.
MR. DAY—
I must congratulate Miss Kinney on her very excellent paper. The
dietary question for all hospitals is vastly more important than ever,
especially now when more scientific feeding is being carried on. I congratulate Miss Kinney on her admirable paper.
MR. GRAHAM—
I want to add my word of congratulation to what Mr. Day has
said. The next paper on our programme is "The Food Problem
as it Affects the Hospital," by Miss G. Sinclair, Superintendent,
Royal Columbian Hospital, New Westminster. Owing to her voice
having failed her through a sore throat, Dr. J. McKay of New
Westminster will read it for her.
THE FOOD PROBLEM OF TODAY AS IT AFFECTS THE
HOSPITAL.
By Miss G. Sinclair, Superintendent of the Royal Columbian Hospital,
New Westminster.
As this topic covers so many every-day problems of hospital work. I
shall endeavor to bring before you briefly the factors which seem to me
most important.
In all lines of hospital supplies and equipment we are using substitutes
or inferior grades, but in none of these do we have the problem that we
meet in the food situation. Even when everything that money could buy
was available, the proper feeding of patients has always been one of the
most important branches of hospital work. Then there was no question of
where or how the materials had been prepared as long as they satisfied;
now the problem is to make the best of the limited supplies which are
obtainable. We are asked to conserve principally wheat flour, fat, bacon
and sugar, the commodities which have always been indispensable to the
hospital dietary. Until this War brought it before us, we never realized
in what luxury and extravagance we lived day after day.
Due to the shortage of wheat, we are now obliged to buy our cereals
in bulk instead of neatly prepared packages as formerly, so that some of
the favorite breakfast foods are unobtainable. Practically the only choice
we have now is corn meal and oat flakes, neither of which are popular
during the Summer months, but during the Winter could very well take
the place of the substances used previously.
The bread we receive today has not the same amount of substance or
nourishment, because the bakers are attempting to make the same profit
when their expenses are so much higher, so that somebody is loser and he
is the customer. Very few hospitals are in a position to have their bread
made in the institution, so must be supplied from the bakers. Then there
is always the waste of bread. The only way to overcome this is to ration
every person in the institution except the patients, and serve to them as
much as they care for, but, if possible, no more. After serving a tray a
few times, a nurse knows about how much a patient is likely to eat, and no
more need be served unless requested. Instructions regarding the serving
of bread and butter should be posted in each serving kitchen, so that the
young nurse will know how to serve her patients without wasting, and yet
let everyone have enough. Substitutes are now being prepared from rye,
potato and barley flour which are very healthy and palatable and are being
used extensively that wheat flour may be conserved.
96 The use of sugar is one of the most difficult to regulate in an institution without actually rationing every individual, which is practically impossible. One means of reducing the amount of sugar used is the use of a
plain sugar syrup on cereal, etc. In some of the Eastern institutions it was
found that the amount of sugar consumed in one week was reduced one-
third, and this plan might be applicable to the hospitals to be used in the
domestics' dining-room and public wards. Such a syrup may be kept in
the diet kitchen for use in all beverages which require sweetening, as it
adds flavor and conserves sugar.
It is also a very difficult matter to observe the food regulation regarding meat today. We are asked to conserve beef and bacon. During the
summer months it is not hard to manage without bacon; but in hospitals,
beef is so very essential—broth, beef tea and stock are continually in
demand and must be supplied. The supply of other meats such as mutton
and lamb is very limited as it is purchasable in large amounts such as is
required in an institution only at certain times, because practically all the
mutton that is now used in British Columbia is being imported from
Australia.
Canned fruit and vegetables are not being prepared as palatable as
formerly and must be remedied in some way. This is probably accounted
for by the fact that such large quantities are prepared in the canneries
in a short time as the fruit must be attended to as it ripens. Some of the
fruit is over ripe at the time of canning and it is during the rush period
that the large cans, much more used in hospitals than the smaller ones,
are prepared. Such fruit as pears are hard and tasteless and must be
cooked again and more sweetening and flavor added. The string beans are
much coarser and the strings have to be removed before they can be served,
which entails a great deal of extra time in their preparation.
Water glass eggs have proved a great resource during the winter
months; and except for the large supply put away during the summer, in
spite of the prevailing high prices at that time, it would be impossible to
keep up with the demand.
These are only a few instances of the problems that arise today in the
hospitals. Besides the ever increasing prices and the absolute lack of certain articles, the ones now supplied require more time spent in preparation,
which leads to another great source of worry which is in very close relationship with the food question, that is, the help. In every department, it is
less efficient than ever before, as the more capable women are filling the
places of men throughout the country. So having obtained what supplies
are available even at fabulous prices and planned our menus, the preparation must have the closest supervision so that everything is used to the
best possible advantage and the most rigid economy enforced.
Conservation in a hospital is a most difficult problem; but as managers
of institutions and heads of various departments, we must endeavor to have
everyone under our supervision understand of what vital importance it is
to our Empire. There are many who would willingly serve their country
overseas if age and circumstances permitted, who fail to realize what great
service can be rendered at home in their every day work.
Cannot we, who are in charge of institutions where waste has been
almost proverbial, do our duty by conserving to the greatest possible
measure and thus share in the pressing needs of our Empire?
MR. GRAHAM—
I am sure we all thoroughly enjoyed this paper, and all realize
what a problem it is today.
If there is no further discussion, we will pass on to the next
paper, "The Assistance of Publicity to Hospitals," by Mr. R. S.
Somerville, member of the Board of Directors, The Vancouver
General Hospital. This paper will be read by Dr. MacEachern in
the absence of Mr. Somerville.
97 ASSISTANCE OF PUBLICITY TO HOSPITALS.
By R. S. Sornerville, Director of the Vancouver General Hospital.
Thanks to the War, the world is experiencing a radical transformation
in ideas and ideals. There has been a great levelling, but also a great
uplifting. A censorship prevails in regard to important war plans and
movements of troops, but in most other aspects of the gigantic struggle
every facility of modern communication is utilized to keep the people well
informed. There are special correspondents and even departments of
propaganda to discuss war topics and progress. At no time and in no other
war has the physchology of publicity been made so much of.
The present conflict has to its credit a remarkable contribution to
general knowledge and to the solution of scientific problems. Take, tor
instance, the mastery of the air, achieved since the outbreak of the war; or
take, what is perhaps more appropriate at this Convention, the development
of medical science in the treatment of wounds and blood-poisoning cases;
or, if you like, the remarkable advancement in the efficiency of war hospitals during the past four years. Thanks to the wide publicity, given to
everything connected with the war, these matters have become household
topics. The man in the street and the pupil in the public school know all
about the "nose-dive" and the "circus" formation of the war airmen; they
know how the medical men have solved trench fever and nerve shock; they
are familiar with the marvellous cures accomplished in the base hospitals,
and the stupendous advance in the providing of effective substitutes for
lost and torn limbs.
It is undeniable that the great majority of persons in this Province
know more about the work being done in the base hospitals at the front than
they know about what is being done in the hospitals of the Province. This
seems a remarkable condition, and there must be a reason. The reason is
that their interest has been enlisted in the base hospitals because of the
many stories written and told about them. For one item they read about
a civilian hospital, they probably see twenty dealing with war hospitals.
Naturally the war is the supreme topic today as it has been for four years,
but civil activities of all kinds must be carried on just the same, and as
far as the public hospitals of this Province are concerned the war has added
to the financial burden in the form of higher prices for commodities, drugs
and equipment, and has most assuredly not lessened the number of patients.
They are in greater need of support than ever.
Support is largely based on two things: knowledge and confidence.
If any of our hospitals are unable to stand the test of taking the public into
their confidence as to their work and affairs generally, there is something
lacking.
Perhaps the reason why some hospitals seek no publicity is that they
have enough sense to keep their mouths shut. But one feels sure that such
hospitals are not represented here today, nor do they exist in this progressive Province.
Publicity does and will do two things for hospitals: it educates and
it enlist.s support. There can be no question that both aims are worthy
and both are closely related. The popularizing of knowledge as to the work
being carried on in an hospital in the treatment and cure of diseases is as
necessary and legitimate as it is for an industrial concern to advertise its
wares. It means securing support in both cases. Most of the hospitals in
British Columbia are public hospitals which have to depend on public
grants and voluntary gifts. They cannot collect all they earn because they
are at all times dealing with the poor and unfortunate. The public can
always be induced to give to worthy objects.
Hospitals, whether in large or small centres, carry on a work of vital
importance to the community. The work is absolutely essential to the
public welfare. The chief asset of a community is its health. The work of
alleviating pain, healing the broken and restoring the sick to health and
vigor is not only of prime importance but is never ending. Institutions of
this kind can have no holiday nor declare a walk-out. Public hospitals
cannot refuse the sick admission. With these facts in mind, there is no
reason why an apologetic attitude should he assumed in inviting support.
98 These institutions must be maintained at a constantly increasing state of
efficiency, and this costs money.
This attitude of hospital managements generally has undergone a
marked change In the past few years in regard to publicity. The absolute
need of it is recognized. Not so many years ago the interior of a big
hospital was as unknown to the average man as the inside of a penitentiary-
is to us. It was a close corporation, with the result that ignorant gossip
had full play. The Vancouver General has had its own experience along
this line, and even yet one occasionally hears the most absurd stories downtown. I suppose that is inevitable, but constant and well directed publicity
will consign most of these fairy tales to the garbage heap.
On the advent of Dr. MacEachern to the general superintendency of
this hospital, he inaugurated a new order of things which has borne much
good fruit. He has always found time to talk to a newspaper reporter and
to send him on his way rejoicing. He has made friends with the local
newspapermen, with the result that he is able to command much valuable
publicity in the press. He has also been able by this means to put a
quietus to many yarns which had no foundation in fact.
Public support will follow public interest. Once a man or woman
becomes interested in the hospital, the next step which is almost certain
to follow is that he or she will support it in some form or another. With
the exception of patients and their friends, there is little direct contact
between the individual and the institution. Publicity bridges the gap between the two. Outside of what may be regarded as self-interest on the
part of the management, the latter is under moral obligation to provide full
information as to the work of the hospital. It is a duty to the public. One
effect of hospital publicity is that it today attracts hundreds of patients
who formerly were treated at home, much to their own detriment in many
cases. The more that is known about hospital work and its steadily increasing efficiency, the better it is for the whole community.
Some definite person should be in charge of publicity. There are a
thousand and one incidents during a week at an hospital which, if told,
would excite interest and comment. Neither humor nor pathos are lacking.
Under a constant routine, hospital officials are apt to grow blind to the
features that have new values—that are unfamiliar to outsiders, picturesque,
humorous, pathetic, and romantic. Here is where a friendly news writer
may well be called upon to assist, and in every community such an individual may be found. The admitting officers, house staff, the nurses, the
social workers and others connected with the hospital should be encouraged to notice and report anything of a possible news value.
All this refers to articles in the press, which, after all, is the most
direct and most successful of all publicity. But many other avenues for
reaching the public should be utilized with advantage. Publication of
monthly and annual reports should be insisted upon, care being taken not
to make them too technical or lengthy. Letters of appeal are an effective
means of publicity. Illustrated folders for direct distribution in public
gatherings and public places are likely to do much good in calling attention
to the equipment and achievements of the hospital. These might also be
mailed to prominent citizens. Occasional receptions direct attention to the
personnel of the institution and extend the circle of well wishers. Last, and
best of all, are the enthusiastic econiums of former patients on the way the
hospital is conducted. By their united verdict an institution must stand
or fall.
The success of this Convention is itself a striking testimony to the
effectiveness of publicity.
