History of Nursing in Pacific Canada

Report of proceedings of the annual convention of the British Columbia Hospitals' Association. British Columbia Hospitals' Association 1920

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 Report of Proceedings
OF THE
Third Annual Convention of the
Hospitals of British Columbia
Held at Vancouver, B. C.
in the King Edward High School
on June 2Srd, 2Uh, 25th, 26th
' 1920
' Held concurrently with several National Association Meetings
THE CANADIAN MEDICAL ASSOCIATION
THE CANADIAN PUBLIC HEALTH ASSOCIATION
THECANADIAN TUBERCULOSIS ASSOCIATION
THE NATIONAL COMMITTEES
Combating of Venereal Diseases
Mental Hygiene *  Report of Proceedings
OF THE
Third Annual Convention of the
Hospitals of British Columbia
Held at Vancouver, B. C.
in the King Edward High School
on June 23rd, 24th, 25th, 26th
1920
Held concurrently with several National Association Meetings
THE CANADIAN MEDICAL ASSOCIATION
THE CANADIAN PUBLIC HEALTH ASSOCIATION
THE CANADIAN TUBERCULOSIS ASSOCIATION
THE NATIONAL COMMITTEES
Combating of Venereal Diseases
Mental Hygiene
G. A. Rocdde, Ltd., Printers, Vancouver
1920
t|.  !■
OFFICERS    FOR    1919-1920
Officers.
Honorary President Hon. J. D. MacLean, 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.
Dr. F. X. McPhillips, Vancouver.
Miss M. P. MacMillan, R.N., Kamloops.
Mr.  Charles  Graham,  Cumberland.
Miss L. S. Gray, R.N.,  Chilliwack.
»     Dr. W. E. Wilks, Nanaimo.
Mr. M. L.  Grimmett, .Merritt.
Mr. D. G.  Stewart, Prince Rupert.
Dr. H. C. Wrinch, Hazelton.
Rev.   Father  O'Boyle,   Vancouver.
Miss J.  F. MacKenzie, R.N., Victoria.
J j       COMMITTEE ON ARRANGEMENTS.
Dr.  H.  R.  Storrs,  Chairman.
Miss  E.   I.  Johns,  R.N.
Mrs. J. D. D- Broom, R.N.
Dr. R. Wightman.
Mr. R. B. Leders.
Official Secretary for the Convention.
Miss Frances Henry.
• OFFICERS  FOR   1920-1921.
' Officers.
Honorary President Hon. J. D. MacLean, Victoria.
President Dr. H. C. Wrinch, Hazelton.
First Vice-President Mr.  R.   S   Day,  Victoria.
Second Vice-President '..Mr. R. A. Bethune, Kamloops
Secretary Dr. M. T. MacEachern, Vancouver.
Treasurer Mrs. M   E. Johnson, Vancouver.
- Executive.
Miss E. I. Johns, R.N., Vancouver.
Miss M. P. MacMillan, R.N., Kamloops.
Mr.   Charles  Graham,  Cumberland.
Dr.  W.   E.  Wilks,   Nanaimo.
Miss L. S. Gray, R.N., Chilliwack.
Mr. G. R.  Binger, Kelowna.
Mr. D.  G.  Stewart,  Prince Rupert.
Rev.  Father O'Boyle, Vancouver.
Miss J. -F. MacKenzie, P.N., Victoria.
Mr. E. S. Withers, New Westminster. Business—Mr. Charles Graham, Cumberland.
Mr. R.  S. Day, Victoria.
Mr. J. Sutton, Nanaimo.
Medical—Dr. R. H; Mullin, Vancouver.
Dr. W. E. Wilks, Nanaimo.
Dr. H. B. Rogers, Victoria.
Dr. G. S. Purvis, New Westminster.
Nursing—Miss J. F. MacKenzie, Victoria.
Miss E. I. Johns, Vancouver.
Miss Pauline Rose, Nanaimo.
Dr. H.  C. Wrinch, Hazelton.
Dr.  R.  M. Large,  Port Simpson.
Accounting Committee:
Mr. E. S. Withers-, New Westminster.
Mr. G. F. Carver, Victoria.
Mr. G. R. Binger, Kelowna.
Mr. G. Haddon, Vancouver. ■1
REPORT
WEDNESDAY, JUNE 23rd, 1920
10:00 a:m.
Joint   Session—Canadian   Public   Health   Association
and British Columbia Hospitals.
The first session of the third annual convention of the B. C. Hospital
Association met in the King Edward High School, Vancouver, B. C. on
June 23rd, 1920, at 10:00 a.m.
It was a joint session with the Canadian Public Health Association.
Dr. H. E. .Young, President of the Canadian Public Health Association,
was in the chair, and after extending a welcome to the delegates, called on
Dr. M. T. MacEachern, President of the B, C. Hospital Association, to
conduct the programme.
Dr. MacEachern, after thanking Dr. Young for the privilege of meeting with the Canadian Public Health Association, announced that the chief
topic of the morning session was a symposium on Nursing and Nursing
Standards. He then called on Miss Helen Randal, R.N., Registrar, ■ B. C.
Graduate Nurses' Association, for her paper on "Nursing Standards."
MISS HELEN RANDAL, R.N.—
A few years ago, to talk on nursing standards would, in one sense have
been a very easy matter, for there were no standards, and really at the
present time, while the name is much in evidence, nursing standards are
mostly on paper and in the air. So far as British Columbia is concerned
the only real attempt at a standard either of educational requirements,
curriculum or what constitutes a training school so far as length of course,
departments, etc., has been obtained through the efforts of the Graduate
Nurses' Association of British Columbia since its incorporation under the
"Graduate Nurses' Act."
At the present time, nurses and their standards, educational, both as
regards hospital and pre-hospital periods, practical and ethical standards
of the students and graduates are much in the public print and in the public
mind; and here we find the two extremes which one is apt to find in matters
of this kind.. To me, who will try to justify the middle course, will probably
come the objections of both extremes—but these thoughts are the result of
considerable experience, observation, and an especially good opportunity of
seeing the real working plan of the nursing schools of this province in my
cursory view of them during the "training school survey" of 1919-1920.
To begin with, at the bottom as one should, what are we planning that
we require a standard for ? Women, well educated, well trained in the care
of the sick, with poise, moral courage, far rarer than physical, good health
and properly equipped for private work, public health services or executive
positions. Just now we hear a great deal of the shortage of nurses, the
terrible conditions of the women. left without nursing care, and a general
indictment of the nursing profession as it now is. We are told that we are
not willing to go out into the country, are not willing to take all kinds of
cases, are not willing to do housework when nursing and that we charge
too much and do not want to work long enough hours. Surely a long list
of things that must be explained satisfactorily or other arrangements made
to meet.
To begin with, I state positively that I do not believe there is such a
shortage of graduate nurses as we are led to believe. That there is a
great shortage in the hospitals, which are growing rapidly and are trying
in almost every case to cover the shortage of domestic help with the plea
of shortage of pupil nurses, I do not deny. Hospitals enlarge their boundaries without counting in the least for the increase of, or accommodation
for the extra nurses, and the real shortage which is in the domestic end
of the work, both inside hospitals and in the homes, is sought to be done
S by the nurses. As to the situation outside, we must remember that during
the last year large schemes, which have been lying dormant, suddenly sprang
to life, and there was at once a cry for nurses to fill the public health
field all over this continent. If this matter could only be taken in a less
hurried way, nurses given a post-graduate course to enable them, by
increased special knowledge of the social end of the work, to fill a larger
field than the nurse without this course, and the field held open for them
until they do, it would not be long*before this shortage would be filled.'
It is ignorance more than anything else, of the work and the needs,
that keeps the number applying for such positions small in comparison
with the need. Some will tell you that the way to start anything is just
to start, but I venture a doubt as to that being the best way. Many a
splendid plan has been spoiled by the unskilled taking charge of it, and
the right foundation to everything is to me the same thing. It is a little
crumb of comfort to the nurse who gets tired of hearing her profession
spoken of as being one that prefers the loaves and fishes of civilization to
the primeval field. I read in an American Journal a short time ago that
the shortage of the "cross-road doctor," as it was there expressed, was
causing much thought on the part of those interested in public health in
rural communities. It was stated, as we well know it to be here in British
Columbia, that the physicians crowded into the cities and places where the
practice was easier, to the neglect of the rural places and people. The
chief difference between the comments on this condition and that of a
similar complaint laid against the nurse is that there never has been, so
far as I have discovered any attempt made to point out that in many cases
a second-grade physician would fill the situation and, in some"cases, the
patients might do as well.
That brings me to one of the extreme arguments or plans for the relief
of the situation or lack of care of the sick and his household. The point
that seems to have escaped most people discussing the situation is that they
are utterly confusing two distinct things. One—the shortage of nurses, and
the other, the far greater shortage, the one that has nothing to do with
nurses, nursing or nursing standards—the real shortage of domestic help.
In this connection may I quote from a report made on giving up the nurse
attendants in Cleveland after a two years trial.
At a recent meeting of the Provincial Association, a well known doctor
spoke to us on the nursing situation, and he, a man of the highest type of
medical man, told us of the nurse that would satisfy him. I am sure he
thought he was sincere, but I venture that he would be the last to use this
woman as a substitute for the trained nurse. This low standard which is
being presented as the extreme, means that the woman need have little
preliminary education—will have a year's training, and then—well, what
then? At the last convention of the Canadian National Association of
Trained Nurses, which met here last summer, the motion was endorsed by
them that they were not opposed to nurse attendants "if the public could
be properly safeguarded." As you may have noticed in the quotation I
gave, they showed that the public was not safeguarded in Cleveland. Now
the only safeguard that can be made is to monopolize the name "nurse" for
the graduate only, and as custom has allowed this to be used for all nursing,
even those who never trained at all, this seems impossible. The next possible step is to license every_ woman nursing, no matter whether an R. N.,
graduate nurse, specially trained or practical, according to her qualifications,
and then see that she is prohibited from doing anything outside of this.
The supervision required.is the next stumbling block and where is she to
be trained, and that is one that I think should convince anyone of the impracticability of the scheme. If you place them in hospitals where there 'is no
training school, then you must have more graduates for the critically ill
and for supervision. It is out of the question, unless you want to kill the
standing and popularity of your training school, to mix the two forms of
training. And how long do you really think she will continue to be a
"nursing housekeeper," a "trained attendant" or what not? She will, as
was shown recently, frequently charge as much if not more than the graduate
nurse, so the financial help to the moderate purse-is not arranged for.   1
6 will kill all desire on the part of the young woman to enter a profession
where they are not to be protected, even as they are now, and so the situation gets worse, not better.
The opposite extreme, insist that the pupil have a high school course—
that the lectures and theoretical part of her training must be most complete,
and it is hard here to show that these are not praiseworthy objects. Surely
everyone recognizes that all other things being equal, the more highly
educated a woman is in all walks of life, the better she is fitted for her
work. But the danger lies in making this standard of pre-hospital education
the one essential for entrance. There are not enough young women finishing
their high school course to fill all the vacancies in the hospitals, therefore,
the woman at the head of the school with this standard fixed, is apt to
consider the scholastic ability rather*than the vocational or physical standard.
| The work done by the Graduate Nurses' Association of British Columbia
in interesting and persuading the girls to finish the high school course will,
in time, help to raise the standard of admission by presenting more to
choose from of properly educated women._ The Educational Department of
our Province must help us, I think, in providing through its technical
schools a part, and not a small part, of the education needed in the nurses'
profession. This, with the combined Domestic Science course, should help
much to educate the girl for her future before she enters the hospital. As
to the standards for curriculum—ours has been approved by Nurses' Associations and by your Association, and while it looks alarming, with our
scheme of affiliation which is working, makes it less of a'bug-bear than
one might think. Still here again, I belong to the middle.path, for there
is a distinct danger to any standard of efficiency where the foundation is
not secure. I should definitely prefer to prepare a nurse for her R. N.
examination who had studied less and that more thoroughly, than the one
who skims over the surface and who glibly tells you of laboratory and
pharmacy periods, whose chemistry is fine in class but who cannot tell you
the chemical effects of the simplest mixtures of acids, alkalies, etc. Please
bear in mind that I am and always have been working towards the highest
educational standards for pupils, but if the educational standards of the
• sp'ecial training for a nurse cannot be obtained in the school to which she
applies, what is the value of her pfe-hospital education?
The physical standards are very essential, and here too the hospitals
have been most neglectful. The great cry that nursing breaks down the
young woman who enters is not due to the work half so much as to the
careless way in which girls who had no business from a physical standpoint were allowed to enter and naturally were unable to stand the work
and dropped out "broken down with the training." In the face of strong
opposition from friends, relatives and from the girl herself, a strong stand
must be made that only young women with the required physical standard
will be accepted. Then after educational, physical and training standards
are complied with there is the greatest standard of all, that of the woman
herself—the vocational and ethical standard. The Chancellor said lately
to the 1920 Class of the Vancouver General Hospital that "nursing was an
art." It is that indeed, and very much more, it is a profession and above
all, a vocation.
Nursing standards will never be any higher than the source, and if the
nurses we turn out have not the true vocational spirit, the spirit that does
the work required with not only mechanical efficiency, but with the true
spirit of service, then our other standards are of no use and the profession
is doomed. Repeating the Florence Nightingale pledge will not make the
graduate realize her duty and her privilege if through her course anything
else than the highest ideals working out from the superintendent to the
porter have been seen by her. These young women absorb the spirit of
the place where they spend three years of the most impressionable part of
their lives, and it is up to all in authority to see that they see always that
"the greatest good to the greatest number" is the motto of their alma mater.
It is of no use to talk of nursing standards if there is not first the
foundation of the standard of the hospital which undertakes to call itself a
school for nurses.    No hospital has any moral right to take three years of a young woman's life and settle down to use her as cheap labor, for that
is what it all comes to, if one removes the frills and furbelows from the
situation. Can a hospital where there is no class room, no equipment, no
woman with time, or in some cases the education, to teach these pupils,
whose hours are so long in the wards that they cannot study and whose
classes are given only after this long day's work, whose departments of
cases consist of usually a fairly good surgical department, plenty of obstetrical work, and that is practically all, call itself in honesty a training
school for nurses? Can they honestly make the three years the length of
stay in their hospital under those circumstances? Put it to yourselves and
see if it is right. With affiliation ready they can give the small school girl
an honest course if they provide enough equipment and class work for the
two years and then give those faithful young women the third year to gain
what they cannot get in their own home school.