I cannot do better, in closing, than to quote some remarks of a well
known New York hospital authority on this subject In a recent address
he said:
"Cultivate good-will. It is too much to expect that the general public
will retain many statistics about your hospital. People read so much and
so carelessly that their minds become like sieves, often with big holes in
them. But though they do not retain many facts, they do retain impressions, and it is their impressions on which they act See to it. therefore,
■that, with the facts to justify it, you establish a reputation for doing a
99 large work, vital to the community and permeated with genuine sympathy.
There is a widespread impression that an hospital is a cold, cheerless,
impersonal place, wrapped in officialism and tied up with red tape. As a
matter of fact, a hospital is a place where people come in pain and find
relief, come in weakness and go forth strong, come despondent and return
with courage. There are few families that do not have grateful memories
of what a hospital has done for one or more of their circle. Capitalize
this feeling."
DISCUSSION.
MR. GRIMMETT—
It may be said that one ought to go slowly in spreading abroad the
good work that he is doing, but I think in this matter it is our bounden
duty to let the general public know the work that is being carried on in the
community in which the hospital is situated. A well conducted hospital
has nothing to fear, but everything to gain from public criticism, public
reports of its proceedings and generally it is better to have the public informed of all that takes place. In this connection it gives me much pleasure
to pay a tribute to the local press of the town from which I come. The
publisher of that newspaper favors every meeting of the Board of Directors
with a reporter, and in the report of our proceedings I have never found
our confidence abused. I find that if you treat the members of the Press
properly and in confidence, that they will repay you in confidence.
I mentioned yesterday that we have in view the erection of a Home
for the Nurses. Considerable opposition has developed in regard to carrying out the intended proposition at the present time. I was greatly delighted on taking up the last issue of the local paper to find that its leading
article was devoted entirely to the advancement of this problem, pointing
out the absolute necessity from the nurses' standpoint that the building be
erected, so that while the public press can render us aid that cannot be
estimated, we should in our attitude to the Press be unreserved, and, as I
said before, they will not abuse any confidence that we may impose in
them.
The meeting adjourned and the delegates and friends assembled
in front of the Nurses' Home where a large number of cars were
waiting to convey them over the Capilano Canyon Drive to the
hotel, where over two hundred guests of the Board of Directors of
The Vancouver General Hospital, sat down to dinner. During the
dinner music was furnished by the Weaver Orchestra, and a few
speeches made by Mr. Devine, Dr. Riggs, Dr> MacEachern and Mr.
Grimmett. Mr. Devine proposed a toast to the delegates and friends
which was very enthusiastically responded to by Mr. Grimmett who
very forcibly commended the Superintendent and Board of Directors of the Vancouver General Hospital for the splendid success
of this Convention. Dr. Riggs proposed a toast to the Graduating
Class of Nurses who were also guests. This was responded to by
Dr. MacEachern for the nurses. The remainder of the evening
was spent in seeing the Canyon and in dancing. All returned home
by midnight, having had a most enjoyable and sociable outing.
MORNING SESSION—Friday, June 28th, 1918.
DR. GATEWOOD—
I have pleasure in calling upon Mr. J. J. Banfield, one of the
members of the Board of Directors of The Vancouver General
Hospital, who has loaned his assistance very materially to making
this Convention a success. Ever since the first suggestion Mr.
Banfield was very interested in seeing this Convention a realization
100 as we see it today.   I will now call upon him to take the chair for
the morning session.
MR. BANFIELD—
I will now call on Mr. E. S. H. Winn, Chairman of the Workmen's Compensation Board, for his address.
THE  WORKMEN'S  COMPENSATION  BOARD."
By Mr. E. S. H. Winn, Chairman of the Workmen's Compensation Board.
It is indeed gratifying to our Board to be favored with this opportunity
of meeting with you in a general discussion of the different phases of the
Workmen's Compensation Act insofar as it applies to hospitals. We believe
that a great deal more can be achieved in a get-together session such as
this than could be done in years by correspondence. As I go along different
questions may arise in your minds which require an explanation. Will you
be good enough to make a note of those questions and ask me for an explanation when I finish this talk. This is the time, therefore, that affords
you an opportunity of asking our Board and my answering you on the
Board's behalf of all matters upon which you seek information. Then,
again, getting together as you are means that each of you will be able to
take up different phases of the questions and possibly adopt some uniform
system in the handling of your particular work which will possibly be more
satisfactory than has been in the past. From our Board's standpoint we
particularly wish to thank the hospitals for their active co-operation during
the past year, for their uniform courtesy in promptly answering our inquiries, and for the care and attention which they have as a whole satisfactorily given to those workmen who were unfortunate enough to have
met with accidents.
You will, of course, understand that the handling of the Hospital Department of the Medicai Aid Department is but a very small portion of the
work of this Board. When you consider that, roughly speaking, we are
dealing with 75,000 workmen, 6,000 employers, approximately 400 doctors,
2,000 nurses, 250 druggists, 200 dentists, steamboat companies, electric and
steam railways, liveries, auto transportation and every other means of transportation available or used in the transportation of an injured workman to
the nearest hospital or doctor, you will begin to realize the enormity of the
work. Roughly speaking, we have 60,000 files containing in the neighborhood of a million documents, a good many of which have called for answer.
We have a staff of forty-seven handling this work.
Then, again, the fact that the Act is new and comprising many new
features in workmen's compensation measures, and particularly as affecting
hospitals by way of unlimited medical aid, it just means that all those with
whom we come into touch must receive a certain amount of knowledge as
to the means necessary to collect moneys owing to those affected, as well
as to a knowledge of the procedure necessary to collect claims. We have
paid' out by way of compensation to injured workmen, and created by way
of reserve for pension for permanently disabled workmen and dependents
and children of deceased workmen, approximately $1,300,000.00. The amount
paid out in medical aid, which would include doctors, hospitals, nurses and
druggists, in the neighborhood of $185,000.00, $75,000.00 of which was paid
to hospitals. The payment of this amount necessarily shows how vitally
interested you are in our work.
In looking over the medical aid files this morning we believe that one
out of every twelve injuries that happen to workmen, where there are three
days' lost time, is a hospital case. Under old conditions, your right to- collect existed against the injured workman. You still have that right, together with the additional right of collecting from our Board, in the event
of our Board being satisfied that the injured workman has suffered personal
injury by accident, arising out of and in the course of his employment. The
Act requires us to be satisfied on those questions, and that being so our
Board has no authority to make payment until those particular conditions
are met.   This new legislation does not in any way interfere with or change
101 your old right of action against the workman, but it does mean that our
Board is interjected into the arrangement as a third party, and as a third
party we are to pay as soon as we are satisfied that the accident has arisen
as mentioned.
Under the Act there are two means whereby medical aid is furnished,
one is where, for example, one cent per day is deducted from the workmen's
wages and paid direct to the Board, and the other is known as the approved
medical plan. Where the one cent per day is deducted the employer is required to pay this amount to the Board, and the Board in turn pays from
the money so obtained all hospital and doctor's accounts, etc. In the other
case the approved plan must be complete within itself, in other words, under
an approved medical plan, for example, say where a dollar month is deducted from the workmen's wages, this amount either goes to the hospital
or the doctor, and the hospital or doctor in either case is required to 'do all
those things and to provide all those medical appliances that the Board
would have to supply if that particular injured workman came under them;
in other words, the approved medical plan takes the place of the Board with
this exception,. that the Board has a supervision over the carrying out of
the requirements of the Act insofar as the plan is concerned. If we find
that the workman is not receiving the proper treatment, we have authority
to transfer that workman to some other doctor or hospital, and thereupon
those receiving the workman's money are required to pay the hospital and
doctor their respective accounts. When a dollar per month is deducted
from the workman's wages it means that no part of that goes to the Board,
and the Board has therefore no means wherewith to pay accounts. That
is why we say that the approved medical plan must be sufficiently broad
and comprehensive as to cover all such things as we would cover if we
administered the funds.
The Board holds that if the injured workman requires a private ward
then that private ward must be furnished to him. If the ward is furnished
under an approved medical plan, then the approved plan must take care of
the expense. On the other hand, if the workman has been the contributor
of a cent per day, as above stated, then the Board would pay for the private
ward expense. We take the position that an injured workman is entitled
and shall receive the best medical and hospital treatment available.
We have endeavored to arrive at a uniform scale of hospital rates. We
realize that an outside hospital cannot be operated as advantageously or
as cheaply as a city hospital, and that therefore they are entitled to more
remuneration.
Our Chief Medical Referee, Dr. G. A. B. Hall, will speak to you when
I finish, and will deal more particularly with some of our troubles with
you.
It may be that some of you think you have grievances. If you have
that feeling, then we would appreciate it very much if you would make it
possible to call at our offices and discuss that grievance with a member of
the Board before leaving this city. You can quite understand that there is
no individual or set of individuals who could remember the contents of
the sixty thousand files that I have referred to, and it is for that reason
that it would be impossible for me at this time to deal with any particular
case without having the file before me.
Our Board also wishes to extend to you a hearty invitation to visit
our offices and get an idea as to how this work is being handled. I am sure
that you will go away firmly convinced that the work is being handled expeditiously, economically and equitably. If at any time you feel that you are
being unfairly treated and can satisfy us on that question, we never hesitate
to reopen it and adjust. If we have underpaid you, you are at liberty at
any time to take up the question of shortage, and if your position is justified you will be promptly paid. We would appreciate it, too, that if at any
time you are not certain as to the attitude of the Board on any question,
that you write us, and if you do I can assure you that you will receive a
prompt and courteous answer. We welcome enquiries, and we urge, that
where a difficulty arises that that difficulty be not permitted to remain any
length of time, but that it be promptly taken up.   Delays are dangerous,
102 not only in the way of creating a certain amount of unrest, but in the way
of our closing our accounts in the different accident cases.
Permit me, on behalf of the Board, to most heartily thank you for the
opportunity that you have given our Board to be present with you and to
be given the opportunity of answering any enquiries that you may make,
and if possible to set at rest any misunderstanding that you may have. We
want you to feel that we are endeavoring to conscientiously and honestly
carry out the requirements of the Act, and we ask your heartiest co-operation. Your co-operation with that of the others effected means that the
Act will be, a success—to be successful means that your interests will be
safeguarded.
ADDRESS
By Dr. G. A. B. Hall, Medical Officer of the Workmen's Compensation
Board.
It devolves on me to make a few remarks concerning some of the difficulties connected with the administration of the Workmen's Compensation
Act relating to hospitals. In this, as in all other new departures, difficulties
are bound to arise, more often through misunderstanding and lack of knowledge than otherwise. It always requires a certain length of time for organization which is essential in any undertaking in life. The difficulties might
be placed in two groups: First, the grievances of the hospital authorities
against the administration of the Act, and, secondly, the grievances of the
Board regarding accounts as presented to them.
One of the objections from the hospital authorities has been regarding
the payment of their accounts, and while there undoubtedly was some
ground for such, shortly after the Act was brought into force, I think there
is very little cause for complaint in that direction at the present time. We
now have an agreement with practically all the hospitals throughout the
province for a flat rate for the treatment of patients coming under the
Workmen's Compensation Act, and all accounts are now given prompt attention, if in order when presented.
Another grievance has been in the case of men coming from outside
points and being treated at the hospital, the hospital authorities believing
that they came under the Workmen's Compensation Act, and afterwards
finding out that such was not the case so far as medical aid was concerned,
the companies for whom the patients were working having had a private
hospital arrangement approved. In this class of cases, the Board is ^not
liable for accounts for medical aid, and it is a matter between the hospital,
the patient, and the company for whom he was working at the time of the
accident, for the settlement of accounts. Considerable thought has been
given this matter to devise some means whereby not only the hospitals, but
the doctors as well, might be notified of this fact, and though many suggestions have been offered, as yet no practical scheme has been brought to
light. However, we are always willing to provide whatever information
we can give concerning this class of cases if the office is communicated
with, and in any event, the hospitals still have the same recourse to collecting their accounts as they did before the passing of the Act, as Has
already been made clear to you by the Chairman.