Special training is given in these small schools where there is the
desire to act up to the nursing standards required, sometimes better than
in the large ones; and my ideal is that there should be an- exchange of
pupils between the large and small hospitals; those from the large gaining
quite as much as those from the smaller in the change. It can "be done as
affiliation has been done, but not till all selfishness in the individual school
has been blotted out and a determined effort made to produce the type of
nurses that British Columbia wants. It would mean great work but it would
be worth it. Whether in the form of the central training hospital or with
several of these in our scattered province, the thing is feasible, and must
come, to get the best effects from our schools.   To sum up:
Firstly—We should require at least one- year's work in high school—
tnore, if possible—as the pre-educational standard.
Secondly—No school allowed as such to train pupils till the standard
■  equipment, mechanical and teaching, is present.
Thirdly—No young woman with low physical standards allowed to train.
Fourthly—A determined effort made to bring out the ethical side of the
profession—the. spirit of service and of altruism, never-losing sight
of the fact that the responsibility of the school  is great as to the
moral and ethical effect of the three years spent there.
DR. MacEACHERN, Vancouver—
"We will now have a paper on 'The University in Relation to Nursing
Education,' by Miss Ethel Johns, R.N., Director of Nursing, Vancouver
General Hospital, and in charge of Department of Nursing in the University
of British Columbia."
MISS E. T. JOHNS, Vancouver—
'The purpose of this sketch is not to give a survey of education in
general and nursing education in particular. It will not compare nor appraise the departments of nursing now existing in various universities on
the American continent. The historical aspect of the movement toward
the higher education for nurses, fascinating as it is, cannot even be touched
upon. It takes no cognizance of statistics, though these are available. All
I can hope to do in the brief time allotted me is to demonstrate to you the
crying need for the broader education of nurses in Canada today. If at
the same time it can be shown that the universities of our country are the
logical centres for such education, I shall be satisfied. If further it shall.]
appear that those who urge this reform are neither wild-eyed enthusiasts
nor sentimental theorists, but women who, to paraphrase Kipling, "Be
neither saint nor sage, but simply .those who do the work for which they
draw the wage"-—why then I shall have succeeded beyond my best
expectation.
The education of nurses has received more attention in the last, five
years than during any previous period in history. The reason is simple.-
Whether nursing is or is not a profession, is a debatable question, but that |
it is a vital art bearing upon life has been amply, even tragically, proven.
during the war and the epidemics which followed it, and during the period
of so-called reconstruction through which we are now passing.
This focusing of puMic interest has shed upon us a light that is some- what disconcerting. The veil of sentimentality disappears and we appear
as we really are—a group of community servants, entirely well intentioned,
but more or less ill prepared for our task. The inquiry now being conducted
by the Rockefeller Foundation regarding nursing and the education of
nurses will entail some extraordinary revelations, but it cannot fail to
demonstrate the one salient fact that the policy of laissez faire in nursing
education is discredited by its results and that a sane, sound, reasoned
plan needs to be formulated and to be put into operation under able leadership as soon as may be.
Present conditions in nursing education in Canada may be rapidly
summed up as follows: In' Canada to day any person or group of persons
may assemble a number of sick persons under a roof and call that place
a hospital. Further, they may inaugurate a nursing school, may offer to
young women instruction in one of the most vital and difficult of arts. It
would be reasonable to suppose that before so doing it would be necessary
to assure some competent educational authority that conditions in that school
were such as would insure the pupil competent instruction and proper living
and working conditions. Such is not the case. The only point in which
specific legislation exists in most of our provinces is that a-certain minimum
number of beds—beds, mark you, not patients, must be available before a
training school is established. And what is that minimum? In some
provinces as high as twenty-five, in others as low as five. No mention of
qualified instructors, no restriction as to hours of duty, no provision for
teaching equipment—just beds and pupils. The fact that many hospitals,
large and small, do their .best to keep faith with their pupils is beside the
point. They do so of their own free will. They are not obligated so to
do. No competent "authority at present exists which guarantees that pupils
entering training schools will receive sound, systematic instruction in their
chosen calling. An attempt has been made by associations of nurses to
lay down certain standards and to conduct inspection. This is a move in
the right direction.
Inspection will doubtless help to standardize conditions in our schools,
but inspection must carry with it more authority than at present or its usefulness is limited.
What does the hospital exact from the pupil in return for unstandard-
ized instruction? It exacts three years of disciplined service. I would like
to emphasize that word disciplined. Pupil nurses are one of the few remaining disciplined groups in the chaos of our modern civilization. True,
discipline, even in schools for nursing, is much more lax than in former
years, but still the organization of most training schools remains essentially
disciplinary. The value to the hospital of this condition of service—I had
almost said servitude—is incalculable, but unfortunately the hospitals have
been tempted to exploit it to such an extent that it is becoming more and
more difficult to recruit pupils except for such schools as are known to
be able and willing to maintain high standards. The proverb of the killing
of the goose which laid the golden eggs has never been more aptly illus
trated than in the present shortage of pupils,—a direct consequence of the
old methods of exploitation. Tt is not just to lay all the blame on the
hospitals. In the last analysis the problem is largely economic. The pupil
nurse was and is a cheap and efficient working force. Relatively few
hospitals, large or small, in Canada, are established on a firm financial
basis. Not the least of their financial anxieties is the ever-increasing salary
list. The solution, for the time, was easy, so long as pupils presented
themselves for training in sufficient numbers.
Now that thev do not, what is to be done? The logical answer is:
Make conditions 'more attractive. But how? Better living conditions?
Yes. Shorter hours? Yes. Higher money allowances? No; pupils enter
for training, not as a means of livelihood. What else? More important
than all, better teaching, more thorough preparation, wider opportunity for
self-development; and the last is, in my opinion, the most important of all.
Pupils today are discriminating, and rightly so. They compare standards
in various schools before making application to any. They do not necessarily choose the largest school. Many applicants have said, ,r
school, but we get as good teaching there;" or,
9
"They offer affiliation in certain branches," or, "The superintendent of nurses is very able; she moulds
her women." Pupils sit in judgment of the- educational standards of their
school far more than the medical staff or the directorates of hospitals
realize.
If good teaching is a factor in the success of any training school, it
surely should not be. difficult to provide that. Just get a competent woman
for director and she will see about it. But will she? How many competent
nurse administrators can teach? How many" can plan curricula? Some
of them have natural teaching ability—more have not. Even the first
group have had little or no opportunity in developing or educating" their
teaching faculty. Until the department of nursing in Teachers College,
Columbia University, opened its doors to women desiring to qualify as
nurse teachers and administrators, there was no institution to which women
desiring such training could turn. This department was founded by Miss
Adelaide Nutting and Mrs. Isabel Hampton Robb, both former superintendents of the School of Nursing" of the Johns Hopkins Hospital. This brings
me to my real topic—-The University as a factor in the Education of Nurses.
All that precedes was background—I hope not unduly black, against which
I hope to show the true logic and Teasonableness of this modern movement
toward the university, a movement which has not b'een without its critics
and detractors. Miss Nutting and Mrs. Robb were possessed of the divine
gift of vision. They saw that, for good or ill, nursing must enlarge the
place of its habitation. They were besieged with demands for teachers
and administrators in schools for nursing. Above all, they realized the
necessity of establishing standards. There seemed no logical means of
establishing such standards except through an independent educational body
such as the university. The modern field of public health and -of social
service cried out that the harvest was plenteous but the laborers were few.
Women of native ability equipped only with their training school experience
were drafted into these new fields, found that their education was -inadequate, and looked about for opportunities for post-graduate study.
Where were they to go but to the university? Their training schools
had given them all they could. Thus came about the courageous experiment in Teachers College which has had such momentous results. Fire
from the torch these pioneers kindled has been passed from hand to. hand
till there are now more than twenty universities on the American continent
taking cognizance of nursing education. The most pressing' need—that of
post-graduate study—-had first to be met, but a new .development is now in
process of taking place. Firmer foundations are being laid. Several universities in the United States and one in Canada—the University of British
Columbia—now offer what, for want of a better term, is called the combined course leading to a degree in nursing. A brief sketch of the course
in this university will illustrate the general plans of all. Students must
possess matriculation standing. Two full years' academic work is required,
during which the student receives instruction in the bas'c sciences of
chemistry, biology, and bacteriology, in addition to English history and
economics., Before she begins her academic work, or "in the interval between
the first and second years, she undergoes a physical examination
and serves a probationary period intended to prove her general fitness and
adaptability for nursing. At the close of two years' academic work she reenters the training school as a pupil nurse and undergoes two years' intensive nursing training. The fifth year is partly academic and partly work.
During this year she elects one of two majors—either teaching and administration of schools for nurses, or public health. At the conclusion of her
. five years' course she is eligible for the degree in nursing conferred by the
university and for the diploma of the hospital as a graduate nurse. It may,
I submit, be contended that a woman possessing training such as this will
be capable of enlightened leadership and direction once she has acquired
the necessary practical experience in her chosen field. Especially is thjs
true of the field of public health. It is plainly shown at a gathering of this
nature what ambitious programmes of public health are being formulated
in the various provinces. But.where is the nursing personnel to come from? .
There is riot. I am sure, a public health or hospital administrator within
sound of my vo'ce who is .not at his or her wits' end to solve this riddle
10 ■■
of the sphinx. The dearth of women who are able to fill acceptably positions requiring initiative and executive ability is appalling. There are
plenty of good nurses, but they have not sufficient education background to
fit them for such tasks, nor in the past has it been possible for them to
obtain it. I can speak feelingly for the training schools,—competent instructors of nursing are very rare. Teachers College has now on its books
more than three hundred applications for women to fill positions of this
kind in all parts of the United States and Canada, which, so far, cannot
be filled because nurses are not presenting themselves in sufficient numbers.
The training schools would once have been the source. Now there is a
better one—the training school and the university. The discipline and
devotion to the technical training of the one grafted on the broad culture
of the other. Hospitals searching for competent superintendents, capable
of leadership, will look here also. Many a hospital directorate today
would respond to an appeal for better teaching conditions if their superintendent could formulate such conditions and direct them and carry them
through after formulation. Show them what to do and they will do it.
It is education for leadership we are striving to obtain, not an impossibly
high standard for the rank and file. Not that the rank and file are debarred. Opportunities for post-graduate study are now available in many
centres in the United States and also in Canada. During the past winter
a short course in public health nursing was given to graduate nurses in
Dalhousie University which was a model of its kind. Students in this
course were given instruction in economic, sociological, and scientific subjects bearing directly upon their work. At the same time they visited the
social welfare organizations of the district and were given opportunity for
a certain amount of field work. Students who took this and similar courses
given elsewhere speak enthusiastically of the inspiration and help it has
been to them in their work. The only fault they have to find is that they
did not get enough. The taste for knowledge was aroused, not satisfied.
Not for nothing is the motto of the American Association of Public Health
Nursing. "When the desire cometh it is a tree of life."
In the United States the experimental stage of the movement toward
the university may be said to be passing. It will not be long before the
same is true of Canada. Short courses in social service and group lectures
to pupil nurses are being given in the University of Toronto. The universities of Saskatchewan, of Alberta, and of Manitoba are swinging into line,
and even that stronghold of conservatism, the University of M'cGill, is
reported to be considering a department of nursing. As yet, the University
of British Columbia is the only one in Canada to offer the course leading
to the degree. It has the distinction of being the first in the British Empire so to do. Eight students are enrolled, three of whom will graduate in
1923 as Bachelors of-Nursing. It is far too early to gauge results from the
combined course. We are building here for the future, but we earnestly
hope that the foundation- will be well and truly laid.
Now, in this connection a word of explanation is necessary. It has
been intimated that the higher education of nurses has its critics and detractors.   Let us examine these criticisms for a moment.
One commonly heard is that nurses will hecome so superior that they
will refuse to perform their real function—that of nursing the sick; that
they will, "in the phrase of_the street, "get too big for their job." If by that
is meant that many of the more highly qualified will choose positions involving responsibility and direction in preference to bedside nursing, the
criticism is true. But is there any reason why they should not accept the
higher, more far reaching responsibility if they are duly qualified? Will
they not insure a'better type of bedside care by their very ability to supervise and to direct others ? 'The number of women who will choose or who
are fit for the higher reaches will be necessarily small. It is not intended
for one moment to recommend that all pupils be compelled to take the combined course.
Further, there is a growing conviction that another nursing group than
that which now, exists will soon have to be formed. Many routine nursing
-and domestic duties now performed by the graduate nurse could be peril formed just as acceptably by women possessing less training, provided they
were properly trained and supervised. The Canadian National Association
of Trained Nurses has gone on record as endorsing the principle of training
licensed attendants, provided legislation can be devised which will protect
the graduate nurse and prevent these women assuming a. status which does
not rightfully belong to them. In other words, nurses at large realize to
the full the necessity for an auxiliary nursing force, and they are willing
to recruit, to organize, to educate and to direct such a force, provided they
themselves are not wiped out of existence by the unfair competition such a
group would involve unless its field of operation were definitely established
by law. The creation of such a force only emphasizes the need for competent leadership. Left to itself, it could easily become a menace to the
public and to the medical profession. Suitably officered and directed, it
will be of great benefit to both.
It is undeniable that the medical profession has been greatly hampered
for need of just such service as such a group could render. It is the circumstances which have given rise to recent opposition on the part of some
medical men to any advanced standard in nursing education. That such
opposition exists is unfortunately true. A few medical societies as well as
individuals in the United States and Canada have gone on record as opposing higher education for nurses. The most charitable interpretation
which can be made of such action is that it was taken in ignorance of the
true facts of the case. The very men who took it are condemned out of
their own mouths, for they themselves exact the highest technical efficiency
for nurses' in certain branches in which they themselves are specialists.