A further objection from some of the smaller hospitals is regarding
their accounts being cut, where they have charged for the day of admittance as well as the day of discharge. However, the explanation that the
principle of not charging for the day of discharge, where the day of admittance has already been charged for, has been adopted by all well-governed
institutions, appears to be satisfactory, and now we are seldom troubled
with complaints of this nature.
Regarding the Second group, we find great difficulty in full information not being given in rendering accounts. You can readily understand
how confusion would arise, when you know, as explained by the Chairman,
how large a number of claims we handle daily. When accounts come in
for patients of the same or similar surnames, many of the names being
foreign, unless accurate spelling and full information  is given, it is very
103 hard to tell which claims the accounts refer to. Ji the number of the claim
were put on each account, it would greatly facilitate the work of the clerks
in the office.
Another objection has been in the case of a patient remaining too long
in the hospital. It not infrequently has happened that a patient has left
the hospital and gone to work on the day following. A case in point is
where a man had a compound fracture of the great toe, and was in the
hospital for a period of approximately six weeks, commencing work three
days after he left. I am quite aware that the hospital authorities are not
responsible for many such cases, as the doctor in charge of the case should
discharge his patient when he feels that he no longer requires hospital
treatment, but some hospitals have control of the doctor treating the case
and it is more particularly to this class of hospital I now refer. I think
that the hospital authorities would be quite justified in drawing the attention of any medical practitioner to a patient who may appear to be using
the hospital as a boarding house rather than for the purpose for which it
was intended.
Furthermore, accounts have been presented for X-ray plates where the
accident was most trivial and where an X-ray would appear on the face
of it to be entirely unnecessary.   Many such accounts have been rejected.
Confusion sometimes arises by hospitals sending in bills as "To account
rendered." We make it a rule not to pay such, and in the event of an account not being paid in full, a letter referring to the same would receive
immediate attention. In other cases the dates of the patient's stay in the
hospital are often omitted.
The Chairman has already pointed out that we will be prepared to
answer any questions.
DISCUSSION.
MR. MORDY—
I would like to ask Mr. Winn concerning payment for artificial limbs
under the approved plan. Does it mean that whatever moneys that are
paid in in connection with it must contemplate the supplying of everything?
MR. WINN—
Before the Board approves of a plan under Section 21 (4) of the Act,
it is necessary that that plan supply all the requirements that the Board
would be bound to supply in the event of the workmen not coming under
that plan, the meaning of that being that where there is an approved plan
that approved plan must take care of artificial limbs. Inasmuch as no
moneys paid under an approved plan comes to the Board, the Board is
therefore without funds to supply those things which the approved plan
is required to supply.
MR. SUTTON—
Dr. Hall made reference to reports being sent in from the hospitals.
In the small institutions the doctor's attitude to the hospital is almost like
a wife to a husband, and the doctor's influence and his attitude is really
predominant in the institution, and his wishes practically governed by his
knowledge in the particular instance. Therefore, I can hardly think that
that would improve things. Coming to X-ray work—the doctor mentions
about an X-ray becoming almost "like a toy in the hands of children."
This is a work that belongs to the doctor, and he is responsible for the
working of that X-ray. I know of instances where the Board has been
charged more than they should have been for X-ray work. I know in our
institution our doctors try to help the men by taking more than one plate.
I believe that the Board is only responsible for the payment of one plate.
MR. WINN—
The Board depends upon the attending physician to see that the treatment is efficiently carried out. We do not desire to do anything which
will deprive the doctor of every possible means available to supply necessary and efficient treatment, but we do say that the X-ray should not be
used as a toy, and by that I mean the taking of unnecessary plates. We
have cases on record where it was deemed advisable by the attending physician to take five different sets of plates.   These the Board paid for.
104 MR. MORDY—
I would like to ask Mr. Winn in regard to regulations to be adopted
by the Workmen's  Compensation  Board in reference to  industrial  communities.    As a member of the  Board  of  Health,  I  understand  that  the
Board is adopting some regulations.   May I ask if that is so?
MR. WINN—
We have authority under the Act to add to the list of diseases already
enumerated therein such other diseases as we would hold were industrial
diseases.    So far we have added three, namely, Cedar poisoning, Sulphur
poisoning, and Trinitrotoluene.
MR. MORDY—
In regard to air space—does the Board undertake to regulate that?
MR. WINN—
No.   We have no authority.   That is a matter that comes under the
Factory Act.
MR. MORDY—
The reason I asked was that I was consulted by some of the representatives of labor, who informed me that the Board intended drawing up
regulations.
MR. WINN—
My friend's informant was in error, as the Board has no authority to
deal with ventilating conditions.
MR. SUTTON—
We  would  like  to pay—we  are trustees  of  certain  funds,  and  those
funds are for the payment of necessary medical treatment only.
MR. WINN—
Mr. Sutton knows that he can go after the doctors if they play too
much with that toy.
MR. GRAHAM—
Supposing that there cannot be an approved plan got out, that is, a
plan submitted favorably to the Board.    What action can be taken?
MR. WINN—
Under Section 30 of the Act the employer is authorized and required
to retain from the moneys earned by each workman in his employment the
sum of one cent per day or part of day the workman is employed, as a
contribution towards the cost of medical aid and to pay the amount so
deducted to the Board. In the event, however, of the one cent per day not
being sufficient, then the Board has authority, under Sub-section 2 of Section 30, to levy an assessment upon the employers generally, except those
having an approved medical plan, the idea being that the employer not
having an approved plan shall supply the deficit, if any, in the carrying
out of the medical aid requirements outlined in the Act.
MR. BANFIELD—
I am sure there is yet a great many questions we could ask
Mr. Winn and Dr. Hall, who have been so good in coming here
this morning; but we must move on, as we have a long programme
yet.
■I will therefore call on Dr. E. D. Carder, Physician to the
Infants' and Children's Wards of The Vancouver General Hospital,
for his paper on "Infectious Diseases and the Control of Same."
"INFECTIOUS DISEASES AND THE CONTROL OF SAME."
By Dr. E. D. Carder, Physician to the Infants' and Children's Ward,
The Vancouver General Hospital.
You are all familiar with the general characteristics of infectious
diseases.
They are caused, or presumed to be caused, each by a specific germ,
some of which have been discovered and can be identified, many of which
105 however, are as yet unknown. The chief common characteristic of them
all is that they may be communicated from one person to another.
This communication is in the majority of cases by direct contact between a susceptible person and another who is suffering from the disease,
or infective material cast off by that person. Such infective material may
be conveyed occasionally through the medium of a third person or through
clothes, books, toys, bed linen, towels, etc.
However, it is not my intention to dwell on these facts, which are well
known to all of you, but simply to remind you of some of the difficulties
in regard to infectious diseases that a hospital has to face, and to suggest
some means by which these difficulties may be minimized—it is too much
to expect that they can be removed altogether.
Though adults are far from immune, yet the bulk of our patients
suffering from infectious diseases are children, and any hospital admitting
children to its wards must necessarily face the problems arising from this
fact. My own experience would lead me to say that most of our troubles
with infectious diseases, as far as concerns the hospital, arise from four
main sources:—
(1) Incorrect diagnosis;
(2) Patients admitted for some complaint while incubating some infectious disease—this fact being unknown to the physician;
(3) Infection conveyed to patients in hospital from outside sources;
(4) Cross infections.
Any community, to deal at all effectively with infectious diseases,
must have an isolation hospital specifically for those cases, or isolation
wards which may serve the same purpose.
But from the purely hospital standpoint, the great necessity, and absolutely the sine qua non, is an observation ward or wards, according to the
requirements of the hospital and the population it serves. I should like to
emphasize the necessity, and I am sure Dr. MacEeachern will bear me out,
as one that saves a hospital superintendent many grey hairs, and, moreover,
from an economic viewpoint, pays for itself many times over.
Now, as to the difficulties which I have mentioned:
(1) Wrong Diagnosis:
We must admit that as diagnosticians, none of us are infallible, and
some of us are careless, but we must not forget that the doctor has at times
to diagnose the rash presented to him under very adverse conditions—bad
light, dirt, unhygienic surroundings—that tempt one to make a long distance
diagnosis if possible. Many, too, do not strip the patient, and it is always
precarious to diagnose from the appearance of one isolated area of the
body. Moreover, it is still more precarious to diagnose a rash by artificial
light.
The hospital must take all these things into consideration, and it is no
reflection on the physician but merely the part of prudence for the hospital
to suggest that cases of the etanthemata be detained at home until morning
unless serious—and that if possible the diagnosis be confirmed by daylight.
Moreover, on admission, the hospital staff should strip and examine under
the possibly more favorable hospital conditions every case, and if the
diagnosis is not agreed with, the patient should be placed in the observation
ward until consultation shall determine the nature of the disease.
. (2) As to cases admitted for some non-infectious complaint but which
are incubating an infectious disease.
These are a source of continued trouble in the children's wards. Every
child admitted (or its parents) should be (1) closely questioned :
(a) As to what infectious diseases it has had and when;
(b) Are there any others sick at home;
(c) Or any known exposure to infection.
(2.) . Thoroughly examined for a rash, sore throat, discharging ears.
Koplik's spots in the mouth; swabs taken from nose and throat; swabs, in
case of female infants and young children, from vagina. They should then
be admitted to an incubation ward and kept there for a period up to two
weeks if their stay in hospital necessitates it—and if the hospital possesses
i06 such a desirable adjunct as a ward of this nature. If not, I should like to
emphasize the importance of small wards instead of one large one for
children, because in this way it is possible to limit at any rate the number
exposed at a time. Moreover, all cases with respiratory symptoms should
be segregated at all times as a matter of precaution.
All cases with an unexplained rise of temperature should be immediately
isolated, and no drugs, which may produce a rash, given, until the nature
of the disturbance is diagnosed.
(3) Infection from outside sources,
It is possible, as I have said, that infection may be conveyed by means
of books, toys, clothes, etc., but the main source of outside infection is
through contact with visitors who have, or have recently had, or are just
developing an infectious disease. Therefore, no children under twelve
should be admitted as visitors to a children's ward. Visiting hours should
be few and limited. Visitors to each child should be limited to parents.
The visitors should wear gowns.
(4) Cross Infections.
The most effective method of minimizing these is by having the wards
subdivided into cubicles and by observing a strict nursing technique. Further, as I have already mentioned, all cases with respiratory symptoms
should be segregated and those with any unexplained rise of temperature
or other untoward symptom^.
Thus very briefly indeed I have attempted to outline some of the
difficulties of hospital administration in dealing with infectious cases, and
to suggest some means of meeting these troubles. If these remarks succeed
in promoting some profitable discussion, or in creating suggestions along
this line, I shall be satisfied.
DR. MacEACHERN—
In the Round Table Conference to take place this morning there will
be ample opportunity for discussion along the lines of this excellent paper,
as there are questions dealing on it.
MR. BANFIELD—
I will now call on Dr. T. H. Lennie, Chief Anaesthetist to Tie
Vancouver General Hospital, for a paper on "The Administration
of Anaesthetics."
"THE ADMINISTRATION  OF ANAESTHETICS IN THE  VANCOUVER  GENERAL  HOSPITAL."
By Dr. T. H. Lennie, Chief Anaesthetist to the Vancouver General
Hospital.
This paper is not intended to be a treatise on Anaesthesia, but rather
some practical points upon the administration of anaesthetics in the Vancouver General Hospital, in the hopes that our experience here over an
extended number of cases may be of some help to those who are not favored
with the same facilities as we.
Doctor Flagg, Anaesthetist to the Roosevelt Hospital, New York, recently published an excellent work which he calls, "The Art of Anaesthesia,"
which title we think exceptionalh' apt, as the administration of anaesthetics
is fast taking its legitimate place as a specialty in the practice of medicine.
Let us briefly consider some of the essentials an anaesthetist should
possess in order to assume a safe and sane administration:
1. He should be familiar with the anatomy and physiology of the Respiratory and Cardio Vascular System;
2. He should know something about physical diagnoses, particularly as
they refer to the Respiratory Cardio Vascular and Renal Systems;
3. He should be able to recognize condition of Shock, Haemorrhage and
Asphyxia;
4. He should have some idea of the physical properties of the different
anaesthetics.
107 For these reasons, and with the belief that the administration of anaesthesia belongs to the practice of medicine, this hospital does not feel
that nurse anaesthetists are at present desirable. Of course, we realize that
in smaller centres it is sometimes impossible to secure the services of
a medical man to give the anaesthetic; under these circumstances, the operator must assume full responsibility.
A glance at some of the clauses in the coroner's catechism of England will convince one of the necessity of a medical man anaesthetist in
case death should result from the anaesthetic, as here the whole responsibility is placed upon the administrator, and not upon the surgeon. Of the
twenty-one questions all are of this nature:
What was the condition of the heart, lungs and kidneys prior to
the administration of the anaesthetic?
What influenced you in your choice of anaesthetic?
How.much time did you take to induce Anaesthesia?
Was the induction period hurried, and if so, for what reason?
The general anaesthetic of choice universally employed at present is
ether.
In this hospital, ether is administered in the great majority of cases by
the open method, and I think from experience it has proven the most satisfactory. In conjunction with ether we almost invariably use a starter
of ethyl chloride. This latter anaesthetic we find an extremely nice way of
starting—5 to 10 cc. are used by the drop method (and not pushed). The
loss of consciousness is rapid and there is little evidence, or not at all if
properly given, of a suffocation sensation. Ethyl chloride we sometimes
use for such short operations as myringotomy, extraction of teeth, opening
abscess, etc.
Another method in which we use ether is the junker—a very simple
apparatus. The ether vapor is introduced into the pharynx by means of
a catheter through the nose, and air pumped through the ether by a hand
or foot bellows. This is a particularly desirable method in tonsil operations and has gained universal commendation by operators. The main
points to be noted are:
1. The patient should be well induced before the junker is started, as
a concentrated vapor will produce coughing and gagging.
2. Sufficient air should be allowed to pass through the air passages. We
also use this method in operations about the head and neck, where the
anaesthetist might be in the operator's way.
We do not possess an expensive intratracheal apparatus, but find we
can get along very well without it by using the junker.
In regard to ether. It is probable that contraindications of its use are
not so numerous as formerly believed, and in my experience ether pneumonia is extremely rare. Some have even advised ether in the treatment of
pulmonary tuberculosis.
As a preliminary medication with adults in ether cases we use as a
routine, morphia grs. 1-6, atrophin grs. 1-150 by htpo., half an hour before operation. I am very fond of this procedure as it brings the patient
to the operating room in a composed state of mind; this combined with
a little reassurance from the administrator, has a great deal to do with
the smoothness of the anaesthetic, the struggling period is considerably
lessened, and in some cases hardly noticeable. There is practically no
trouble with mucous, and the breathing in the majority of cases is quiet.
Chloroform with us is used sparingly and only in cases where there is
some pulmonary indications, or where the patient has been very sick following some ether anaesthetic and there is no contraindication to its use.
Chloroform and ether we use fairly frequently, equal parts, some times
as a starter when ether chloride is unobtainable, and frequently when there
has been a history of bronchitis. We find that large muscular people,
plethorics and alcoholics do well on this mixture; it should always be administered by the drop method on an open mask.
108 Nitros Oxide and Oxygen.
For the past few years we have administered nitros oxide and oxygen
in a great number of cases, and often mixed with ether. In selected cases it
is an ideal anaesthetic. It can be given to all ages, and we have used it
for from a few minutes to three hours. Recovery is very rapid. It is very
refreshing to remove the mask and have complete consciousness in about
sixty seconds. We find this an admirable anaesthetic in all chest cases
either pulmonary or pleural, where ether is contraindicated, in conditions
where shock, toxaemia or failing of circulation is evident, and in mastoids.
With this apparatus oxygen is always at hand and can be administered if
necessary. We frequently use nitros oxide oxygen with ether when relaxation is required. This anaesthetic should only be administered by
trained anaesthetists. The patient requires constant attention, and with
these conditions the anaesthetic is very safe. The morphine and atropin
preliminary is here used three-quarters of an hour before operation. If the
patient is muscular, morphia grs. 1-4, atropin grs. 1-100.
Spinal Anaesthetics.
We owe all our findings in spinal anaesthesia in this institution to Dr.
Riggs, who has successfully used it in hernias, hydroceoles, varicocles, varicose veins, amputation of the lower extremities, etc. Stovaine 5% and glucose 5% is used. The patient's head should be raised and the puncture is
made in the region corresponding to the nerve supply of the part to be
operated upon. Blood pressure is always taken during the operation, as
this is the important point. It is almost invariably lowered. We formerly gave drinks of hot coffee and other stimulants such as strychnine,
camphor, etc. The stimulant which we found most valuable is adrenalin
MX., hypodermically, and this has invariably brought about the desired
leaction. Probably we have not had sufficient experience to speak with
authority concerning spinal anaesthesia, but the theory of the thing is
that shock is prevented by nerve blocking.
Stimulants.
The stimulants which we find of most use upon the operating table
is normal saline given either intravenously or subcutaneously. An intelligent use of saline puts the hypodermic needle in the discard. We do not
find very frequent necessity for stimulation, but when stimulants are required, then intelligent use will often save the life of a patient. A very
favorite method with us, when the operation is to be prolonged, when there
will undoubtedly be considerable shock as in bowel resection, partial gastrectomy, amputations, etc., is to start an interstitial saline as soon as the
patient is under the anaesthetic. The needles are introduced through the
pectoral muscles into the axillae and saline allowed to flow at about the
rate of twenty ounces to the hour. In this way fluids are introduced before shock is present and according to the theory of shock, enough fluid
is present in the body to take the place of that which is carried to the
splanchnic area. In these major operations with interstitial saline we frequently see no evidence of shock at all during the operation. The patient
leaves the table in as good or better condition than when he appeared before operation. Shock may develop later and salines should again be
given. If it is evident that saline is needed at once, an intravenous should
immediately be given.
Carrying a Patient Through an Anaesthetic.
You are all familiar with the stages of anaesthesia, such as loss of
consciousness, struggling, surgical anaesthesia, etc., also pupillary signs.
While these are very essential in the teaching of anaesthetics, yet it is my
belief that the more experience one has in the administration, the farther
these fall into the background. Anaesthesia resolves itself into induction
and maintenance and that maintenance to be light, medium or deep according
to the nature and stage of the operation. For instance, exploring the abdomen requires deep anaesthesia, bowel suturing, medium, and suturing of
the peritoneum, deep anaesthesia again.
109 Induction.
The induction should commence by (1) gaining the confidence of the
patient by reassuring words and manner, a quiet room with pleasant surroundings, preferably away from the actual operating room. (2) The administration should at first be slow; this assures against suffocation. When
this stage is past, the anaesthetic can be pushed to the surgical stage, or
stage of maintenance.
When the neck is short, the patient muscular, the chin receding and
hard to hold forward, a rubber tube or Connell's metal tube introduced
to pharynx will often produce an even and unobstructed breathing. The
mouth gag^and tongue forceps habit is a pernicious one and is in most cases
extremely unnecessary.
It is hard to explain what makes a good anaesthetist. Any amount of
teaching will not make some men good anaesthetists, while others grasp
the art very quickly. For this reason, it is an art, and the artist finds it
difficult to teach this to another. He does not lay too much stress upon the
pupillary signs, nor is he continually watching the respiration, but he is
in constant touch with the patient and guides him through a difficult storm
as a pilot through a perilous sea. There seems to be something in merely
being in touch with the patient which enables him to anticipate trouble and
apply the necessary treatment 'ere it is too late.
DISCUSSION.
MR. GRIMMETT—
The last two papers are highly technical to us who are not nurses or
doctors. You mentioned that the last speaker was an expert. I would like
to put an adjective before that word—I would like to call him a "poetical
expert." The manner in which he has expressed himself has been highly
attractive. I don't think my attention wandered for one moment listening
to this paper. Perhaps the paper preceding was more practical to some of
us, perhaps more useful to outlying districts—Infectious Diseases and the
control of same. In small places where we just have the one building, the
question of isolation is a difficult one, and I was pleased to hear Dr. Carder
say that it was possible to isolate these people by means of private wards.
I can assure you that I am highly benefited by both of these papers.
DR. FEWSTER—
What measure is usually taken with reference to that form of poisoning which we sometimes see following the use of chloroform?
DR. LENNIE—
We do not use chloroform very much, but we do have to deal with
acidosis. We make a routine examination of the urine prior to the anaesthetic. This report is found in the operating room half an hour before we
commence the operation, which shows if there is any sugar or acetone in
the urine. If it is absolutely necessary to give an anaesthetic we prefer to
use gas.
DR.  FEWSTER—
I think possibly that the term "ether pneumonia" is a misnomer.   Pneumonia that develops after an operation very often is due to other causes
than the anaesthetic.
DR.  LENNIE—
In the Vancouver General Hospital we are fortunate that we have the
means of heating the blankets while the operation is proceeding.
MISS  AITCHISON—
I would like to ask Dr. Lennie if he uses the A.C.E. Mixture.
DR.  LENNIE—
No, we don't use it.   In mixing the three things, alcohol, chloroform
and either in different amounts, it is hard to tell how much of each you
are giving.
MISS AITCHISON—
In Summerland it often falls to my lot to give anaesthetics, and I use
the A.C.E. Mixture.
110 MR.  BANFIELD—
I will now call on Mr. E. Hall. Pharmacist to the Vancouver General
Hospital, for his paper, "The Hospital Pharmacy."
"THE  HOSPITAL   PHARMACY."
By Mr. E. Hall, Pharmacist to the Vancouver General Hospital.
In this paper we shall confine our discussion to the institution which is
not sufficiently large to employ the services of a dispenser continuously.
Experience has shown that the following points must be considered essential in conducting a well equipped or well managed pharmacy:
1. Your stock; its arrangment and storage.
2. The dispensing of extemporaneous prescriptions, and the manufacturing of stock prescriptions, stock solutions and galenicals.
3. Your buying.
4. Economy in all matters.
In public and private institutions we all strive to the same end and
to the same extent as a commercial enterprise; at all times, therefore, at
the outset make provision for expansion, as the proper arrangement of
your stock depends largely on available space. To this end it might be
suggested that when having your pharmacy designed, the services of a
pharmacist be sought. One having experience in this branch of your service
might in all probability make suggestions which would save time and trouble,
and expense in proportion.
In regard to the storage of your goods, your pharmacy must of necessity be kept cool and dry—drugs and sundries alike are less apt to deteriorate, and working conditions are much more pleasant.
From a professional standpoint, your dispensary and its work are second
to none in importance of any department of your institution. The dispensing must be performed accurately and with pure drugs and chemicals,
if the confidence of your physicians is to be maintained and therapeutic
results obtained.   This also applies to manufacturing of all descriptions.