The modern operating room nurse, the modern supervisor of obstetrical and
eye, ear, nose and throat^departments are required to possess unusual techna|
cal skill and theoretical knowledge. They are required to possess them by
the very men who cry out for a- return of the good old days when an old
woman who would do what she was told was all that a man needed. What
these men do not not stop to consider is that they require, and are justified
in requiring, two separate and distinct types of service—the fully trained,
highly specialized type, and the fully trained routine worker. The trouble-
is that they insist that the same worker shall adapt herself and become
at the will of the physician employing her, the one or the other, or both.
Gentlemen, with the best will in the world, it cannot be done. Those of us
upon whom is laid the heavy task of preparing the women of either type
for their life work know that it cannot. The same blind routine cannot
and will not meet either need. Specialized methods of education must be
formulated for both,.suitable teachers must be provided for both. And so
we return to the need of education for leadership, and there is no logical
source for that but the university. Such a high authority as Mr. Justice
Hodgins, in his recent report on medical education in Ontario, stated that,
so far, whatever betterment had been brought about in nursing education
had been due to the efforts of the nurses themselves, In a measure, this is
true. But if we have had opposition from the medical profession and
from the laity, we have also had most generous support. Men and women
in both walks of life have believed in us and in our cause. This province
is an illustration of that fact. The establishment of a department of nurs- |
ing in the University of British Columbia is largely due to the vision and
energy of a physician, the executive head of the Vancouver General Hospital..
The chancellor of the university, also a physician, has stood its staunch
friend, as has the provincial officer of health for this province. The relation
in which these men stand to the community has demonstrated to them that
something must be done to enlarge the mental horizon of women upon
whom such heavy responsibility is being laid.
To those who are in opposition or are in doubt, one last word, if there
are any of such here: Will you not listen to the appeal of those upon whose I
shoulders you yourselves lay such heavy burdens? You see so many faults,
so many blunders in our nursing service. So do we; they are not hidden
from us. You cannot imagine why things should not run more smoothly^
but we can; we know it is because of insufficient teaching and supervision,
You do not realize how complex your own profession has become. How can
we expect you to realize how difficult it is for us, with few of your edu-
12 cational advantages, to keep up with the advance shown in medicine? And
yet we have tried to keep up. Slowly but surely the routine processes of
medicine are being delegated to us. We are expected to give acceptable
service as anesthetists, as laboratory and x-ray technicians, as your field
workers in preventive medicine. You have taken us for granted, as men
always take their women folk for granted.
If we had not wished to develop ourselves you would have forced development upon us. Some years ago I stood and watched with a high
heart the woman's suffrage parade in New York City. Near the end of
the long procession, in which women from every walk of life participated,
came a group of young girls with a banner inscribed, "All this comes of
teaching girls to read." Remember, you taught us our letters in nursing.
You should not have set our feet upon the road if you did not mean that
we should climb the hill. You should not have taught us our letters if
you meant that we were not to read the chapter.
But most of you do mean that we shall read, and we shall convert the
others. In the meantime, what can you do to help? Well, hope all things
and believe all things of us. Reserve judgment and be patient with our
failures. Throw the weight of your great influence on our side. Don't
pass resolutions condemning the higher education 'of nurses unless you
really must. This movement cannot be killed; it can be retarded, it can
be prejudiced in the eyes of the public by so doing. Give us a fighting
chance, a fair field, and no favor.
There is a long, uphill struggle ahead of us. The universities are
sympathetic, but their sympathy is tempered with caution. At first they
felt that opening their jealously guarded portals to nurses meant lowering
the standards for the maintenance of which they exist. Once jt was clear
to them that we were willing to have our students meet the same requirements as the rest of the student body,- they became more friendly. But the
fact must be faced that we constitute a serious educational problem to
them. Suitably equipped personnel for the faculty of nursing is difficult
to obtain. Few of us possess full academic standing—no precedents exist.
Compromise is necessary. No one knows that better than the pioneers of
this movement. But before long adequately prepared women, the output
of the combined courses, will be available. ' Until then we must carry on
as best we can.
You are met here to consider ways and means whereby the community
may be better served in health matters. The educational phase of this
gigantic task is continually emphasized in your discussions. Surely we
can enlist your sympathy in support of a movement which has as its object
the development of a nursing force worthy of the cause to which it and
you alike are dedicated—the prevention of disease and the conservation
of life lived to the full, active, healthy, and happy.
DR. MacEACHERN, Vancouver—
' I will ask Miss Jean Browne, Director of School Hygiene, Provincial
Department of Education, Saskatchewan, for her paper on "Health Education in Rural Schools."
MISS JEAN BROWNE, Regina—
The term "Health Education" is in itself rather significant, indicating
as it does the trend of modern opinion. A few years ago in speaking of
health work in the schools one heard only the term "medical inspection.
Medical inspection had its inception in 1879 in Paris, and meant inspection
of school children fat contagious diseases. Shortly afterwards it was introduced into Germany and in 1891 we find its beginning in London, England.
We find it first in the United States in the City of Boston, in 1894. In 1902
the first school nurse in the United States worked out a very successful
experiment in New York City. It is hard to fix the exact date, but about
the beginning of the Twentieth century medical inspection of schools which
before had for its object the reduction of contagious diseases began to take
on a broader meaning and a beginning was made in examining children for
physical defects such as defective vision, defective hearing, enlarged tonsils,
adenoids, decaying teeth, etc.
But those who were making a study of child welfare soon began to
see that inspection work alone would never get us very much farther ahead,
13 and gradually there came to be evolved out of the old idea of medical inspection, the idea of health education. It includes as one of its phases at
the present time the inspection of children for physical defects, but it aims
at something infinitely bigger and better—physical perfection. Its aim is
the prevention of defects, the removal of which occupied the whole time of
the old systems. In a system of health education, the self activity of the
child is our starting point. In the old systems of medical inspection this
well-proven pedagogical principle was scarcely considered. The principle
upon which health education is based is the essential principle underlying
all education, that is, that the child is an entity, and there is no sharp line
of demarcation between the mind and body, and that education means the
development of the whole child.
When teachers grasp this fundamental idea, there will be no lack of
harmony in connection with health work in the schools, It is largely a
matter of getting rid of the old pernicious tradition that a child can be
divided into three separate compartments distinctly labelled "physical,"
"mental" and "spiritual." When we think of the child as a whole, we can
then plan for the development of the whole child. It seems to have been
due to a lack of understanding of this that in many instances in the past
our teachers were trying to devote themselves exclusively to the education
of children's minds, while another set of professional people were attempting
to look after the same children's bodies. Both of these professional groups
have been characterized by narrowness of vision, and in the struggles for
their rights, the rights of the child have been largely overlooked. In
teachers' conventions you used to hear the invidious comparison made between the respective incomes of the man who merely looked after the needs
of the body'^arid those who ministered to the needs of the mind. On the
other hand we frequently hear child welfare discussed in health conventions
as if it had only to do with healthy bodies. Recently in a nursing journal
I came across this :—
"The average person would be horrified to find that the teacher who
taught his children had no certificate, and yet thought nothing of employing
a wholly untrained or half-trained person for something infinitely more
important—their care during a serious illness." I think most of us would
hesitate to admit that there is anything "infinitely more important" than
the education of a child. As a matter of fact one of the great weaknesses
of the old system of medical inspection was that' sharp line of cleavage.
The more elaborate the system, the more completely was the responsibility
of the child's health taken from the teacher. Obviously this was working
from a wrong standpoint, since the education of mind and body are in-
dissolubly linked together. With this principle in mind, let us not take this
responsibility from the teacher, but rather let us prepare our teachers to
educate the child in his entirety. To be sure, the teacher of yesterday
thought it her business to teach the curriculum—no more, but a transformation is taking effect in our schools, and we find the teaching profession
is coming to realize that their business is to understand and direct the
lives of their pupils and to realize that education means development of the
whole child.
But the teacher must have training along health lines, and so our normal
schools will have to commence to give an earnest course in School' Hygiene.
To be sure our normal schools have always; had Hygiene on their programme, but if the work given in this subject in the largest normal schools
of Ontario some years ago may be taken as an example, then it might far
better have been left off,- because it left the idea with the students that
Hygiene was of no importance. The only lasting impression I have of it
was a venerable -old gentleman, who was an authority in his specialty in
anatomy, exhibiting to the class specimens of the various kinds of bones
and joints and talking to us about a jacketed stove. It isn't likely he had
ever been inside a rural school. The course in Hygiene should be taught
with one aim in view—to teach teachers in training how to conserve the
health of their pupils and how to teach health habits. This teacher of
Hygiene must be a trained teacher and must be thoroughly familiar with,
the conditions that obtain in our schools, particularly in rural schools. In
Saskatchewan we have on the staff of each of our normal schools, a school
14 nurse who has had pedagogical training., She gives lectures in Physiology,
practical school hygiene, first aid- and some home nursing. She inspects
the students for physical defects and urges on them the necessary treatment.
In classes A. B. and C, at the Regina Normal School this year there were
143 students, 117 of whom had remediable defects. Of this number 114 received the necessary treatment. The teachers in training are taught to use
a Snellen's Eye Test card, and to roughly test their pupils' hearing by the
watch method and the whisper method. They are also taught. to detect
adenoids and diseased tonsils. They are particularly taught the care of
the teeth, and are warned of the importance of preserving sixth year molars
in children. They are taught the symptoms of chorea. The teacher who
does not recognize the sign of this disease is almost bound to punish unjustly and so aggravate the disease. They are taught the signs of incipient
tuberculosis. I have .known of a considerable number of cases if incipient
tuberculosis which have been reported by observant teachers befofe the
cough occurred. They are particularly taught the necessity of having hygienic conditions in regard to the lighting, heating, ventilating, desks and
seats, cleaning, and toilets of the school. These points that I have mentioned will possibly give you an idea of the kind of work being given in
the school hygiene course in our normal schools. For the older teachers
and the teachers who come to us from outside, we have a health education
course at the summer school at the University. This course consists of
Physiology, Practical School Hygiene and Physical Culture. It is a great
mistake to have School Hygiene and Physical Culture separated. They are
both integral parts of health education.
I believe that a wise course of study in Hygiene taught by teachers who
are impressed with the importance of this work is our greatest single
instrument in health education. Last year for the first time, hygiene was
made a compulsory subject in our province, from the time the child entered
the elementary school until the end of the third year of the secondary
school. During the first two years, however, there is no formal teaching
of hygiene. It is a matter entirely of fixing right health habits in pupils.
Now it would be ideal if our teachers were so widely read and so well
informed as not to require text books at all, but at the present time much
depends on the selection of texts. We use a graded series of text books
by Ritchie:
For Grades III and. IV—Primer of Hygiene.
For Grades V and VI—Primer of Sanitation.
For.  Grades VII and VIII—Primer of Physiology.
First-year Secondary Schools:
Text—The Saskatchewan Public Health Act—Regulations and
Bulletins.
Bulletins issued by the National Commission of Conservation. Such
topics as the following are dealt with:—
1. How a  supply of pure  water may be obtained  in the locality  in
which you live.    Conservation of rain water.
2. Pure Food Laws:
Regulations governing the sale of milk for domestic use.
The part played by flies in the pollution of food.
-3.   Contagious diseases:
Typhoid Fever, Tuberculosis, Measles, German Measles, Whooping
Cough, Influenza, Chicken Pox, Small Pox, Scarlet Fever, Diphtheria,
Mumps, Trachoma. .    .
Characteristic feature of each and mode of transmission.
Regulat;ons  for isolation  and  quarantine.
4.   Union hospitals—how organized.
Second year:
_ Text—Human Physiology—Ritchi
Third year:
Text—Human Physiology—Ritchie.   Chapters XIV to XXVI inclusive.
Through   teaching   of   this   sort   we   are   building  up   self-constituted
health corps among the older boys  and girls.    Not long ago a  group  of
15
Chapters  1 to XIII  inclusive. high school girls on the playgrounds of a small town school discovered1.-
that one of the number had a rash. They'went inside and consulted a
pasteboard card showing the symptoms, period of incubation and period of
isolation of each of the common contagious diseases. One of these cards -
hang on the walls of every class room in the province. After consulting
the card the girls decided that their class-mate had chicken pox. She
asked permission to go home. The family _physician was called in and
corroborated the diagnosis. In a prospectus sent out by the World Book
Company it is stated that four children after reading the Primer of Hygiene
discovered for themselves that they had adenoids and insisted on their
parents taking them to the family' physician. In educational work of any
kind, our greatest asset is the self-activity of the child, and we shall make
a sorry failure of health education if we do not make use of the principle.
Possibly there may come a time when the teacher, the family physician,
specialist, dentist, medical health officer and parents will be able to manage
the health education of the rising generation in rural schools, at any rate,
without assistance. But that time has not yet arrived. And so we must
provide for special health teachers, a group of people who are specially
trained in both hygiene and pedagogy. In Saskatchewan we have school
nurses, most of whom have been successful school teachers before taking
a nurse's training. They are given a short post-graduate course in our:
system before being sent into their fields. In New York State they take
and give them a year's course in Pedagogy, School Hygiene and Physical
Culture. They are called "Health Teachers." They have the advantage
over our school nurses in one respect at least,, in that they are qualified to
direct work in physical culture. In the University of Mississippi a special
two years' course in Hygiene is given to train teachers to be health teacheSS
These courses have been planned with the idea that health is a matter of
education, and that health education is an essential part of education.
The principles of health education are the same whether in rural or
urban schools, but the necessity for the rural work is greater. In
Saskatchewan 77% of our school population is rural, so that our problem
is overwhelmingly rural. In considering this work we must also bear
in mind the fact that the health standard in rural communities is generally
• lower than in cities. There are few, if any, organized health activities in
rural communities so that if the school shirks its responsibility the outlook
is dismal indeed. Health work in rural schools cannot be copied from
cities.   A too ambitious programme in rural schools defeats its own ends.
Permit me to outline for you how this problem is being met in Saskatchewan. In April, 1917, the Minister of Education, who is also tfce Premier
of the Province, appointed a Director of School Hygiene to organize a provincial school hygiene branch. In connection with this branch there is a
gradually increasing staff of specially trained school nurses, most of them
with pedagogical training. At present this work is financed entirely by the
Government, and the unit of operation is for the most part the inspectorate.-'
The school nurse travels with the inspector in fine weather in his car, and
conducts her inspection work at the same time as the school inspector.
This works out without any waste of time for either. Its disadvantage is
that it allows the school nurse very little time to visit parents. In winter
time . she inspects schools in towns and villages along railway lines. Ultimately this work will have to be undertaken and financed locally, but under
our present form of administration, the small district-with its school board,
of three members, this is an impossibility. We are still hoping for the
larger unit of school administration, whether it be the municipality or a
still laTger unit. In the meantime a considerable number of municipal
councils are interesting themselves in this work. At their request, we send
one of our school hygiene staff, and the council arranges and finances her
transportation from school to school within the municipality.
The one-room rural school is the pivot round which our system chiefly
revolves. Out of 4475 school districts, about 4000 are one-room rural
schools. But it is worse than folly to attempt to teach health in a school
that breaks all the laws of hygiene. Children are very quick to detect inconsistencies in grown-ups. Our present and very pressing duty then is to
put right with  as little delay as  possible the hygienic  conditions  of our
16 schools. The first definite piece of work undertaken by the school hygiene
branch in our province was to send out a questionnaire dealing with hygienic
conditions, to all the rural and village schools. A bulletin was then prepared based on the replies to this questionnaire. I submitted this to the
Deputy Minister for publication, but it looked almost too bad to print.
However, after inserting the following paragraph it was finally printed:
"In regarding this survey as a whole we find that it offers immense
opportunities for improvement. On the other hand, it compares favourably
with, conditions as revealed by surveys which have been conducted in the
United States. It is altogether probable that it would compare not unfavourably at least with conditions existing in other provinces in Canada,
but, to the writer's knowledge, no such survey has been conducted elsewhere in the Dominion."
During the three years that have elapsed since this bulletin was prepared, conditions in regard to lighting, heating, ventilating, water supply,
washing facilities, general cleanliness, school toilets and desks and seats
have been on the whole greatly improved. Our method of attacking the
problem was to issue pamphlets on the most neglected phases of school
hygiene, and to conduct school hygiene exhibits at Trustees' conventions.
But our most effective means has been the work of the nurses on- the
Provincial School Hygiene staff. Besides inspecting the pupils in our
schools, these nurses make detailed reports on the hygienic conditions of
the schools. They send in definite recommendations to the School Boards
and they are asked to report a little later what has actually been done.
In cases of continued neglect the school inspector recommends a discontinuance of the government grant until the most urgent improvements are made.
I do not think that this phase of health work can be over-estimated
since it spells prevention. As a people we are still more concerned with
the treatment of disease than with its prevention. How ready a response
meets the appeal for the immediate needs of a tubercular child, but how
loath we are to spend money that will prevent hundreds of children from
developing the disease. We cannot afford to economize on the hygienic
conditions of our schools. I remember about six years ago being home ori
a vacation in my home town in Ontario, just after there had been an inspection of the pupils. There had been a clinic in connection with this work,
and a number of children had been operated on for tonsils and adenoids
and a number of them had glasses fitted. All of which was excellent. I
marvelled, however, that nothing had been done to improve the school, and
I asked if I might see the report that was made to the School Board regarding the hygienic conditions of the school. But no such report had been
made. And so the old school was left to keep on breeding unhealthful
conditions. I think I must take a moment to describe it. It was an old
four-roomed frame building situated on grounds inadequate in size and so
low as to be covered with mud except in dry weather. In summer the
grounds were covered with dank weeds. Two of the rooms were lighted
on opposite sides of the room, and in all four the amount of window space
was grossly inadequate. Two of them had only north lights. The seats
were all stationary and double at that. The blackboards were shiny, and
opaque window blinds were used. No means were provided for the pupils
to wash their hands. Drinking water was supplied in an open pail, beside
-which rested that old criminal, the common drinking cup. The floors were
dirty and the rooms were dusty, but worst of all were the outside toilets.
They were really too offensive for me to describe to you. I have related
this to illustrate how shortsighted has been some of the so-called health
wbrk carried on in schools.
At the present time, however, the need of inspection for physical defects
is great. Our school nurses find throughout our province that 88 per cent
of the pupils inspected have physical defects mostly of a remediable nature.
One of our greatest difficulties in this connection is the scarcity of dentists
'n the smaller towns. Although we did not expect intensive results since
our work is spread over such large areas, still we find that 2295 rural children had defects remedied last year, as the result of notifications sent home
by our school nurses.    But in undertaking any such work there always
17 remains a considerable number of children whose parents are not able to
pay for treatment. The Junior Red Cross in our province has now stepped
into the breach and is undertaking the treatment of such children.
Important as inspection work is we must always remember that our
aim is Health Education. We believe that there lies ahead of us a golden
day when, because of the education of all the people, there will be no need
of sanitoriums. I have been told that this school work could have no
relation to Infant Welfare and pre-natal work. I am not so sure. When
girls are taught in school the intelligent care of their own very wonderful
bodies and the sacredness of human life, they will not rush into motherhood
lightly. There is no end of literature on the care of infants and on prenatal work, but the difficulty is that expectant mothers do not realize the
need of securing it. A good deal of what is distributed finds its way into
a waste paper basket. Medical science can do no good in a general way
until the people begin to appropriate it themselves. And it is at this point
that the Health Education work of our school bridges the gap.
The cure of all the troubles of this restless world, is education, and as
a part of that great panacea we claim a forward place for Health Education.
When this work is firmly established we shall see a glimpse of what St.
JohiVsaw in the Revelation: "And I saw a new heaven and a new earth."
DR. MacEACHERN, Vancouver—
"Mr. .John Ridington, of the Red Cross Executive and Librarian of the
University of British Columbia, will address us on 'The Role of Voluntary
Societies in the Care of Public Health.'"
MR. JOHN RIDINGTON, Vancouver—
Among the notable advances of the past half-century is the recogmtioa|
and the rapid expansion and extension, of the principle of community care
and responsibility of public health. Among savage peoples the sufferer
from physical or mental ailments was regarded as afflicted either by god
or devil, and he was left, as is the sick or wounded animal by its kind, to
recover, if the restorative powers of nature could successfully assert themselves, or to die, should these fail.  •>
At an early -stage of civilization the diseases of afflicting mankind
became the subject of study, and in the long centuries of human progress
there slowly arose the sciences of medicine,- developing from incantation,-
empiricism and quackery to what is today, in some of its aspects, a science
as exact and unerring as mathematics. But until within recent years both
the knowledge of and responsibility for the physical care of mankind was
considered the special duty, as well as the sole prerogative, of the medical
profession. There was an utter absence of general public co-operation as
to the general care of health in any organized or recognized form.
Doctors, from a mistaken sense of their privileges, looked with a certain
measure of suspicion on such few efforts as were made to supplement their
services by nonprofessional aid, and, truth to tell, some of the earlier
attempts to enlist the co-operation of the laity were not of the kind to justify enthusiastic professional encouragement or support.
The only direction in which for many years the general public could I
work in conjunction with the medical man in the work of public healthj
was by provision of more ample financial means to enable them to enlarge
their sphere of usefulness. By religious bodies and private benevolence
money was contributed for the establishment of hospitals and related institutions. The benefits of these becoming more and more apparent, they were
aided by grants from citizens and towns.
The basic facts of public health became at length matters of more
general public knowledge through the publicity given them by a newspaper
press; they every decade became a larger factor in civilized life as the
result of more general education and intelligence.
The- mortality that resulted from ignorance of proper working conditions in the revolutionized industrial and economic conditions that came in
consequence of the factory system resulting from the invention of the
steam engine and the adoption of power machinery—the mortality that came
from congestion and the slums, from the exploitation of child labour, from
18
—al occupational diseases—the terrible toll of tuberculosis and infant ailments—
these things became more generally known, and their grim significance in
the national life somewhat understood and appreciated.
City and state governments, being reflections of the citizency appointing
them, began to take cognizance of these conditions, and there was thus
gradually built up a realization that the care of health was a responsibility
no longer to be wholly assumed by medical men, but that it was also one
of the obligations of governments. At first concerned almost solely with
the control of epidemic and infectious diseases, this newer function of
government has extended and expanded in scope, until at the present time
there is, in the more advanced countries, hardly an aspect of the physical
welfare of the community that is not accepted as much a part of governmental responsibility as national defence by army or navy, or a postal
syste'm, or a municipal fire brigade.
This was a notable advance, but the individual citizen had little or no
more personal share in the' new activities than in the days when epidemics
were regarded as visitations of God, and the medical profession fought the
fight against diseases alone and unaided. The ordinary citizen reported
diphtheria or measles, submitted to isolation when infectious diseases afflicted his household, had his children vaccinated, their eyes tested and teeth
examined—refrained, sometimes much against his will, from putting them
to,work before prescribed ages, and paid, with more or less cheerfulness or
reluctance, the taxes the new fangled health service necessitated. But while
benefiting with the community at large, from the gradually improving conditions that became more and more evident as public health service developed,
he saw no necessity, nor manifested any desire, to participate in the movement that each succeeding census showed was creating superior standards
of physique, reducing mortality, lengthening life, and generally broadening
the basts of human welfare and happiness.
The beginnings of community co-operation in the cause of public health
. first became general in the early days of the century. When the Great War
broke out six years ago, there became manifest a widespread—indeed a
universal—desire, a desire that amounted to a national and individual passion, that all that thought, labour and money could possibly do to give
whatever of help or comfort was possible to our brothers, fathers, husbands,
and sons who represented us in the firing line, should be provided. No
sacrifice was too great either in toil or in treasure, if the lot of the nation's
representatives on the battle lines could be lightened. In less than a week
from the outbreak of war the Canadian Red Cross, for years a moribund
institution, sprang into national activity, and soon there was not a village
or hamlet in the wide Dominion where women were not knitting, sewing,
and making surgical dressings. If the scope of today's discussion permitted, the  story  of  the  Canadian  Red  Cross   during  those  five  terrible
' years might be sketched, at least in large outline. It is a glorious story,
that may well make tingle with reverent gratitude and patriotic pride, not
alone every Red Cross worker, but every son and daughter of Canada.
Hitherto, unthought activities were month by month grafted on to the
recognized scope of Red Cross work, and behind this work, and its new
subsidiaries, supporting and energizing it, making it effective, national,
colossal] were literally thousands of volunteer organizations, some connected with churches, others with fraternal societies, others devoted to
particular military units, and yet others organized for special needs, but all
co-operating in a common humanitarian and patriotic cause, and each rendering some needed element in support of the nation's military effort. And
as the struggle grew more protracted, and hope of victory was deferred;
as the lengthening casualty lists were issued, and men shook hands in silent
sorrow with war-bereaved friends, there grew up in Canada, and in every
nation at war, a sense of community care, of personal as- well as national
responsibility for those on whose behalf -we laboured. And as we worked
we came to realization—a heartenirig realization—that we were really doing
something to help. We found joy in the consciousness that the care of our
men was not merely .the charge of an impersonal government, but of ourselves, and the sense of inward satisfaction that came from the knowledge
19
L that we were doing our share to discharge these obligations stimulated us
to greater sacrifice, more active industry, higher endeavour. It was natural,
inevitable, that this quickened and aroused sense of kinship, of personal
responsibility should be extended, even during the war, to other worthy
objects not essentially military. There never was, in the whole history of
Canada, so widespread and general a sympathy for all worthy causes, moral,
mental, or physical, as during those years when Freedom was in peril of
perishing from the earth.
This quickened consciousness exists today, despite all we may hear of
"reaction," due to the disappointed hopes that sustained us through those
dark and terrible years. The war has accustomed us to co-operation in
countless directions by voluntary societies of every imaginable sort Many
of these voluntary societies have disbanded, others are disintegrating, but
many of them still exist, and, realizing the effectiveness of their aroused
sympathies, their effective labours, can find benevolent expression. Many
of those that are moribund could be resurrected into active, effective agencies
if a worthy cause were so presented as to show a real need. Why cannot
these organizations, these voluntary societies, be enlisted in some of the
various phases of the cause of public health? Why should not these great
reservoirs of human sympathy and human energy be diverted into these new
and needed channels? The menace that• necessitated the whole DomiriidjB
springing to arms is, we believe, finally crushed: to all present seeming we
can look forward to coming years of peace. Can we not provide a permanent outlet to those instincts of generosity and helpfulness that found
such magnificent expression between 1914 and 1919? Ought not this fine
experience to be continued? Must it be wasted, its lessons forgotten, and
men and women who have learned the satisfaction of helping others go
back to futile and selfish activities? Cannot the strong still continue to
bear the infirmities of the weak, and embark on a new ministry of love
and service?
Some of our voluntary societies are already doing this. Foremost among
them is the Red Cross, which, from an organization designed solely to help
soldiers in the field, is today undertaking a programme totally different, but
equally patriotic, equally necessary, now that "the war drum throbs fnR
longer, and the battle flags are furled." It has secured from the Canadian
Parliament changes in its charter that authorizes it in days of peace to
undertake, on its own initiative, or in co-operation with governments and
medical authorities, a public health programme that justified nation-wide
support. Here in British Columbia the Red Cross is co-operating with the
staffs of our mental hospitals. It has given appreciative financial assistance
to the Victorian Order of Nurses; it has undertaken to establish a system
of Red Cross Public Health Nurses in sections of the province remote from
hospital or medical care—a service that is co-operating with the school
authorities, and already doing valuable service in soldier settlements. It
organized a convalescent camp at the seashore, at which hundreds of soldiers,
weary of long months of hospital routine, were re-heartened and re-invigorated and many cured. It has undertaken educational leadership in the cause
of public health, having obligated itself to maintain for a period of at least
three years, a Chair of Public Health in the University of British Columbia
—the first chair of its kind on the continent to be maintained by any voluntary society. It is looking forward to enlarging these services,' and originating others, as means and opportunities permit.