In the case of all hospitals, large or small, much may be said in favor
of a hospital pharmacopoea.    It serves two important purposes, viz.:
1. The elimination of much wasted material.
2. The economy of labor by elimination of numerous extemporaneous
prescriptions.
No doubt, it also gently leads the physician from the path of proprietary
and patent medicine prescribing, which path is easily trod in pleasant dispensaries where the dispenser is unknown. I have no doubt but that the
Superintendent of the Vancouver General Hospital would be pleased to supply to those who desire it, a copy of the pharmacopeoa—a book which has
undoubtedly been proven to be a success in regard to the above mentioned points, as well as pleasing to the physician who has made use of it.
Your dispensary, as in other departments, can be the source of unlimited waste if proper check is not kept on your stock. This is true from
the time the orders are given till they are used in whatever form necessary
by the institution. The buying of your drugs and sundries needs the
same careful consideration as to price and quality as does your surgical
instruments or edibles. These are two methods usually followed in buying:
in the first place, you can give your order without comparison of prices, for
one hundred dollars worth of goods; or in the second place, you buy the
same goods, the same quantity and the same quality for eighty-five dollars. This branch of our work is too extensive to go into detail, suffice to
say that to buy right a great deal of time and attention is necessary to
thoroughly understand conditions which effect the source of supply, which
in turn effects the price. Competition and manipulation are causes also
to be considered.
The following rules may govern to some extent your buying:
Buy as lightly as possible without allowing your stock to run too low.
(Let the wholesale house carry your stock.)
Do not allow the salesman to stock you with what you do not need or
more than you need for a definite period; determined, of course, by con-
Ill ditions such as the available supply, the distance you are removed from your
dealer, etc.
During the present strenuous conditions more than usual attention to
these matters is necessary.
If you will consider the four points which I have here tried to present as
concisely as possible, you will perhaps understand more fully the advantages of a pharmacist to your work. If you will permit, I would suggest
that any hospital of one hundred beds or more, could quite profitably entertain the advisability of having a dispenser on the staff.
In the case of smaller institutions, consider the advisability of having
your buying done by some one experienced in the work, on a salary or margin basis. If you have a druggist in your vicinity, you might profitably
arrange to have your stock prescriptions and stock solutions manufactured
on the premises, or arrange with him for your supply, the alternative being
your wholesaler.
ROUND  TABLE  CONFERENCE.
MR. J. J. BANFIELD—
You have all had in your possession a questionaire of thirty-six questions. These have been left in the hands of Mr. Mordy whom I am going
to ask to conduct this Conference.
MR. MORDY—
Our committee appointed took charge of these questions and have
grouped them into the various classes:
Organization—7, 10, 11, 12, 13, 15, 23, 36.
Administration—5, 6, 16, 19, 26, 28, 29, 31, 32, 33, 34.
Medical—14, 17.
Nursing—20, 21, 24, 30.
Public Health—1, 9, 18, 22, 25, 27, 35.
Financial—2, 3, 4, 8.
We have arranged with certain members of the Convention to be prepared to speak on each of these, but I am afraid we cannot cover them all.
However, what we cannot finish today, we'll make further arrangements
about.
Organization—7, 10, 11, 12, 13, 15, 23, 36.
MR.   GRAHAM—
Organization is the main thing in running a hospital or in business, but
I am not going to deal with the question of organization itself, for each
hospital represented here must have their own organization suitable to the
institution in question. We will, therefore, take the questions as they
come.
Question 7—"Government or City rest rooms in a private hospital in a
town of four thousand five hundred, where there are no rest rooms in connection with the stores or the Y.W.CA."
The opinion of the committee is that the hospital is not the place for
a public rest room, and under no consideration should it be connected with
the hospital.
Question 10—"What suggestions or advice would you give for the removal of prejudice against a privately owned hospital which is in need
of home support?"
We are rather doubtful as towhat is meant by "home support." We presume this means keeping patients from going to other hospitals. Let the
people know what the hospital is doing, and what it is capable of doing.
Give it a full line of publicity.
MRS. CURRIE—
Whoever owns a hospital, finds it is her daily bread, and she must
have a doctor or certain doctors favoring it. Through them the public
could be educated to know that the hospital was worth while sending their
patients to.
112 DR.   MacEACHERN—
We have* In Vancouver a few very successful private hospitals and one
of the most popular hospitals in the city is the    Bute Street," under the
able management of our good friend, Mrs. M. E. Johnson.   Therefore, I
think Mr. Chairman, she could answer this question best of all.
MRS. JOHNSON—
I try to send all my patients home satisfied, making sure they have been
comfortably and well taken care of, and also well fed.   Then they will tell
somebody else about it.
DR.  MacEACHERN—
The solution to this question is the personal element of the hospital td
a great extent, the personality of the superinendent and staff, who show to
the patient kindness, sympathy and careful attention. Mr. Somerville's
paper covers this point on publicity, and Mrs. Johnson has sounded the
key note.
Questions 11, 12, 13—"The organization of a cottage hospital," "The
raising of funds for the management of a cottage hospital," "A practical
layout for a cottage hospital."
MR. GRAHAM—
These questions all have bearing on the cottage hospital. Any discussion?
DR.  MacEACHERN—
Mr. Chairman, these questions were to have been answered by two of
our delegates who are running cottage hospitals, viz:  Mrs. Schultz of North
Vancouver and Mrs. Newton of the Grandview Cottage Hospital.   I do not
think either of these ladies are present.
MR.  GRAHAM—
If there is no discussion on these questions, I'll pass on to the next.
Question 15—-"Hospital Propoganda."
I do not think we can deal any more effectually with this than refer
the delegates to Mr. Somerville's paper on "Publicity Work" in hospitals.
We will now pass on to the next.
Question 23—"Isolation hospitals for small centres to be established by
the Government."
The committee thinks that the Government should be called on to establish isolation hospitals in small centres, that is, not to serve any particular small town, but to serve a district such as referred to in Dr. Young's
paper the other night. If it is just a question of transportation, it is not a
very difficult matter to move a patient quite a few miles; it can be defflC
in a very short time. The committee Was of the opinion that this Convention ought to pass a resolution calling on the Government to furnish
isolation hospitals in the rural districts of the Province and the municipalities
to either furnish them or compel the rmifiicipalitie's to furnish isolation hospitals;
MR.   MORDY—
The point is that the Government should be asked to furnish isolation
hospitals. I would like to ask Dr. Yo'Ung What power or means there is
of preventing the carrying of infectious diseases by a community such as
a Chinese section from their homes when they are tJfeen to a hospital for
some other reason, such as a fracture or sickhesS which is not of an infectious nature* arid whether there are any QoVeffifti'litt mle"S or regulations
governing the inspection of such districts which are very thickly populated
and are not in the very best sanitary condition.
DR. YOUNG—
In regard to the carrying of infectious diseases by patients being brought
in, that is something that we cannot safeguard agairist Dr. Carder referred
to all that in his paper. If there is an epidemic in the community or probably in the house from which the patietit comes, doctors would take every
precaution.
As regards the Chinamen being brought to the hospitals—this question of the Chinese quarters in each town in British Columbia is really a"
good deal of a public one. In going over the situation I do not see that you
113 can lay at the door of the Chinamen any more cause for the spread of
infectious diseases than you can against the uneducated whites. It is quite
true that the sanitary conditions of Chinatown are very low. They are
accustomed to living in a different manner than we do, but if you will
go carefully over the statistics of the infectious diseases in British Columbia,
you will be very much surprised indeed to find how very few cases of infectious diseases you will find in Chinatown.
The supervision of these quarters is in charge of the local Health Officers in Vancouver and the same in Victoria. I have never had from Dr.
Underhill or Dr. Price of Victoria any complaint in particular as regards
these places. It is to be regretted, of course, that their gathering together in the way they do is in our opinion a possible source of infection,
as in our view the conditions existing would be favorable to the development of infectious diseases.
The handling of these cases in regard to hospitals and isolation hospitals is one that is in the making in British Columbia. The Government
heretofore has assisted at some places in the establishment of hospitals, but
in the small community the question of an isolated hospital is one of very
difficult solution. It may not have a call for a year or two; on the other
hand, you don't know the minute, especially in a moving population such
as we have in a new country, when you may have to use it. The building
is supposed to be always ready to receive a patient. Those in charge of
hospitals know what that means. You have to have the whole equipment ready, to have the nurses to take complete charge, to discontinue all
their other work. In small places we cannot do it. The suggestion which.
I made a few years ago and which I endeavored to carry out, of building
isolation hospitals, was begun in the Province, but unfortunately, like vaccination, there is nothing done when no one is sick. If the hospitals can be
placed at any point, taking into view proper distribution of population, then
L think this Convention could very advisably submit this scheme to the
Government. At the same time (I am not speaking for the Government, but
speaking as a medical man), I believe the suggestion might be entertained.
At the same time, a suggestion of that kind would be entertained much more
favorably by the authorities if it were supported by the fact that the municipalities would also lend their assistance.
As regards the maintenance. An isolation hospital was built in Victoria, and one of the terms that I made with the authorities in Victoria
was: A patient coming from the unorganized districts, the Government
would pay, but that that hospital was obliged to receive them, though it
was immediately under the care of the Jubilee Hospital. The maintenance
for these patients from outside of the city was paid by the Government,
and from other municipalities, of course, charged as against that municipality. The question of maintenance might be threshed out with the
Government and a per capita allowance granted on the same basis as the
per capita allowed in public wards.
We have been very fortunate in the last few years in escaping many
epidemics. Look at the situation—the boundary line to the South of us and
che seacoast to the West—these are the chief causes of epidemics. The
United States authorities freely admit that their people are not very strict
about carrying out rules. I think those connected with hospitals should
bring more forcibly before the Government the necessity of looking out
for these cases. If we are going to insist on quarantine for all infectious
diseases, then we have got to provide the means for carrying out the enforcement we insist upon.. This should come from those representing hospitals.
Moved by Mr. Mordy, seconded by Dr. Rogers:
THAT this Convention call on the Provincial Government to furnish
isolation hospitals in rural _ districts and to provide for the maintenance,
also to compel municipalities to maintain them in their particular district.
Resolution Carried.
114 MR. GRAHAM—
In connection with the expense, if the Government carries out this resolution the Province would be put to an enormous expense. Why not build
collapsible hospitals, moving them from district to district as the disease
might appear?
DR.   FEWSTER—
I How are you going to make the people in the outside districts send
their loved ones to these isolation hospitals? If we are going to build our
isolation hospitals there should be some means by which home ties will
not be entirely severed. It is the case of the protection of the community
infringing on the sanctity of the home. I know perhaps that I have not
the sympathy of this Convention with me. If a child is taken sick, better
to die in a house even if their loved' ones die with it, than have it go to
another place where it would be left alone. I have always felt very strongly
on this isolation question. Isolation hospitals are usually very badly administered.
DR.   MacEACHERN—
We have got to get in this Province up-to-date infectious hospitals. If
you want to see an isolation hospital where you can converse with friends,
see the smallpox hospital of the City of Vancouver. Often patients come
in to our isolation hospitals dying, simply because they were prejudiced
against isolation hospitals. There is the life of the child on one hand and
the separation from home on the other. In my opinion, the life of the child
should come first.
DR.   MULLIN—
Every case is not predestined to die. It seems to me that if the sympathetic manner of treating patients is going to be carried out in the future
as it has been done too much in the past, that we will never get to the
point. There is too much sympathetic treatment extended to the families and not enough to the community. I think that the attitude of the
community, which has been expressed by the last speaker, is due entirely
to the fact that in the past cases of infectious diseases were taken to a
hospital which was temporarily arranged and temporarily equipped and
temporarily staffed. The nurse in charge very often is not a trained nurse
and possibly the doctor attending doesn't visit his patient as often as he
might have done. I think it is a rare instance in these days for infectious
cases to die unless the epidemic is a very severe one. Eradicate this idea
that all infectious cases are fatal. The only way is by building a hospital
which will be an up-to-date institution with an up-to-date staff. Arrange
to have a nurse go from a general hospital to attend.