What are the results of these new activities of the Red Cross in British
Columbia? Not the least important, from its own point of view, is the fact
that the Society is not disintegrating, but is still an active, energetic organization, with aims to be accomplished that summon and challenge the fine
qualities so splendidly demonstrated during the war. Should, unhappily,
war again break out, the B. C. Red Cross will be ready, the organization
will not, as in 1914, have to be created under the dreadful urge of instant
necessity. Should another disaster, such as that that overtook HalifaSI?
occur,—a serious mine accident, a powder mill explosion, an epidemic—=tiBl|
Red Cross will be ready for service at a moment's notice.    Its personnel,
20 ■■
its supplies and equipment,  its moral and material resources, can at once
be turned from its normal avenue to the channel of the new emergency.
1 And while in time of peace the Red Cross is thus prepared for war, of
what far-reaching and permanent benefits to the district, the province, the
nation, are the new public health activities that keep it in condition for
urgent and military service? The Red Cross is helping reduce the terrible
number—35.000 a year—of babies who die in Canada because of neglect,
indifference or ignorance. It will help lessen the thousands of Canadian
mothers who die every year for lack of proper pre-natal care and attention
in time of confinement. It will lessen, proportionately, too, the greatly
increased number who suffer preventable illness or lifelong impairment of
health. Canada's yearly tuberculosis toll is 8,000—one quarter of all who
die between twenty and fifty are victims of the Great White Plague. We
can greatly reduce this drain on our national vitality, and such services as
the Red Cross has begun to render will assist materially in so doing.
Behind the battle lines in every army are the reserves. In the fight for
lengthened life, better standards of living, sound physique, the same holds
true. Our medical men, our hospital staffs and nurses, our research investigators, with the hospitals or laboratories to which they are attached, con?
stitute our front line. Close behind these are our Boards of Health, our
municipal and provincial governing bodies, that by authoritative regulation
and compulsory or optional education, prveent much of the disease formerly
regarded as inevitable. Co-operating with both, there is room for unlimited
voluntary effort of the widest variety of value and interest From widespread education of the fundamentals of public health to the actual and
practical technique of health service, for both sexes and all ages, and for
almost every variety of mental and physical disability or affliction—the
field is wide enough to engage some aspects of every citizen's personal
interest and activity. .The more varied the needs sought to be met, and the
more numerous those engaged in the work, the more quickly will the principles of public health be understood, the more thoroughly they will be
appreciated, with resulting henefit to the community, the nation, the race.
Every hospital, every health institution, every nursing organization, not
alone at headquarters, but in -every locality in which it operates, should have
one or more, according to its need and scope, volunteer societies seeking and
finding means to reinforce and supplement the public work it is performing,
to buttress it in public confidence, and thus make its activities more effective-and more widely known.
.These volunteer organizations should have representation on the executive or governing boards of the services they assist, and every means possible should be adopted to stimulate the interest of the members in the
work they are aiding.
I am of the opinion that the present is an opportune time to enlist the
active help of volunteer societies in the cause of public health. From sea
to sea knowledge of physical disability was never so exact or so general—
that was among the fruits of the war. Nor was sympathy with a progressive
health programme so widespread or so active. Nor lastly, were the means
to make a notable advance ever so available as at the present time. For
almost every item on a progressive public health programme little or big
bands of men and women can be organized, if they are not already in _ being,
that will render in days of peace the same devoted, conscientious, intelligent, effective help that they gave their country and its cause in the days
of war.
DR, MacEACHERN, Vancouver—
"We will now have a paper on 'The Co-ordination of State and Private
Enterprizes in Public Health Work,' by Dr. W. H. Hattie, Provincial Health
Officer, Halifax, N. S."
DR. W. H. HATTIE, Halifax—
- Four years and more of the stresses an'd distresses of war taught us
many a useful lessoir We learned something of our strength, something of
our weakness, and a mighty lot of the value of co-operation.   We learned
21 that even a destructive force, to be efficient, must be cori"served—that the
outcome of the struggle depended not merely upon the number of the enemy
that could be killed, but to a great extent upon the number of our own
soldiers that could be saved. We .learned that conservation of health and
life is a practicable thing, and not merely a pleasant fiction. And we learned
that a righteous appeal meets with a worthy response. These are but a few
of the lessons, jolly well needed, which the great experience taught us, but
the greatest of them all is the value of team work, with absolute unity 9
direction.
Such wars as that from which we have recently emerged are but episodes in the history of the world. Though rightly called the great war, the
devastation it caused was trivial, and its influence upon mankind will be
but ephemeral, in comparison with a struggle which has waged incessantly
from the earliest times and which will continue as long as the world lasts.
On the one side, every living soul—on the other, the hosts of death; and
never a doubt as to the ultimate result. This, too, is war—war against a
relentless foe which respects neither age nor sex nor social position, which
never asks for a truce and which never enters into a treaty. We cannot
hope to completely conquer such a foe, but we can combat it so that it®
ravages may be materially lessened, and its toll of life and efficiency and
material things may be greatly reduced. Even such a result is well worth
striving for, and the degree of our success will be determined by the intelligence with which our efforts are directed and by the harmony of our team
work. The handicap under which we are placed permits of no misdirectloM
or dissipation of energy.
Nothing has been more heartening to public health workers than the
growth  and  spread of  interest in public health possibilities  which  recenjg
years have witnessed.    The stimulus has been felt in many ways, and has
aided greatly in furthering advance.    While zeal may at times have outstripped prudence,  leading to  multiplicity  of organizations  with  resultant .
overlapping  and  perhaps  clashing  of  interests,  the  tendency  towards   coordination of effort has been steadily becoming more evident.   And, now that
the League of Red Cross Societies has been formed with so magnificent a-
purpose in view—"the improvement of health, the prevention of disease, and
the  mitigation  of  suffering throughout  the  world"—we  have  an  ally  the.
strength of which can scarcely be overestimated, and which has the unquestioned confidence of the people of every nation.    If then we take advantage,
of this alliance and determine upon effectively correlating the activities of
all agencies with similar aims, whether they be state or private organiza-J
tions, in a united endeavour to improve the general health, we should make,
tremendous strides towards our common goal.    And because of Red Cross
connection there should develop a feeling of mutual interest and sympathy
among nations which should become- a most important factor  in  securing"
and preserving peace throughout the world.
It is particularly gratifying to those in the service of the state that the
League of Red Cross Societies has definitely recognized that the prptection
of the health of the people is a responsibility and a function of government,-
and has decided that public health work under Red Cross auspices will be
supplementary or complementary to that underftaken by other voluntary and
state agencies. The readiness of so powerful, an organization to enter the
public health field in what might almost appear to be a subordinate position
is indicative of the splendid spirit which actuates Red Cross activities generally. It, moreover, shows the consistence of an organization which has
won a reputation for such efficiency as can be attained only through centralization of authority. So fine an .example will doubtless overcome any
hesitation which other agencies might have in agreeing to carry on their_
undertakings under greater or less control by a central authority. It is very
human to desire independence of action, and to crave public applause, but j
in the great work of saving life and of increasing the comfort and happiness
of mankind the attitude of all good workers will be one of complete unselfishness.   -
When, therefore, it is said 'that the general direction of all health work,
should be in the hands of the health administrator of the state, it  is not
22 because of any -wish that such official should receive anything more than
merited kudos for the results achieved. It is because such an official is the
logical person to whom this great responsibility should be assigned. Much
public health work can be carried on only under statutory enactments, for
the formulation and enforcement .of which the state is responsible. Practically all the progress which has been made in this work has been either
initiated by or made possible by state health organizations. Much of the
larger part of the expenditure which has thus far been made on behalf of
the public health has been from state funds. Officials of the state have
opportunities for acquiring information as to both general and local needs
and for determining the most promising lines of action which are in but
exceptional instances available to private persons. And the people generally have come to look to the state for leadership in such matters. If.
therefore, we are to agree upon the principle of unity of action, it would
appear that the co-ordinating and harmonizing force should be the state
organization. It certainly should not be hoped that any private enterprise
could be assigned such a place without arousing the antagonism of other
agencies which are doing most useful work along similar lines.
* The amount of control which the state organization might exert over
private enterprises should, however, not he more than is necessary to prevent wastage of funds and effort. As far as possible there should be no
interference with automony. Every possible assistance should be rendered,
every encouragement sjiould be offered, and every credit should be given
by the state organization to the co-operating agencies. And while all
private activity in respect to health work should perhaps be conditional to
the sanction and oversight of the state organization, the pressing need for
such private activity and the unquestioned value of a great deal of the
opinion which evolves from such sources, should prevent any unreasonable
interference with the work they are carrying on. There should, of course,
be frequent conferences in order that there may be definite and complete
understanding in respect to policy and the relationship between the various
organizations.
While not suggesting that there should be any diminution of state activity or lessening of state responsibility in matters which are definitely
functions of the state, it would appear that unofficial organizations could
materially aid in the furtherance of our aims' by encouraging investigation
along promising new lines, especially through financial assistance to laboratories; by assistance through endowment or otherwise in the teaching of
public health to medical students and others—as to graduate nurses who
desire to enter our field and to those who wish to engage in welfare work;
and by assistance to national organizations now engaged in propaganda
which has a bearing on public health. The proposal of the Red Cross
Society to provide in whole or in part for the support of public health
nurses in communities in which local funds are insufficient for such a purpose is a most practical method of co-operation. Further assistance might
be rendered by furnishing paid and voluntary workers to help at health
centres, health clinics,, etc., in rendering clerical aid, stimulating interest,
distributing relief, and carrying on such other work as does not require
technical training, so as to conserve the time and energy of those who have
such training. In such ways immense impetus would be given to the work
of the official agencies.
The inspiring programme which the League of Red Cross Societies has
laid down, and the splendid work on behalf of the public health which has
been carried on by the Victorian Order of Nurses, Antituberculosis Leagues,
Child Welfare organizations, local nursing associations, women's institutes
and kindred enterprises, merit our heartiest commendation. The self-sacrifice shown by so many of our people, who have given freely of their time,
energy and substance in the effort to ameliorate the conditions of their less
fortunate fellows, cannot be too highly extolled. Those holding positions in
the service of the state owe to these noble people a really burdensome debt
of gratitude. We need the stimulus and the encouragement as well as the
help they give. It is with no desire that their activities should be curtailed,
or that any irritating restraint should be put upon them, that it is suggested
23 .that they should work under state direction, but rather to increase their
efficiency and to obtain through harmonious co-operation the best possible
results in "the improvement of health, the prevention of disease, and the
mitigation of suffering."
DISCUSSION
A few minutes were spent in the discussion of these papers.
Dr.-J. G. Fitzgerald, Professor of Hygiene in the Toronto University,
opened the discussion, and paid a tribute to Miss Browne for the excellent |
paper on Public Health Education in Saskatchewan.    He stated that "we
^have the scientific knowledge of hygiene, etc., but do not put it into practice;" also, that many diseases could be controlled, such as diphtheria, ctK
Dr. Bounden, of Quebec, spoke of the Health Educational work cameos-;
on in the convent schools by the sisters who had special training in Public
.Health work.
Dr. George, or North Bend, discussed Miss Randal's and Miss Johiijsg
paper.    He was greatly impressed with the organized work of The B. C.
Graduate Nurses' Association in trying to protect the graduate nurses.   He
also spoke of the necessity of home helpers in the rural communities where,
graduate nurses were not always available.
Dr. H. E. Young expressed his thanks for co-operation of The B. C.
Hospital Association, and stated that the papers read at this session were
of vital importance, and paid a tribute to the nurses who had given such
valuable suggestions in their papers. He also stated that Mr. Ridington's
paper contained valuable plans as to what the Red Cross Society was prepared to do in health work in British Columbia.
Meeting adjourned.
NURSING SESSION—WEDNESDAY, JUNE 23rd, 1920, 2:00 p.m..
The meeting was called to order by the President, who extended to all
the delegates a hearty welcome. He pointed out that this convention was
being held at the same time and place as several other important national
health and medical conferences, constituting one of the largest meetings of
this kind ever held in Canada. Many present would have opportunity of
attending sessions of the other meetings, if interested, and by so doing
secure great benefit. He made several announcements to the delegates, particularly calling their attention to the special exhibit demonstrations, the
accommodations of the building such as rest rooms, cafeteria, and to the
reception to be held that' evening. He then called on Miss Jessie F.
MacKenzie, R.N., Superintendent of Nurses, Provincial Royal Jubilee Hospital, Victoria, B. C, to preside at Part I of the nursing programme for the
afternoon.
MISS JESSIE F. MacKENZIE, R.N., Victoria—
"I will now call on Miss Helen Randal, R.N., Registrar of the B. C
Graduate Nurses' Association, for her paper entitled 'A Survey of Training
Schools in British Columbia.'"
MISS HELEN RANDAL, R.N., Vancouver—
When at the first gathering together of the graduate nurses of British I
Columbia in 1912 to organize the Graduate Nurses' Association of British
Columbia, one of the first matters that was felt to be of vital importance
to it was that of a Registration Bill to be presented to the Legislature; the |
feeling of those present being that by it the status of the nurse graduating
from the training schools of the province would be established, the public
safeguarded, and last, but probably as important, the standards of the various sized training schools might be arranged that no hardship would occur
to even the smallest, and that the largest should act through affiliation in
such a way as to help all who needed help. It was most strongly insisted
upon that we had no right to ask for legislation until we could assure the
smallest school that if there was lack of training along special lines, or
when the -number of cases of all kinds was not sufficient to give proper
•experience that each pupil was entitled to, this lack would .be filled through
the courtesy and help of the largest hospital training schools in our provinetR
24 It was not till_ after the Act was put into force in 1918 that the important
matter of making a training school survey was considered. At the September, 1919. general Quarterly meeting of the Graduate Nurses' Association
of British Columbia plans were made to reach the schools through the
assistance of the Registrar who would go and visit them, look over the
hospital and possibilities, its training school equipment, etc., meet, whenever
possible, the hospital Board and in addition to talks to pupil nurses and
the resident graduate nurses of that town, reach, when asked, the high
school girls and through talks with them see what could be done to urge
them to continue their education in the high schools, till they graduated,
urging the plea that in all walks of life the educational start was indispen-
sible, and that time could never be recovered or the lack replaced. In all
cases the school authorities were glad to have the point of longer attendance
at the secondary schools impressed 'upon the children, and considered the
talks as distinctly educational. We have felt for a long time that the
proper place to begin our propaganda for better nursing conditions was
with the Boards of the schools for nurses connected with our hospitals.