MR. MORDY—
When I came to Vancouver I was to have been met by my eldest son.
The first word that I got was that he was laid up in bed. The first thing
that I did was to get a doctor. He diagnosed the case as "measles." I sent
him to the Vancouver General Hospital. I don't see why there should be
any objection to an isolation hospital.
DR.  MULLIN—
All of these infectious diseases are not individual diseases, they are
communicable diseases, that is, if a case of infectious disease occurs it is
not that household alone which is affected, it is every individual. The
rights of that household must be superseded by the rights of a community
as a whole.
DR. MacEACHERN—
One suggestion—to get over the objections raised by Dr. Fewster, put
in a telephone and let the extension be long enough to allow the patient
to speak to the people at home and everybody will be happy.
MR. BENZIE—
The isolataion hospital is somewhat costly, owing to necessary arrangements. A proper cottage hospital arranged to hold five or ten cases would
cost about $10,000.00. The plan shown yesterday could be used or elaborated for any of the ordinary small hospitals.
115 MR.  GRAHAM—
Coming now to Number 36:
Question 36—"The value of a central information bureau for all hospitals in British Columbia."
This is a splendid suggestion.   We need it, as we are all going back
to improve and develop our hospitals.   There is information we will want.
DR. MacEACHERN—
So far as we can, I am sure we'll be glad to give any information, advice or assistance to any hospital in British Columbia at any time. Write
me any time. If I haven't got the information, I'll try and secure it as soon
as possible. s
MR.  GRAHAM—
This ends our first series of questions. We will now take up those
classified as Administration or Management.
Question 5—(Answered in Round Table Conference Wednesday afternoon.)
Question 6—(Answered in discussion following Miss McKenzie's paper
on Wednesday afternoon.    See Mr. Wilke's discussion.)
r    Question 16—"What is the best way to deal with old soft wood floors
that are very worn and splintered, and walls cracked and soiled?"
MR. BENZIE—
You may "scrape" or "plane surface" of floor either by hand or by
electric planing machine—if the floors are not too badly destroyed. Possibly, it would be necessary to lay a new floor. Some have covered such
a floor with a filler and linoleum. The cracks in the wall can be filled
with plaster and painted.
Question 19—"What is found the best way of regulating the diet in a
small hospital, and is a dietitian or a practical housekeeper found the most
economical and efficient?"
MRS. M. E. JOHNSON—
In regard to the dietitian or practical housekeeper, in my own hospital I have been very fortunate in having my sister. I think in the sipall
hospital a housekeeper would be more practical than a dietitian and the
most efficient. In large hospitals, as the Vancouver General Hospital, the
dietitian is necessary.
Question 26—"Annual Reports for Hospitals."
MR. COOE—
Annual reports are of very great importance as far as the hospital is
concerned. We have had several remarks from different spurces on the
value of publicity. I think that the value of publicity to a hospital, either
large or small, can hardly be exaggerated. I think it would be well that the
different details that the hospital has to deal with in every year, from the
financial standpoint, should be adequately put forth in an annual report
in such a way that the public can see at once our source of supply or income,
the annual expense that we are up against, the actual income received and
the actual disbursements; and there is also another thing frequently overlooked in the small hospital, that is, a valuation of the hospital, its plant,
furniture and all accessories, with a proper amount allowed for depreciation. I think that the annual report should be made out in intelligent
form and published regularly.
MR. GRAHAM—
We will now pass on to Number 28.
Question 28—"The Hospital and Aesthetics."
DR.  MacEACHERN—
Every hospital should pay particular attention to the color scheme and
decoration of their hospital. Remember the sick patient lying there all
day. Make it as easy as possible on the eye, and pleasing. Add to your
wards and rooms such features as will make them more homelike. Careful study should be .given the color scheme throughout. In the hospital
here we use light tints, as many of the days are very dark.
116 MR. GRAHAM—
We now come to the next question.
Question 29—"Local buying at a loss."
DR.   MacEACHERN—
Naturally, we should patronize home dealers, and they have to charge
more. You will recall Mr. Leders' paper where he emphasized two things—
Standardization, Centralization. If our local dealers knew they were handling a standard line and one not likely to change, then they could give us
a better price.   Let us work to the principles involved in that paper.
MR.  GRAHAM—
Passing on now to,
Question 31—"The best way to deal with cockroaches."
MR.  MORDY—
Use Keating*s Insect Powder.   Use rhubarb leaves around the room.
DR. MacEACHERN—
Get rid of old wooden floors.   Cement, Terrazo or tile instead.
MR.  GRAHAM—
Question 32—"A standard list of furniture for private room."
DR.   MacEACHERN—
One bed with back rest One easy chair
One  mattress One plain  chair
Two pillows One  reading lamp
One bedside table Two floor mats
One washstand One toilet set
One dresser Window shade, hangings, etc.
One wardrobe For linen, see standard in Mr.
One  rocker Leder's paper.
MR.  GRAHAM—
Question 33—"Should all hospitals keep medical records?"
DR.  MacEACHERN—
All hospital should keep medical records, no matter what the nature
of the hospital is.    In small hospitals this can be done as well as large.
MR.  MORDY—
I desire to move the following resolution:
"THAT this Convention fully believe they' should keep accurate and
systematic medical records in their hospitals, and that they ask the Executive Committee to draw up standard forms of reports which shall
be suitable for all the hospitals in British Columbia, and that these be
standard."
DR.  MacEACHERN—
I have much pleasure in seconding the resolution.
MR.  BANFIELD—
I declare the motion carried.
MR.   GRAHAM—
Coming now to
Question 34—"How to make green soap."
Can anyone answer this?
DR.  MacEACHERN—
The following is the answer: Take one pound caustic potash to four
pounds of raw linseed oil and add enough chlorophyl to give it a greenish shade. Place the caustic potash in a vessel, p<?ur over it enough water
to cover and boil until all dissolved. Then pour in your oil and chlorophyl.
Boil slowly until it becomes soap, then add sufficient water at times until
vessel is filled. The longer the material is boiling the better the soap. Be
very careful not to add any more water to material other than dissolving
potash before you get soap or your material is wasted.
MR.   GRAHAM—
This ends our second series of questions.
117 DR.  MacEACHERN—
Mr. Chairman, the morning is now well spent and we have to leave for
New Westminster at 2:00 p.m. Therefore, I fear we will have to drop our
questionaire and take up the business which is yet unfinished. I would
suggest that these questions be gone into later and answers sent to the
various hospitals.
MR.   BANFIELD—
I will therefore declare the discussion closed and we will proceed with
the unfinished business.
MR.   GRIMMETT—
Owing to the foresight of Dr. MacEachern, our duties have been very
light. We found prepared for us a draft of Constitution and By-laws, which
have been altered very slightly. I have much pleasure in presenting this
report.
CONSTITUTION and BY - LAWS
—for—
THE   B. C.   HOSPITAL   ASSOCIATION.
C. Hospital Association.'
Article 1.—Name.
The name of this Association shall be "The B.
Article 2.—Purpose.
It shall be the purpose of this organization:
(a) To serve as a means of intercommunication and co-operation between the hospitals in British Columbia,
(b) To establish, maintain and improve standards of hospital work.
(c) To promote the efficiency of all hospitals in the Province,
(d) To stimulate intensive and extensive hospital development,
(e) To make all hospitals of more community service.
Article 3.—Officers.
The officers shall be:
Honorary President,
President,
Vice-Presidents,
Secretary,
Treasurer,
Executive Committee of Ten.
Article 4.—Membership.
The members shall be all persons connected directly or indirectly with
hospitals paying the membership fees hereinafter mentioned, and such members shall be classified as follows:
(a) Active,
(b) Associate,
(c) Honorary,
(a) "Active" members shall include all who are actively engaged in
hospital work, and this means on the regular staff of the hospital.
(b) "Associate" members shall include all who are engaged in hospital work but are not on the regular staff, and shall include attending doctors, nurses, members of trustee boards and hospital
auxiliaries,
(c) "Honorary" members. Active honorary members shall be the active
and associate members who have ceased to take an active part in
hospital work after years of faithful and recognized service.
Article 5.—Election of Officers.
This shall take place at the annual meeting each year, and shall be by
ballot.   All officers shall be elected for a term of one year.
118 Article 6.—Executive Committee.
The Executive Committee shall be composed of the officers and ten
other members, elected from the Association at the annual meeting.
Article 7.—Quorum.
Five members shall constitute a quorum of the Executive Committee,
which shall meet at least once a year, and at other times at the call of
the chairman or any five members. Ten per cent, of the members shall
constitute a quorum of the whole Association. The Executive Committee
shall carry on the affairs of the Association during the year and report to
the Association at the annual meeting.
Article 8.—Meetings, Time and Place.
The annual meeting of the Association shall be held at the time of the
Hospital Convention, notice of which shall be sent out to each member
one month in advance. The place at which the annual meeting and convention shall be held will be decided on at the annual meeting or convention
of the previous year.
Article 9.—Amendment to By-laws.
By-laws may be amended at any regular meeting by a two-thirds vote
of members present.
Article 10.—Recommendations.
All recommendations and suggestions must be sent in in writing to the
Secretary  of  the  Association,   who   shall   lay   same   before   the   Executive for discussion and    consideration previous to the annual meeting of
each year.
Article 11.—Membership Fees.
All hospitals paying the following fees shall be entitled to membership
in this Association :
1. Hospitals of 10 beds or under, $5.00 per annum,
2. Hospitals of ten to twenty beds, $10.00 per annum.
3. Hospitals of twenty to fifty beds, $15.00 per annum,
4. Hospitals of fifty to one hundred beds, $20.00 per annum,
5. Hospitals over one hundred beds, $25.00 per annum.
DATED at Vancouver, B. C, this twenty-eighth day of June, A.D. 19i8.
(Each By-law was taken up separately and voted upon.)
DR.   GATEWOOD—
I beg to move that the Constitution  and By-laws  be adopted  as  a
whole.
MR. GRAHAM—
I second that motion.
MRS. J. D. BROOM—
I think there should be an individual membership for such people as
are not attached to  any particular hospital but interested  in them.   Of
course, we understand that the hospital membership may include a great
many.
DR. MacEACHERN—
I would like to move an amendment to the Constitution and By-laws to
be added to Article 11 in regard to membership fees.   This motion is: "That
individual membership be obtained on paying a fee of Two Dollars per
year." '
MR.   MORDY—
I have much pleasure in seconding that.
The amended Constitution and By-laws—Carried.
MR. BANFIELD—
The next order of business is the election of officers.
DR. MacEACHERN—
I would like to move that the same Committee as drafted the Constitution and Bylaws draft a slate of officers.
119 DR. WHITING—
I second that motion.
MR. BANFIELD—
Is there any further business to take up while the Committee is out?
I think Dr. MacEachern wants to make some announcements.
(At this juncture Dr. MacEachern explained the arrangements made
for the afternoon trip to New Westminster and the Colony Farm.)
MR. BANFIELD—
I will ask the Committee for their slate of officers for the coming year.
MR. GRIMMETT—
I have much pleasure in submitting the following slate:
LIST OF OFFICERS
of
"THE B. C. HOSPITAL ASSOCIATION"
for
THE FIRST YEAR.