To too many of our hospital Board officials there was practically a
total lack of real understanding that our nurses entered the hospitals as
pupils, or that as a school there was a definite contract entered into between
the probationer and the hospital that she was to have a definite course of
study, both in theory and practice, and that equipment, books, time for study
and above all, teachers who were competent to instruct her in all the branches
included in the curriculum, provided. In exchange for this she gave her
services to the institution, her hard work forming the practical working
out of the theory she was supposed to be taught.
In October, 1919, I left for some of the schools on the mainland, and
throughout the whole survey found the greatest courtesy and consideration
and the acknowledgment that this meeting together of those interested in
nursing progress with those interested in the better conditions of hospitals
and schools as represented by the Boards of these institutions must result
in mutual help and understanding of the difficulties connected with the
work. The chief difficulty seemed to be, as in almost everything else at
the present time, the lack of sufficient income to meet the increased cost of
living, and the shortage of those wishing to take up nursing as a life work.
While the Boards realized, and expressed themselves very frankly in favor
of the shorter hours, better housing, more instructors and better supervision
by graduate nurses, there was still the painful showing on the books of a
deficit, or at best, nothing left for the school as an educational part of the
hospital. There, was full and free discussion of conditions and all agreed
that with enough money to finance, improvements as to educational and
housing standards would be easy to accomplish. The nurses, pupil and
graduate, were pleased to bring us all together in the one wish for better
and higher standards, and the high school girls were- keenly alert and
appeared ready to take in the earnest appeal that they should continue their
education through the high schools, and the nurse's life with its opportunities—greater than any other profession that women have open to them of
advance—was shown to them, though not to the exclusion of other forms of
woman's work which all require the higher education to fill.
The hospital Boards' viewpoint showed that we must bring some plan
to them to help the financial side of the school, and the suggestion is now
made that a direct appeal be made to the Provincial Government for a
definite sum to be spent on education of nurses alone. Sums are asked for
special equipment, buildings, etc., but the educational requirements of those
entering a school are quite overlooked. Education of nurses in training
schools is distinctly something that is "up to" the Departments of Education,
as it is a special school or secondary school, which should be financed by
that Department. There was an appalling lack of school equipment in most
cases, nothing in fact that would lead one to suppose that young women
were in a "school." Cheap nursing to the advantage of the hospital and to
the detriment of the pupils has been gradually taken as something too common to  notice.    The   standard  curriculum  was  presented,   and   a   definite
25 willingness expressed to buy such equipment as is required. Suggestions
for the improvement of our British Columbia schools are as follows:
(a) Presentation of the case to our Legislature of the right of training
schools in hospitals to be financed in part by government money.
(b) Standard curriculum and inspection of schools to be enforced.
(c) Training school houses or accommodation for nurses to be provided.
In too many cases was this found sadly deficient—rooms crowded,
generally in hospital buildings where no opportunity for recreation
was provided—no room for laboratory, diet kitchen or study provided.
The Registrar feels that in every city a suitable home could be built and
the money obtained if a strong campaign of advertising for a "drive" among
the citizens was started. The nurses are or should be residents of the
province, and an appeal for better housing will carry much weight. Part
of salary of instructors, equipment and even buildings should be asked,
not as a favor, but as educational right, from the government. Enough
money, good accommodation and the continued appeal to high school girls,
with the shorter hours and knowledge of a successful equipment for after
life, will bring again the application of these young women to our schools.
Records were inadequate, and a sample standard record sheet is to be
presented at the next visit to the schools.
It is with great pride in our future that the Registrar reports that in
training schools it was not alone the large ones that had a realizing sense
of responsibility, but in some of the smaller ones it was shown that not
size but interest and responsibility as a training school counted, and in all
cases the needs of the patient were considered first; which spirit of service
is the keynote and the beginning of the nurse's training in her work as a
graduate nurse. This she is, after obtaining her diploma, no matter what
her future activities are and her responsibilities as such and as a citizen,
leave these conditions in the schools, if unchanged, a constant reminder to
her of a duty undone.
In the Graduate Nurses' Association at their annual meeting they decided to again pay the expenses of the Registrar to repeat her survey. "This
is not an inspection of schools. We can, through our Association, make
these surveys and thus bring about the changes and improvements that we
wish.
(It was deemed advisable to withhold all discussion till the papers were
all read).      i§0±
MISS JESSIE F. MacKENZIE, R.N., Victoria—
"I will now call on Miss M. P. MacMillan, Superintendent of the Royal
Inland Hospital, Kamloops, B. C., for a paper on 'The Shortage of Applicants
for Training—the Causes and Suggested Remedies.'"
MISS M. P. MacMILLAN, R.N., Kamloops—
It is apparent to all who have been closely connected with institutional
work during the last four or five years that there has been a great need
for greater numbers and better types of applicants for our training schools.
This shortage of applicants has been partially due to the engrossing nature
of war work and the filling of positions left vacant by men who had gone
overseas; the latter condition has not improved, as .a great many of the
men who have returned came back unfit to resume their former work, and
women who have stepped into the breach are not now willing to leave the
field of commerce and enter a profession which will mean a number of
years of hard work and small remuneration. In this age no one should be
idle; all should have an aim in life, and many fine types of womanhood ate
going into commercial life not only on account of having to earn their
living, but more especially on account of large salaries. Money at the
present time is one of the chief attractions, notwithstanding the fact that
large salaries are necessary in these times to meet the increased cost of
living. On the other hand, there are many cases where parents find it
impossible to give their daughters financial assistance and the hospital does
not pay enough to allow for clothing—only sufficient to cover their sundjy
26
 I expenses; consequently girls choose the profession which  in their opinion
will make them more independent.
In order to encourage girls who are either indifferent to the profession ,
of nursing and its possibilities, or come under the classes before mentioned,
I would strongly recommend that everything be done that lies within the
power of the hospital to make the training school and nurses' home well
equipped and attractive in the most efficient manner and as far as possible
try to reach those whose home training has been a matter of careful consideration. Girls who have been taught to think and live in a reasonable
manner are an asset, their minds are well balanced and their influence for
good is felt.wherever they are. It is only fair they should be kept in healthy,
pleasant and attractive surroundings. We should be willing to give the
best before we can expect to receive the best.
When nurses come off duty tired in body and mind, as the duties of a
nurse are a strain mentally and physically, how refreshing it would be for
them to go into rooms that did not in any way suggest—hospital. A large
cheery reception room, nice pictures on the walls and good books besides
hospital matter. I would suggest a social evening occasionally, nurses could
invite their friends and there is always someone who can play, and dancing
is one of the best entertainments. It is always well to remember that where
too much restraint is enforced students will think; their liberty is .being
taken "away and will seek enjoyment away from .the hospital, which is not
the best for the nurses themselves or the hospital. Too much restraint very
often sows the germ of discontent which grows rapidly and very soon has
spread beyond the walls of the institution and hinders to a great extent>the
decision of prospective applicants.
Some hospitals have considered the question of increasing salaries and
have already carried it out—junior, intermediate and senior years respectively $10.00, $15.00 and $25.00 per month. Since living expenses have increased greatly in the last year or two I believe this is essential, although
I do not believe that students should be paid too much, when we consider
that they are acquiring a profession; at the same time they must have at
least the bare necessities, and even with the increase mentioned it is very
difficult for them to have a little for pleasure, and we cannot expect them
to economize until it hurts.
The question of employing maids to do the dusting, bathroom work
and washing of diet cups, is one perhaps worthy of consideration; although
I believe nurses should be taught to do this sort of work, for the reason
that when they leave the hospital they will doubtless go into homes where
they will have to see that this work is done properly and it will in all
probability be necessary for them to do it themselves. Many hospitals have
adopted the eight-hour day system, but I think the individual hosoitals
have to work this problem out to suit themselves. In any case, shorter
working hours should be adopted, and I am sure all superintendents feel
this, and as soon as we get the required number of pupils conditions will
be improved.
One of the greatest advantages of the modem training school is a well
equipped class and demonstration room. Nothing should be left undone
towards equipping this room in a most efficient manner. The teacher
should be able to bring out the best in the pupil nurses, impress upon them
the greatness of the profession which they have chosen in life and create
- in them the desire to give only their best, and do all in her power to
make the classes something for the students to look forward to with
pleasure. I would suggest standard equipment be used by all hospitals.
I am trying to equip a demonstrating room under difficult circumstances,
as the hospital .has- outgrown its capacity. I have the Chase hospital doll
and copper-wired skeleton, and intend to get a lantern with teaching slides
and the different charts.
DISCUSSION
Dr. H. C. WRINCH, Hazelton—
I want to express my very very high appreciation of the papers that
have' been given at the convention today. This morning they were of such
a nature thai I cannot find words to express my high opinion of them for
27 the splendid material which they contained.   The papers this afternoon are
equally good.
In regard to Miss Randal's remarks I have noted four points which'
I want to take up. First,—let me say that in the training of nurses a high
standard has been set. We are all agreed upon that. The Nurses' Association have wisely set a high standard for their nurses to attain to. I
do not for one moment think it is too high, for they cannot be too highly
trained, nor can we in any phase of our work, whether nursing, medical
or other be too highly trained and efficient. The standard is so high that
it will qualify nurses for the highest position they may take, which we
very much want and desire. Miss Johns' paper this morning was excellent
and shows the value of the most highly trained nurses we can have. This
brings me to my second thought. It seems to me that up to the present
the standard has been prepared well and high, but it is admitted that a
lower standard or a less elaborate course could be taken by those doing
bedside nursing, and particularly the smaller training schools where teaching
facilities may be more difficult. Today we find several training schools in
the province affiliated with some of the larger ones. The nurses are taught
in their home training schools and then they go to the affiliated school for
the third year and final examinations. In order to fall in line with the
other training schools these nurses must have a thorough ground work in
their own schools. The present curriculum is almost too large and extensive
to be covered properly with the average facilities available, and if it were
boiled down or limited so that the teachers in the smaller training schools
could have a better idea of the extent of the subject on which the pupil
was to be examined, it would give them a better opportunity to prepare
them. I would suggest that a curriculum be prepared for nurses doing
bedside work, as the present one seems somewhat extensive and difficult
to carry out in our training schools. Thirdly,-r-it is very easy to find teachers
for the pupils in the larger centres where there is all kinds of material to
draw from, including doctors, trained nurses and other highly trained
people in every phase, but it is not so in the smaller schools where there is
a trained nurse and a night superintendent—the minimum number who can
conduct a training school—and perhaps one or- two busy outside practitioners. Where then, are these people to get their training before they go
to the final year of affiliation? Are they to get all in the final year? We
should not only have it defined as to how much they are going to get in
their own home school, but I would further suggest that instead of the
Nurses' Council requiring a superintendent and a night supervisor on the
staff of training schools, that they require a superintendent of nurses and an
instructor. Smaller hospitals can get along nicely without night supervisors, but we require more trained instructors. We have been told that
the Nurses' Bill and the whole organization is yet in a form of elemental
stage, subject to any changes that will.improve it. I would like to see the
clause changed to that of an instructor instead of a night supervisor. We
are agreed it is often difficult to find one who is good at executive -work
and a good instructor. However, instruction is the all important thing.
My fourth point is another suggestion, and is: that marks in standing
on term work should be taken in lieu of making their whole standing
depend on their final examination. If fifty per cent, of their standing were
given for the term work that these nurses have performed in their home
schools ,the final examination perhaps would be a fair test. While the
University course is fairly well defined, the other has yet to be defined,
and it almost seems that we are beginning at the wrong end. We must
have the examination of these -nurses for the general work and they will
be ready for that before they go through the full complete course. I am
delighted with the University course for higher trained nurses.
MISS HELEN RANDAL, R.N., Vancouver—
Dr. Wrinch's hospital is one where the interests of the nurse always
comes first, and I am very much pleased with the whole attitude of the
hospital staff. So far as the examinations go, I think I can safely assure
Dr. Wrinch that nothing but the essentials will be taken along all nursing
subjects. The principles, so far as surgical and other forms Tjf nursing
goes, are all the same.   I do not think there will be any -difficulty so long as the nurses have been taught those principles. So far as taking their
term-work marks into consideration, that is a matter which will have to
be taken_ up when working the plan out. Until we get our teaching more
standardized I am afraid the standing will have to be set pretty much on
the final examination. However, I have always felt that term-work should
count, and we will certainly take this up in our council meetings before the
examinations commence.'
MISS PAULINE ROSE, R.N., Nanaimo—
There is one point I do not agree with, and that is making- a higher
salary for the nurse-in-training. I think anything of this nature places
nurses on a lower standard, -and I think you will find in keeping the
salaries at the regular amount as has a rule been allowed for nurses-in-
training, that the standard of nurses will be kept higher. When the salary
is raised you will find more of a menial class wanting to train. To my
mind there are several reasons for the shortage of applicants,—
First   —Inadequate education given by many schools and the standard
of   our   school   being   put   up,   which,   of   course,   I   heartily
approve of.
Second—The long hours of duty.
Third —The unattractive living conditions which Miss MacMillan has
pointed out.
Fourth—The shortage of students which is felt in all institutions and
branches of work at the present time.
Fifth   —So many hospitals opening throughout the country, making it
very hard  to fill  all  the  posts.    No  adequate  supply  can  be
secured through the usual sources with suitable standards, and
therefore such standards have been lowered to meet the current
needs of such institution.
The large majority of nurses  are lacking in two  respects—they  are
neither old enough nor have they the necessary education to enter upon the
course of training.   The age limit, until the last few years, was  twenty-
three years, but this has been reduced till now they are taken in at the age
of eighteen.   It seems to me that these immature girls are hardly equal to
the heavy physical- demands and responsibilities that await them, and it is
hard to safeguard and protect either* patient or puoil under these conditions.
There are so many other openings for girls since the war where they
need only perhaps take a  six months' course to fit them for their work,
when they are able to obtain a position at a  salary nearly equal  to the
girl who has been doing three years' hard work, even supposing she has her
profession at the end.
A few suggested remedies :—
First   —Have all training schools placed on a proper educational basis.
Second—Establish eight-hour duty (though in small hospitals we cannot
always do that.)
Third —Proper living conditions.
Fourth—Education of the public to the value of the graduate nurse.
I think a  great many people,  especially throughout the country  are
perfectly willing to have an under-graduate if they can attend the homes,
if the case is not serious, but when it comes to a time when the case requires
someone with a better training they then turn to the graduate nurse.
It seems probable that our main supply of nurses for training must
come from the high schools and colleges, and consequently our profession
must be kept in the-foreground so that these pupils, in thinking of what
they intend doing when finished school, will at least know something about
nursing. The only way. to accpmplish this is to appoint someone to address
these pupils at intervals on this subject. The country girl as a rule makes
a very excellent nurse but is often handicapped owing to insufficient
education.
MJSS HELEN RANDAL, R.N., Vancouver—
I do not agree with one idea expressed by Miss Rose in her remarks,
that is the amount of money given to the nurses when in training, which
she claims should not be increased. I think it should. It is all very well
to say that we do not want a menial type of nurse.   We do not, but I think
29 it is perfectly absurd in the face of the price of things today to expect a
young woman to provide herself with boots alone on $8.00 per month. Hospitals must either provide her with these things from their own funds or
raise her allowance. She cannot give herself any recreation or clothe herself
on that amount. Some hospitals provide hospital uniforms, books and
boots. I feel we are going about things in the wrong wav, and it is the
menial end of it that has to be looked after. We cannot get nurses in and
expect them to do the menial work; in some hospitals today they even have
to do the spring cleaning.    It is rather a shortage of maids.
MISS PAULINE ROSE, R.N., Nanaimo—
We pay more than $8.00, we pay up to $15.00 for our nurses. I do
not think over that amount would be advisable.
MISS E. I. JOHNS, R.N., Vancouver-
There may be exceptional cases. Many of the pupils would find it a
very great hardship.- The Red Cross offers scholarships to suitable young
women which would help them during their period of training. I think the
idea was to deal with cases individually and to provide for the good type
of applicant who would finance herself by means of this scholarship.
MRS. J. D. D. BROOM, R.N., Vancouver—
I do not fully agree with Miss Rose. At the same time every nurse
needs to be thoroughly domesticated, to know housekeeping and be a good
cook.
PART II
Round Table Conference conducted by Miss E. I. Johns, R.N., Director of
Nursing, Vancouver General Hospital and Director of Department
of Nursing, University of British Columbia.
MISS E. I. JOHNS, R.N., Vancouver—
In planning this programme it was thought better to indicate by some
means what the general trend of discussion was to be. It was therefore
considered most advisable that we should have a round table conference
on 'Nursing service in hospitals of twenty-five beds and under..' Large
hospitals have their problems also, but I have been, until I came here, in
charge of a small hospital, of which I am truly proud, because I feel that
the small hospitals are doing some of the most unselfish and heroic work
that is being done anywhere. Their problems are often difficult, with mighty
little force behind them. There is nothing of greater importance than trying
to build up and augment nursing forces in the rural districts and giving to
the people in the province a proper nursing service. Our subject is divided
into three sections, the first section being (a) Nursing by graduates only
,or by nurses-in-training. I will ask Mrs. M. E. Johnson, R.N., Superintendent of the Bute Street Hospital. Vancouver, B. C., to open the
discussion.
MRS. M. E. JOHNSON, R.N., Vancouver—
A. twenty-five bed general hospital with a daily average of twenty
patients, when properly equipped, could advantageously conduct a training
school for nurses, giving the pupil nurse a good training and the patients
a good nursing service,- but any hospital under twenty-five beds will find
it very difficult indeed to conduct a training school and give the pupils
adequate training without affiliation with the larger hospitals in the third
year. Therefore the question arises : how can we have an efficient nursing
service in such a hospital? I consider a staff of graduate nurses with
ward ma'ds, attendants or helpers, will give a much better nursing service
with very little more expense. In conducting a training school however
small, two graduates are required for teaching and supervising, and a much
larger staff of pupil nurses required. The living expenses of the pup"
nurses and the equipment needed to carry on training school work will
offset the larger salaries of the graduate staff.
In my own private hospital of fifteen beds I employ graduates and
one or two attendants who have had some training school experience for
routine hospital w^rk.   The staff is on eight-hour duty and live outside the
30 hospital. Their salary includes meals when on duty. I would not think of
conducting a training school or even an affiliated course of training. In
my opinion, small hospitals, by employing graduates, can give a much
better nursing service and are relieved of a great responsibility of conducting
a training "school under such conditions.
We have heard a good deal of the trained attendant. There is great
need for the trained attendants or nurses' aids. The Canadian National
Nurses Association at their last annual meeting in Vancouver in July, 1919,
endorsed the training of attendants but realized the impossibility of having
them in the same hospitals where training schools for nurses are being conducted. Calgary has passed a bill providing for attendants and schools-for
their training are being established. Some feel that a better training could
be given attendants in a Puhlic Health centre. Why could not the Public
Health centres and small rural hospitals combine and give an attendant's
training in British Columbia? A year's course could be given, nine months
practical work in a small hospital and three months district work in the
Public Health centre, subjects to include elementary nursing, cooking and
dietetics, bedside care of patients, household duties, etc. There is great
need in British Columbia for such a helper provided there is provision
made for legislation and supervision. I do not see why it would not be
possible in British Columbia where/we are establishing Public Health
centres for the smaller rural hospitals to carry ton an attendant's course
of training
MR. CHARLES GRAHAM, Cumberland—
So far as I am concerned, from my experience in the small hospital,
I am not in favor of the operation of the training school. It is not fair to
the hospital, to the patient or to the nurse-in-training. It is not fair to the
nurse insofar as she cannot get the proper training to fully equip her for
her profession. It is not fair to the hospital or to the patient insofar as
where there is only one graduate - nurse she cannot give the nurse the
proper supervision and see that the patients get good attention. I am
therefore opposed to training schools in hospitals of twenty-five beds or
under. In Cumberland we have graduate nurses only, and I certainly am
strongly in favor of such an arrangement.
MISS E. I. JOHNS, R.N., Vancouver-
How do they compare from a financial point of view?
MR. CHARLES GRAHAM, Cumberland—   '
There is no question whatever but that the cost is greater when you
have graduate nurses.    You have more nurses when you have nurses-in-
training than you have  with  graduates, but the  advantage  far  outweighs
the consideration of cost,
DR. H. C. WRINCH, Hazelton—
Our  hospital  has  thirty-three  beds.    We  did  start  a  training school
when we had twenty beds, but we would not attempt to start one now with
less than twenty-five beds.   I would not recommend  a training school  in
a hospital under twenty-five beds.
MSSS HELEN  RANDAL,  R.N.,  Vancouver—
I think Dr. Wrinch's Hospital is exceptional. I do think that British
Columbia is rather-unique in having very few training schools in hospitals
under twenty-five beds. I think it is possible to have a training school in
a smaller hospital providing you do not consider you are giving a three-years'
course. You are not entitled to give a three-years' course in a twenty-five
bed hospital, but can give two years' with affiliation for the third. In so
doing you will fit the nurse very well for her work.
MISS L. S. GRAY, R.N., Chilliwack— ...
I certainly think it could be carried out with two Years' training and
one year affiliation if it were so arranged.
MR. PHILIP DU MOULIN, Kelowna—
We have a twenty-bed hospital in Kelowna and a staff of five.graduate
nurses. I do not think it would be possible to have nurses-in-training in a
hospital of that size.    Our nurses have a twelve-hour .shift and under the
31 present circumstances it is indeed difficult to get five trained nurses. We
are' trying to conduct our hospital with three trained nurses and two
maternity nurses. I feel it would be impossible for us to start a training
school, though our institution has been running for fourteen years.
MISS E. I. JOHNS, R.N., Vancouver—
I will now call on Miss L. S. Gray, R.N., Superintendent Chilliwack
Hospital, to open the discussion on—Nursing service in hospitals of twenty-
five beds and under, (b) If by pupil nurses, how can their training be
broadened:    By affiliation,
By travelling instructors,
By specially planned curriculum.
MISS L. S. GRAY, R.N., Chilliwack—
It is a truism that the value of the pupil nurse's training depends in a
large measure on the extent of the opportunities afforded her for gaining
experience. It is not so clearly understood, however, that these opportunities depend less on the size of the hospital than on the system of the one in
charge. It is, therefore, the duty of the one in charge of the smaller school
to see that her system is such that it will have a broadening effect on the
training of the pupil.
Affiliation, then might be taken as the first means to this end, and from
the point of view of what is to be best for the widening of experience for
the pupil of the small school, much could be said in favor of the system.
Let the pupil at the start fully realize what this greater experience will"
mean to her when the time comes for her to enter the battle of life as a
full fledged nurse. If this is done, the work will take on an added interest,
and all through her course, if she is kept encouraged, she will feel that her
training is to be of real value to her, that even although, let it be allowed
her practical experience is of the best, she may lack in points, but she is
assured that she will gain a fuller knowledge when she takes her affiliation
course. She will be encouraged to think that she is to have the privilege
of this added training which will enable her to compete favorably and
creditably with the graduate of the larger training school.
A question, however, to be debated is: How is the theory to be presented to the pupil so that she be efficiently prepared to cope with a third
year of training in the large school? Can the same curriculum be applied
to the smaller school as is used for the school where the pupil expects to
affiliate? It is-here, then, where a travelling instructor might-be of benefit
in the difficulty presented, but just how this system could be operated would
be a matter of much thoughtful study and planning, but in my mind would
be quite worthy pf consideration, for apart from possibly being of much
benefit to the pupil, who would then have the aid of a standard curriculum,
it would be of great assistance in a long-felt want to the superintendent of
the small school, whose duties are many times so numerous, that she has
not the needed time for a most important branch of training her pupils—
that of Theory.
A specially planned curriculum might solve the difficulty where it is
impossible to carry out the curriculum as is planned and arranged in the
larger school. A careful study should be made of this curriculum to meet
the special needs of the pupil nurse in the small school, having it so planned
that the instruction given will equip her for the demands made in the larger
school of affiliation.
MISS E. I. JOHNS, R.N., Vancouver—
We were to have Miss M. A. Andrews, R.N., of Salmon Arm, to open
the discussion on the third section of our subject, (c) Could Ward assistants be utilized in small hospitals, and if so, what work could be given
them? She is not present today, but has sent a few notes to Mrs. M. E.
Johnson, Secretary, who will convey to us her remarks on this subject.
MRS. M. E. JOHNSON, R.N., Vancouver—
The question which we are considering is whether ward assistants can
be utilized in small hospitals. Possibly you will all agree that the answer
to such a question should be given in the affirmative, but where can we
32 find this type of person for the position if created? The amount of help
kept in the rural hospital' depends on its efficiency and capacity. It is often
on such a small scale and calls for such a diversity of knowledge that it is
difficult to-get such people. We wonder if the rural hospitals are rendering
satisfactory nursing- service, and if not, why? The nurse may be ever so
ready and willing and capable to give any necessary care to the patient,
but if she has the daily round, or the common task such as sweeping, housekeeping, buying and numerous other duties, she has little time for her
technical work and education. If these duties could be turned over to the
ward assistant, possibly it would not be so difficult to get the pupil nurse.
It is, however, more difficult for the rural hospital to secure the staff which
they require.
Personally, I therefore think that the ward assistant might be used in
the rural hospital under supervision, if such type of women were to be
secured.
DISCUSSION
MRS. J. D. D. BROOM, R.N., Vancouver-
It would seem that the attendant referred to would have to come
really through the domestic side first into the ward. The question is, could
you find women who want to take up that work? In the rural district many
growing girls might be interested in their hospital and would be willing to
go in that way to start with and take up the full nursing course later if they
wished.
MISS HELEN RANDAL, R.N., Vancouver—
I think the great difficulty is the economic question. Young women are
not willing to go in unless they are paid for it. In any house today you
can get $40.00 a month, and I doubt if you can get anyone for less than
that.
MISS E. I. JOHNS, R.N., Vancouver—
In the smaller hospitals she might perform the routine nursing duties
that otherwise a graduate nurse would have to be employed for. Although
you have to pay her $40.00 or $50.00 per month, it would thus free the
graduate nurse to do the actual nursing work.
DR. M. T. MacEACHERN, Vancouver—
We are now facing a condition that we have brought on ourselves.
In looking over the four Western provinces we find that in Saskatchewan
today hospitals cannot drop here and there over night, without any regulation as to architecture, as to number of patients, as to organization, as to-
training schools, etc. In British Columbia you can start a hospital anywhere you like and any way you like practically, as there are no regulations.