Honorary President Hon. J. D. McLean, Victoria
President Dr. M. T. MacEachern, Vancouver
1st Vice-President Mr. R. S. Day, Victoria
2nd Vice-President Mayor Gray, New Westminster
Secretary Mrs. M. E. Johnson, Vancouver
Treasurer Dr. C. H. Gatewood, Vancouver
Executive Committee:
Dr. F. X. McPhillips, Vancouver Mr. M. I,. Grimmett, Merritt
Miss M. McMillan, Nanaimo Mr. D. G. Stewart, Prince Rupert
Mr. C. Graham, Cumberland Dr. H. C. Wrinch, Hazelton
Miss L. S. Gray, Chilliwack Miss B. E. Langley, Fernie
Miss Pitblado, Kamloops Miss H. Campbell, Vernon
MR. GRAHAM—
I move that this list of officers for the coming year be adopted.
DR. GATEWOOD—
I second the motion.
MR. BANFIELD—
(After putting the motion.)    I declare these officers elected.
On behalf of the Convention, I beg to extend to Mr. Grimmett and his
Committee their hearty thanks for the good work done.
DR. MacEACHERN—
I beg to move that Victoria be selected as the place for holding the next
Convention.
DR. GATEWOOD—
I have much pleasure in seconding that.
MR. BANFIELD—
(After putting motion.)   I declare the motion carried.
MR. GRIMMETT—
Mr.  Chairman,  I  have very much pleasure in moving the following
resolution:
"That the very heartiest thanks of this Association be tendered
Dr. M. T. MacEachern, the Board of Directors of The Vancouver
General Hospital, the Staff of The Vancouver General Hospital, the
ladies and gentlemen who furnished their cars for our entertainment,
including also the cars for this afternoon, and the University for the
use of the Convention Hall."
MR. MORDY—
I have great pleasure indeed in seconding this resolution.
MR. BANFIELD—
(After putting motion.)    I  declare the motion  carried, and our new
Secretary will see that a letter of thanks is sent on to each.
120 PR. MacEACHERN—
It gives me great pleasure to move a most hearty vote of thanks to the
Press representatives here who have so ably, so enthusiastically, given
publicity to our proceedings. The Press of the city always do things right
MB- GRAHAM—
I have much pleasure in seconding Dr. MacEachern's motion.
MR. BANFIELD—
(After putting motion.)   I declare the motion carried, and our Secretary
will act accordingly.
MR. MORDY—
Permit me to move another vote of thanks, and that is—to Dr. Gate-
wood,  Chairman  of the  Convention;   Miss   MeKenzie,   Secretary  of  the
Convention;  and to all who gave papers, addresses, and took part.
MR. GRAHAM—
I have much pleasure indeed in seconding that motion.
MR. BANFIELD—
(After putting motion.)    I declare the motion carried.
DR. GATEWOOD—
On behalf of the Directors of The Vancouver General Hospital, I am
sure we feel admirably repaid in the splendid and enthusiastic manner in
which you have responded and helped to make this Convention a success.
Anything the Board of Directors of The Vancouver General Hospital has
done, I assure you, has been a great pleasure. •
MR. BANFIELD—
As a citizen of Vancouver, I can assure you that your coming here and
taking part in the Hospital Convention has been greatly appreciated. Without your presence the Convention would not have been the success it is,
and, besides, we have met many fascinating ladies and clever gentlemen,
and we can say the Hospital Convention has been the means of bringing
those together. It has been very gratifying to the citizens of Vancouver,
and on their behalf I thank you for your attendance, and I hope we shall
see you other years and we will be glad to meet you all again.
MRS. JOHNSON—
On behalf of the Graduate Nurses' Association I want to say a few
words. We have scarcely had a chance to welcome the visiting nurses—our
programme was so full we have been unable to arrange it. However, I
shall be glad to meet any who have time, at the Bute Street Hospital, this
afternoon or tomorrow.
DR. MacEACHERN—
I want to thank you most sincerely for the great favor you have conferred on me in electing me first President of The B. C. Hospital Association. This has come to me rather suddenly and so. I am not prepared to
make a speech, but will defer same till we meet in Victoria next year.
However, I must say that it has been the greatest pleasure that I have had
in connection with anything—this Convention. There has been a splendid
response to our few letters sent out. What pleases me and delights me is
not alone because we have had a large number of doctors and nurses present,
but that we have had a large attendance of lay people, men and women in
business and various walks of life, who have come here and taken the
greatest interest and entered into the most intelligent discussions that I
have ever heard on the different subjects. I have heard that one of the
largest international Hospital Associations was commenced with a mere
handful at their first few conventions, whereas ours started off with
approximately one hundred delegates. I was very pleased indeed to represent The Vancouver General Hospital at Cleveland last year, but this year
I will be more delighted to represent The British Columbia Hospital Association at the American Hospital Association at Atlantic City.
MR. BANFIELD—
This brings our proceedings to a close. You will meet in front of this
building at 2:00 p.m. to leave for New Westminster and Colony Farm. I
will therefore declare this Convention closed.
"God Save the King."
121 TRIP TO NEW WESTMINSTER, ROYAL COLUMBIAN HOSPITAL,
AND  TO  PROVINCIAL  MENTAL  HOSPITAL  AND
COLONY FARM AT ESSONDALE.
Some hundred delegates left the Auditorium at 2:00 p.m., Friday, June
28th, and had a very delightful drive. They first went to the Provincial
Mental Hospital at Essondale, where they were received by Assistant
Superintendents Drs. Crease and Ryan. They were escorted through this
magnificent and interesting institution. After this a visit was made to the
Colony Farm, where the visitors were shown about. The trip was delightfully interesting and delegates were loud in their praise of the hosts. Alter
this the visitors proceeded back to The Royal Columbian Hospital, where
they were hospitably received by His Worship Mayor Gray, Miss Sinclair,
Superintendent, and Staff, and a Committee of ladies. Afternoon tea was
served in the Board Room and then a very extensive tour of the institution
was made. This was of great interest to the delegates who took time to
make careful note of matters pertaining to equipment and administration.
After spending two extremely interesting and profitable hours the party
returned home most delighted with their afternoon.
Nurses' Graduation of The Vancouver General Hospital at 8:00 p.m.,
June 28th, 1918, was largely attended by a large number of delegates, being
invited guests of the occasion.
On Saturday, June 29th, the delegates remaining in town visited many
of the Vancouver hospitals.
EXHIBITS
Instruments and Hospital Supplies
By B. C. Stevens Co., Ltd., and Chandler & Fisher, Limited
Beds, Mattresses, Hospital Furniture
By Restmore Manufacturing Co., Ltd., and Alaska B. C. Bedding Co., Ltd.
Maternity and Surgical Belts
By Mrs. Foster
Hospital Paints
By Hunter-Henderson Paint Co., Ltd.
Soaps
By The Armour Soap Company
A most extensive and elaborate Exhibit of "home-made"
shown by the Vancouver General Hospital.
The Exhibits were of great value and interest to all.
appliances was
FINIS.
122   Th
13, 14,
1.
2.
3.
11.
12.
13.
14.
17.
20.
22.
24.
25.
30.
35.
e following questions remained unanswered—Nos. 1, 2, 3, 8,.9, 11, 12,
17, 20, 22, 24, 25, 30, 35:
Methods of fumigation and disinfection for rooms, clothing, ■ etc.
The petitioning of the Provincial Government to levy a hospital rate
for rural hospitals, on the same principle as rates now levied for
school taxes.
Compulsory uniform charges in all hospitals receiving Government
aid.
What amount of money would be required for the permanent or
yearly endowment of a bed in a hospital (the condition being a private hospital in a small city with outlying country towns).
All hospitals receiving Government aid are now required to take
in tubercular cases, incipient or advanced. Would it not be best to
have compulsory segregation of all, or, at least, advanced cases?
The organization of a Cottage Hospital.
The raising qf funds for the management of a Cottage Hospital.
A practical layout for a Cottage Hospital.
Should maternity cases have a separate building or wing, or should
they be all under one roof ?
What form of universal fracture treatment apparatus will be the
best for a hospital to acquire having in view modern frames for the
treatment of all kinds of fractures?
What is found to be the ideal way of running a hospital ward for
the first three hours in the morning, with reference to the duties of
nurse, orderly or ward nurse—washing, sweeping, cleaning, etc.?
What risk is run in admitting typhoid patients to the general ward,
and is it sufficiently great to warrant refusal to a case that has not
home facilities?
A short course of training in orderly work  (preferably returned
soldiers) in large hospitals for work in small hospitals.
Ventilation and location of lavatories and toilets in hospitals.
The special nurse and the diet kitchen.
The preventing of sepsis in the hospital wards.
123 OUT OF TOWN DELEGATES.
Name Representing Address
Miss Summerland Hospital Summerland, B. C.
A. M Chemainus Hospital Chemainus, B. C.
ss, Mrs. Mary Bass Maternity Hospital Victoria, B. C.
ittie, Miss  _ Military Hospital New Westmin
ster, B. C.
B.
Aitchison
Andrews,
Bass
Bea
Bent, Miss E ...Bent Sanatorium Cranbrook, B. C.
Broom, Mrs. J. D. D., R.N. M. H. M. H. Hanover, N. H.
Campbell, Mrs. H Vernon Hospital - Vernon, B. C.
Campbell, Miss J Victoria  Infirmary Glasgow, Scotland
Campbell, Miss K General Hospital Cumberland, B. C.
Clark, Mrs. W. A ..Local Council of Women—Merritt, B. C.
Cook, E. M Chemainus Hospital Chemainus, B. C.
Currie, Mrs. A. B Salmon Arm General
Hospital Salmon Arm, B. C.
Day, Robert S Provincial Jubilee HospitalVictoria, B. C.
Dobbs, Miss Mary E ..Royal Columbian Hospital-New Westminster,
Down, R .Down Maternity Home. Kamloops, B. C.
Forrester, Mrs -Royal Columbian Hospital-New Westminster,
Garner, Mrs _ —•- -: Fernie, B. C.
Girlig, Miss  Government Civil Hospital-Hong Kong, China
Graham,   Charles Cumberland Hospital— Cumberland, B. C.
Gray, A. W. Royal Columbian Hospital-New Westminster,
Gray, Mayor    Royal Columbian Hospital..New Westminster, B
Gray, Miss L. S Chilliwack Gen'l HospitaLChilliwack, B. C.
Grimmett, M. L Nicola Valley Hospital Merritt. B. C.
Hayes, W. H Summerland Hospital Summerland, B. C.
Henderson, Dr. A St. Luke's Hospital Powell River, B. C.
Henderson, Miss A. G King's Daughters Hospital-Duncan, B. C.
Hughes, Miss   Lady Minto Hospital -Ashcroft, B. C.
Langley, Miss Bell E Fernie Hospital Fernie, B. C.
Leitch, Miss -Victoria, B. C.
Letts, Annie  V. O. N New Westminster, B
MacAllister, Miss L Royal Columbian Hospital-New Westminster, B,
MacMillan, Miss  Nanaimo Hospital Nanaimo, B. C.
MacNaughton, Dr. G. K Cumberland Hospital Cumberland, B. C.
McCue, Miss  - Royal Columbian Hospital-New Westminster,
McKenzie, Miss J. F. Provincial Jubilee Hospital-Victoria, B. C.
McLean, C.  G Mill Creek, B. C.
McNamara, Miss  Great Northern Hospital Liverpool, England
Menzies, Bell, R.N Great Falls, Mont.
Menzies, Edith Pitt Meadows. B. C
Miles, Miss  M. P - Brainerd, Minn.
Mordy, T Cumberland Hospital Cumberland, B. C
Mowett, Miss New Westminster
Patton, Mrs Chilliwack, B. C.
Pitblado, Miss Kamloops Hospital Kamloops, B. C.
Richards, Mrs. J. R. A Salmon Arm General
Hospital Salmon Arm, B.
Robertson, Miss E King George Hospital Winnipeg, Man.
Rogers, Dr. H. B Provincial Jubilee Hospital..Victoria, B. C.
Rose, Mrs. W. M V. O. N Marpole, B. C.
Schultz, Mr. F. C Chicago, 111.
Selkirk,  Miss   Philadelphia Gen. Hospital-Philadelphia, Pa.
Sinclair, Miss G Royal Columbian Hospital-New Westminster,
Sloan, Miss  Governm't Civil Hospital—Hong Kong, China
Smith, Mrs. Paul  Royal Columbian Hospital-New Westminster,
Smith, Mrs. T. H Royal Columbian Hospital-New Westminster,
Stewart, D.  G Prince Rupert Hospital Prince Rupert, B.
Stewart, Kate E  North Vancouver,
Sister Mary Claudia St. Joseph's Hospital Comox, B. C.
Sister St. Edmund St. Joseph's Hospital Comox, B. C.
Sister Mary of Nazareth St. Mary's Hospital New Westminster, B
124
B. C.
B. C.
B. C.
B. C.
C.
B. C.
B
C.
B
C.
C.
B.
C. Name Representing Address
Sister Mary Catherine—St Joseph's Hospital Victoria, B. C.
Sister Mary Modeste St. Joseph's Hospital Victoria, B. C.
Sister Mary Peter. St. Joseph's Hospital Victoria, B. c!
Sister Mary Anna '. St. Joseph's Hospital..—™...Victoria, B. C.
Wickham, Miss L. St Bartholomew's
Hospital   Lytton, B. C.
Wilson, Mrs. M. M-. - South Framingham, Mass.
Wilkes, Dr.  -..-.Nanaimo Hospital  Nanaimo, B. C.
Wrinch, Dr. H. C ..—Hazelton Hospital  Hazelton, B. C.
Young, Dr. H. E Provincial Board of
Health Victoria, B. C.
VANCOUVER DELEGATES.
Name Representing Address
Arent, Miss M. ..—Vancouver Gen'l Hospital-Vancouver, B. C.
Archibald, Miss L. G — Vancouver, B. C.
Ashworth, James     : Vancouver, B. C.
Banfield, J. J Vancouver Gen'l Hospital-Vancouver, B. C.
Benzie, Mr. J. A   — —Vancouver, B. C.
Benzie, Mrs. J. A %4c  '■ ~ Vancouver, B. C.
Berkinshaw, Mrs  ■.....,— , Vancouver, B. C.
Bone, Miss     -Vancouver, B. C.
Breckon, J. T , Vancouver, B. C.
Breeze, Miss  Vancouver, B. C.
Brown, Mrs. E. ——„. .—— Vancouver, B. C.
Brydone-Jack, Dr. F. W. Vancouver Gen'l Hospital-Vancouver, B. C.
Bufton, Mrs. A. L —.  — Vancouver, B. C.
Burd, F. J  -. — Vancouver, B. C.
Burnett, Dr. W. B i : Vancouver, B. C.
Buttle, Mrs. M  Vancouver Gen'l Hospital—Vancouver, B. C.
Cameron, .Geo. H  , —Vancouver, B. C.
Casselman, Dr. V. E. D  —.—.— Vancouver, B. C.
Carder, Dr. E. D —Infants' Dept., Vancouver
General Hospital Vancouver, B.
Vancouver, B
Vancouver, B
Vancouver, B
Vancouver, B
Vancouver
Carter, Miss V. O. N.
Clark, Miss I —Vancouver Gen'l Hospital-
Clement, Miss N   V. O. N 	
Cleveland, Miss  „ 	
Cole. Miss  ■„—_ . -
Colthard, Dr. W. A  ——~~ Vancouver,
Curlin, T. V.  —.  Vancouver,
Day, C. L   Chandler & Fisher, Ltd Vancouver,
Devine, H T — Vancouver Gen'l Hospital—Vancouver,
Dickie, Mrs _ .. ,. —. ■ Vancouver,
Ditmars, W. C - -—Vancouver Gen^l Hospital—Vancouver.
Drainie, Miss A. N -.Vancouver
Military
Duncan, Capt. G. E———Vancouver
Effinger, C. E.———..—.Vancouver
Elmer, Mrs. S. C  _ —— ; Vancouver,
Esplen. Miss F. Vancouver Gen'l Hospital—-Vancouver,
Esselmont. Miss ——Vancouver Gen'l Hospital—Vancouver,
Ewart, Miss ~ —Vancouver,
Fewster, Dr. E. P. 1 , '. Vancouver,
 West End Hospital Vancouver,
C.
C.
C.
c.
c.
B. C.
Gen'l Hospital
Annex —[ Vancouver,
Gen'l Hospital—Vancouver,
Gen'l Hospital—Vancouver,
C.
c.
c.
c.
c.
c.
Forget, Rev. L i —. Vance
B. C.
B. C.
B. C.
B. C.
C.
C.
c.
c.
c.
Forshaw, Miss
Fraser, Mrs.	
Gatewood, Dr. G. EL.
Green, Mrs. Roland..
Griffin, Mrs. W. H-_
Haddon, Geo. E	
B
B.
B
B.
B. C
—V. O. N. Vancouver, B. C.
 , . Vancouver, B. C.
—Vancouver Gen'l Hospital—Vancouver, B. C.
..... • Vancouver, B. C.
 Vancouver Gen'l Hospital—Vancouver, B. C.
—Vancouver Genl Hospital—Vancouver, B. C.
MS Name
Hall, E. H	
Hall, Dr. G.
Address
Vancouver, B. C.
C.
C.
c.
c.
c.
c.
B.
Representing
..Vancouver Gen'l Hospital
B Workmen's Compensation
Board  - Vancouver,
Hamilton, Miss A. B Vancouver,
Haskin, Miss C. M Medical Librarian  Vancouver,
Henry, Miss F Vancouver Gen'l Hospital—Vancouver,
Hodges, Miss Alma Vancouver Gen'l Hospital—Vancouver,
Hooper, Edgar  18th Field Ambulance Vancouver,
Howell, Enid St. Paul's Hospital Vancouver, B. C.
Jackson, Annie  St. Paul's Hospital Vancouver, B. C.
Johnson, Mrs. M. E Bute Street Hospital Vancouver, B. C.
Jones, Dr. Milton Vancouver, B. C.
Judge, Miss Ruth Vancouver, B. C.
Kennedy, H. M — Vancouver, B. C.
King, Rev. Harold G. .. Vancouver, B. C.
Kinney, Miss E Vancouver Gen'l Hospital-Vancouver, B. C.
Lamarque, Mrs Vancouver, B. C.
Langdon, Miss _ Vancouver, B. C.
Leders,  R.  B Vancouver Gen'l Hospital..Vancouver, B. C.
Lennie, Dr. T. H Vancouver Gen'l Hospital-Vancouver, B. C.
MacEachern, Dr. M. T ."Vancouver Gen'l Hospital-Vancouver, B. C.
McGibbon, Miss Helen .. Vancouver, B. C.
MacKay, Miss  City Health Department Vancouver, B. C.
McKechnie, Dr. R. E - Vancouver, B. C.
McLeod, Miss Maud Vancouver Gen'l Hospital-Vancouver, B
McLennan, Miss  V. O. N Vancouver, B
McLennan, Miss School Nurse Vancouver, B
McPhillips, Dr. F. X _ Vancouver, B
Mcintosh, Mrs. H. H _ Vancouver, B
Making, Mrs Grosvenor Nursing Home....Vancouver, B,
Mahony, Dr. D Vancouver Gen'l Hospital..Vancouver, B,
Manning, Lottie  St. Paul's Hospital _ Vancouver, B. C.
Mills, Miss Vancouver, B. C.
Moody, Miss E. M Vancouver, B.
Mowett, Miss    Vancouver, B
Mullin, Dr. R. H  Vancouver Gen'l Hospital-Vancouver, B
Murray, Miss E Convalescent Home Vancouver, B
Murray, Miss M Convalescent Home Vancouver, B
Newton. F. E Grandview Hospital  Vancouver, B
Newton, Mrs Grandview Hospital  Vancouver, B
Nohle, Miss  Vancouver, B
Oke, C. F Chandler & Fisher, Ltd Vancouver, B
Onney, Mrs. A. S Grosvenor Nursing Home—Vancouver, B
Pedden,  Miss   V. O. N Vancouver, B,
Pearcy, Mrs Vancouver, B
C.
C.
C.
C.
c.
c.
c.
c.
c.
c.
c.
c.
c.
c.
c.
c.
c.
c.
c.
Pearson, Dr. J. M Vancouver, B. C.
Perriton, Mrs St. Luke's Home Vancouver, B. C.
Prince, Judith  - :St. Paul's Hospital Vancouver, B.
Procter, Dr. A. P — Vancouver, B.
Ramsay, Miss  St Paul's Hospital Vancouver, B.
Riggs, Dr. H. W Vancouver, B.
Robinson. Miss B _ Vancouver, B.
Robson, Mrs. C. E Women's Auxiliary  Vancouver, B. C.
Rogers, Dr. E. E .Vancouver Gen'l Hospital
Military Annex  Vancouver, B. C.
Rose, Mrs. J Grosvenor Nursing Home....Vancouver, B. C.
Sainsbury, Mr _. Vancouver, B. C.
Schultz, Mrs. Maude D — Vancouver, B. C.
Scott, Miss A Kitsilano Private Hospital-Vancouver, B. C.
Seldon, Dr. G. E Vancouver, B. C.
Sheffield, Mrs. Alfred Winters Maternity Home....Vancouver, B. C.
Stevens, Miss B Vancouver, B. C.
Sister Frances  St. Luke's Home Vancouver, B. C.
126 Name Representing Address
Sister Mary Alphonsus St. Paul's Hospital Vancouver, B. C.
Sister Mederic  —St. Paul's Hospital Vancouver, B. C.
Takahara, Dr. K. S _. Vancouver, B. C.
Tdlmie, Mrs. H. G  West End Hospital Vancouver, B. C.
Tomley, Mrs  Grosvenor Nursing Home....Vancouver, B. C.
Turnbull,  Dr.  H   Vancouver, B. C.
Walker, Miss Margaret  Vancouver, B. C.
Walters, Joseph  „ Vancouver, B. C.
Warner, L. B   Vancouver, B. C.
Waterman, Miss May Infants' Dept, Vancouver
General Hospital  Vancouver, B. C.
Weld, Dr. O— Vancouver, B. C.
Webb, Mrs South Vanc'r Maternity
Hospital _  South Vancouver,
White, Miss E Vancouver Gen'l Hospital-Vancouver, B. C.
Whitelaw, Dr. W. A  Vancouver Gen'l Hospital—Vancouver, B. C.
Whiting, Dr -..Vancouver Gen'l Hospital..Vancouver, B. C.
Wilkes, Mrs St. Paul's Hospital  Vancouver, B. C.
Wilkinson, Miss G -Vancouver, B. C.
Wilson, Miss Mary Vancouver, B. C.
Wilson, Miss  Infants' Dept., Vancouver
General Hospital  Vancouver, B. C.
Winter, Mrs. J. B Winters Maternity Home Vancouver, B. C.
Winn, E. S. H -Workmen's Compensation
Board   Vancouver, B. C.
Witt, Nurse  Vancouver, B. C.
Wright, C. H Vancouver, B. C.
Wright, Miss H Vancouver Gen'l Hospital-Vancouver, B. C.
Underhill, Dr. F. T Medical Health Officer Vancouver, B. C.
127 :

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