Consequently we have hospitals all over the province that cannot grow to
sufficient capacity to ever support a training school, but the most important
factor of all is the fact that these institutions have no money to do things;
properly, to pay for an instructor, to secure the teaching equipment necessary
to give the nurses an adequate training. The hospitals and superintendents
of nurses, no matter what their ambition and enthusiasm may be, have not
the opportunity to make the training in the smaller hospitals in British
Columbia and other provinces attractive and what we want. Today, therefore, we are debating whether or not these hospitals should carry on training
schools or use graduates and ward assistants. If we are going to turn
out nurses in this province to make training schools we must have financial
backing in a much sounder way than at present. The training schools
must receive more financial support, wether it be from the hospital, the
municipality or the state. In the discussion the question, of _travelling
inspectors has arisen, an ideal condition, provided transportation is possible
and the expense taken care of. In speaking of affiliation, the only objection
we have heard in this Association is the fact that the hospital loses the
services of the nurse in the third year. That is a disadvantage which is
out-balanced by the many advantages, for it makes a better and stronger
training school and induces more and better apnlicants to come to such a.
school. As President of the Association, I would like us not to leave this
question  today  without   some   start  on  the   road  to   solve   it   for  British
33
m~ Columbia. These fine papers and discussions must not pass on without
precipitating something more constructive to solving our difficulties. My
energies are going to be devoted to the getting of more money for the
hospitals to carry on their different services, and I believe that if this is
provided they can do anything that is required. Therefore, we as hospital
superintendents, as professional men, as administrators and business men-
many being members of Boards of Directors, must try and supply you
people, the nurses, with the necessary funds to do this work, as you are
the experts and you "know how best to do it.
MISS HELEN RANDAL, R.N., Vancouver—
The real difficulty in improving our standards is the fact that we have
not the money to properly do it. I throw out the suggestion that the Government should be approached for support in the way of money to be spent
on educational purposes in our training schools. I hope that real representation will be given to make the Government see it from this angle.
DR. H. C. WRINCH, Hazelton—
I realize the importance of the point which Miss Randal has just made.
I had thought of asking for a grant, particularly for the educational side
of nursing. Assistance along the financial side for the paying of instructors
will help materially in improving our training schools. The opinion of
different people as to the ward assistant is variable. I know-of several
cases of young girls who want to take training but there is no opportunity
for them at that particular time, but they might be willing to help for a
few weeks to hold the opening when it did occur. These girls would be
much better equipped to do the work and would have a better knowledge
of the work than the girl who just came out of the high school. If she
has the practical work before she comes in to train she will have more time
to give to her academic training. Someone said Public Health centres would
be a suitable place for training these girls.   Would this be possible? I
MISS J. FORSHAW, R.N., Saanich—
The health centres are organized to assist in the prevention of disease
and to assist the Public Health nurse in bringing health education into the
home. I do not think we could attempt to establish any training centres for
ward attendants or assistants.
DR. M. T. MacEACHERN, Vancouver—
The ideal way is training the nurse in the hospital, and all hospitals
that can should train nurses. Let us suppose one of the faraway places
should have a hospital of twenty-five .beds and that this institution should
have the requirements as regards equipment, personel, etc., as laid down by
the B. C. Graduate Nurses' Association in their curriculum—could such a
place get applications under these conditions? We will further suppose
that there is good living conditions, good working conditions and everything to be desired. Will young women go to the out-of-the-way places
under these conditions? If not, could any regulation be made by which
there could be some distribution of applicants? If so, our motive should
be to produce such conditions, but possibly this is too idealistic. However,
-we must be more idealistic than materialistic in these days.
MR. CHARLES GRAHAM, Cumberland-
It seems to me there are a good many objections to affiliation. First,
from the hospital's standpoint—they lose the nurse-in-training at the time
when she becomes really useful to them. That, probably, is a selfish viewpoint for the hospital to take, but it is very vital to them because for the
first year the nurse-in-training is not of very much value as far as looking
after the patient is concerned.' In the second year she is of more value
and in the third year she becomes really valuable. In that third year she
goes to a larger hospital to complete her training, so that the small hospital
loses the real value of that nurse-in-training. The important question,
however, comes from the point of view of the nurse. A girl studies two
years in the small hospital, then she goes to the affiliating institution, such
as the Vancouver General Hospital. She graduates, not from the Vancouver
General Hospital, but from her own hospital.   This does not give her the
34
_J standing she would have had she graduated from the larger institution.
As I understand it, such is an unusual thing and does not correspond with
what happens in colleges, where we find that practically all the large
colleges today taking students from affiliating colleges graduate them from
the former. The only reason, therefore, for affiliation, is that the nurse
| will receive all the benefits in the third year, or that the graduate does.
MISS E. I. JOHNS, R.N., Vancouver—
I think that the first two years are really by far the most important.
I have had considerable experience with the question of affiliation. I find
that pupils who come in from the affiliated schools are among the keenest,
brightest pupils we have.
MISS I. SMITH, R.N., Vancouver-
One time I had the privilege of being in charge of a small hospital and
there has always been a tender spot in my heart for the small hospital
since. Another point, we can get very valuable material from the surrounding country. We have often had young women who could not afford
to go very far from home and were- only too glad to avail themselves of
the opportunity of training. At the same time there was teaching material
for the very finest work. It means extra labor for the superintendent in
order to maintain a training school in the small hospital because she must
look after everything and her eyes must be everywhere. That is where the
greatest difficulty comes in. At the same time I think it is possible to get
very good nurses-in-training in a small hospital, but we must not lose our
ideals and we must not think that we can give them a full training. They
can be trained for two years and affiliated with the larger hospitals for
the third year. The first two years in the hospital are certainly the most
important for the nurse. The third year is the rounding out and finishing.
She can only get it from the principles that stay with her through the first
two years.
DR. F. C. MIDDLETON, Regina—
Regarding the question of what your requirements are as to the number
of physicians attending at the local hospital, I may say that in Saskatchewan,
as you possibly know, we require a hospital to have a capacity of thirty
beds with a daily average of twenty patients before it can consider a training school. • We further require four medical men, each located within a
radius of two miles. These conditions are necessary before instituting a
training school for nurses.
DR. M. T. MacEACHERN, Vancouver—
We do not specify the number of physicians, only the number of beds,
not the number of patients.
MISS G. M. CURRY, R.N., Chemainus—
In Chemainus we have twenty beds and just one doctor who is connected
with the hospital. Chemainus is a small mill town. We are affiliated with
the Vancouver General Hospital. I have written Miss Johns and she has
helped me out a great deal by sending me examination papers and text
books. In a small hospital I think the matron ought to be a graduate of
the affiliated hospital, then they would have their proper lectures, class
books and methods. We have four nurses, and as far is I can manage it
we have a workable eight-hour day duty.
DR. M. T. MacEACHERN, Vancouver-
Have you any trouble getting applicants?
MISS G. M. CURRY, R.N., Chemainus—
I had when I first went up there, but have two or three on the waiting
list now.   My nurses are all in their first year.
MISS E. I. JOHNS, R.N., Vancouver-
Would it help if there was a definite printed curriculum based on the
standard laid down by the Graduate Nurses' Association?   We know that
the whole of this cannot be put into operation in the smaller hospitals.
MISS G. M. CURRY, R.N., Chemainus—
I think that the matrons  of the  smaller  and larger training  schools
should get together and arrange this.
35 there   should  be a
any hospital where
MR. J. SUTTON, Nanaimo—
I am not quite clear whether it is the desire of the Association to make',
it compulsory for those hospitals having twenty-five beds or less, to affiliate
with the larger institutions such as the Vancouver General Hospital. Is!
that the viewpoint? As far as our institution is concerned in Nanaimo,-
we have been highly praised for the work that is being performed in our.
school, and I believe that the nurses would rather serve their full course
of training there than take one year's course elsewhere.
DR. M. T. MacEACHERN, Vancouver—
The concensus of opinion, I understand, is that
minimum of twenty to twenty-five patients per day in
a training school was established.
MISS E. I. JOHNS, R.N., Vancouver—
I do not think that the question of affiliation can ever be forced on any
institution. It must be voluntary. I do not- think that any hospital having
more than thirty beds need affiliate.
DR. M. T. MacEACHERN, Vancouver-
Miss Johns, what number of beds do you require to affiliation in your
training school?
MISS E. I. JOHNS, R.N., Vancouver-
There is no limit.   We will take from any hospital in the province that-
is conducting a training school.    Presumably they should be placed, as the-
Act calls for, namely,—fifteen.
DR. H. C. WRINCH, Hazelton—
I would like to ask how it would affect the hospitals, all the hospitals
of fifteen beds or over, sending their nurses for the final year. Have we
any statistics to show how many nurses are graduated from hospitals of
fifteen to forty beds?   How would it affect your Training School?-
MISS E. I. JOHNS, R.N., Vancouver—
During the last year we have had approximately eight at different
times.
DR. M. T. MacEACHERN, Vancouver-
Do not lose sight of the fact that there are other hospitals in this
province that affiliate outside of the Vancouver General Hospital, and I
should think that any hospital of one hundred beds and over, with a good
training school, might affiliate. There are five institutions in this province
that I know of having one hundred beds or over, and it would not necessarily
all fall on one institution.
MR. CHARLES GRAHAM, Cumberland-
Small hospitals cannot get probationers, as they have to graduate from
the small hospital. Even though they have a year of affiliation they get
no credit from any person. When the decision comes as to the question
of a nurse, the Board will say, "Oh, this young lady graduated from the
Vancouver General Hospital, this one from Chemainus General Hospital,"
and that is the way the Board- looks at it. The Board says: "We will
take the Vancouver General Hospital nurse." The girl going into training
says: "If we have to affiliate with the Vancouver General Hospital for
the last year we might as well go there for the whole period," and thus it is.
MISS E. I. JOHNS, R.N., Vancouver—
I think Mr. Graham is wrong. The nurse would much prefer to graduate
from her own Hospital.
DR. R. W. LARGE, Port Simpson—
I think there should be some arrangement made by which affiliated
hospitals might have recognition for the fact that their nurses have spent
one year in the larger hospital. I also think it will be necessary that some
modifications be made in regard to affiliation before it will become popular
with the smaller institution.   We are obliged to give the nurse her holidays
36 II
for her third year before she will go to the larger hospital. It is not fair
to the nurse herself. She should not be called upon to take her holiday at
the end of the second year. I would like to see something in the diploma
to show that she took two years in the smaller and one year in the larger
hospital It should be done in justice to the smaller hospital and to the
,nurse- in-training. I think it is a splendid idea to have affiliation for the
smaller hospital. We have had no difficulty since we became affiliated with
the Vancouver. General Hospital.
MRS. J. D. D. BROOM, R.N., Vancouver—
.   I would very much like to see nurses' holidays arranged every eight
months, and I think your school would go through-without any sick nurses.
MISS E. I. JOHNS, R.N., Vancouver—
r i'Jjg; Dr. Large's  contention  with  regard  to  the  recognition  in  the  larger
hospitals can be well taken up.
DR. M. T. MacEACHERN, Vancouver-
Speaking in regard to holidays every eight months, we mjght find it
rather disturbing to the nursing service. I would prefer the eight-hour
system adherred to and good living conditions. During my years of experience I have seen a good many sick nurses. Seventy-five to ninety per cent,
of our sick nurses come from our old home, in Vancouver, where living
conditions are not good, whereas in the new home it is entirely different.
Living conditions are very important and should receive attention in all
training schools.
Meeting adjourned, to meet again at 9 p.m.
EVENING SESSION, WEDNESDAY, JUNE 23rd, 1920, 9 p.m.
"Get Together" Round Table Conference.
The evening session was in the form of a round table conference, which
was called to order by the President, Dr. M. T. MacEachern, in the chair,
who announced that at the close of the session there would be an informal .
reception to which all were very cordially invited.    He then called on Dr.
R. W. Large, of Port Simpson, to open the discussion.
DR. R. W. LARGE, Port Simpson—
I am sorry I missed the major part of the discussion this afternoon.
These questions are of vital interest to the smaller hospitals. Like most
doctors. I took my training in a large city and at the end of my training
spent a year as interne in the largest hospital in Toronto, and I came in
touch with conditions under which nurses worked in the large institutions.
We have duplicates of these large institutions everywhere, but twenty-three
years ago when I came to this province I was doing my first operative
work with an Indian giving the anaesthetic, and with an old woman looking
after the boiling of instruments with instructions to keep her fingers out
of it. Those are the conditions we dealt with. It would have been very
much easier for us to have remained in the larger centres. The need,
though, has to be met and we must keep that before us—what is the need
and how best we can meet that need. It is difficult to get nurses, either in
training or graduates, for these outlying places. The problem is not solved
by saying: "Use graduate nurses." "i have had experience in trying to get
these graduates and as long as they can get employment in the centres they
will not go to the outlying districts. Just as the doctor, so the graduate
nurse feels her call is in the larger centre, where she is in touch with conditions in many ways advancing. It is quite possible for us to close the
small hospitals—it can be done. There are some of us who are beginning
to feel that really things are getting so tiresome that we will drop out and
go down to the city.   .
It is well enough for Saskatchewan to make regulations requiring four
doctors in any centre. During the war we did not have four doctors from
Nanaimo to Alaska in any centre. We have-tried various methods. We
are what might-be called a "mission" hospital.    While we are a general
37 hospital, we could not exist without the payment of our nurses' salaries,
without the Women's Missionary Society. At that we have difficulty making
ends meet. We have to administer to a great many who cannot pay. It is
our privilege—we must do it. We have tried getting nurses who can take
a partial course. We have considered that. Those who have not the educational advantages, yet would like certain partial courses—nurses who
could assist the doctor under a doctor's direction would be of very great
help in the sick room. That is difficult, especially at the present time.
There are girls who have not had the advantages; then the making of the
educational standard higher. Most of us in the North send our children
away from the time they are thirteen. The boys and girls have to even
come out to get their high school training. You can see there are many
of our girls who have the natural ability but have not the educational advantages, so it is impossible for them to measure up to the present day
requirements. These girls have far more dependency nad initiative than
those who are surrounded by many more advantages and strictest supervision. That difficulty we have tried to solve by taking in nurses with
partial courses. We might get the under-graduates. The financial difficulty is not the only one. Lack of social intercourse is the greatest difficulty. The nurse who goes out to .the outlying district must be one with
some idea of missionary work. She has to have a spirit of sacrifice to go
out to these outlying places. We have not been able to get in touch with
that type of nurse. We could lower our standard and offer special inducements; such as salaries, but that would not satisfy us. These small hospitals
are doing just as good work as the larger hospitals in the larger centres.
In the smaller hospital the nurse sees everything. She knows every prescription and what is in it. In the smaller hospital if there is an operation
every nurse that can be spared is in that operating room, and I think in
most cases" the doctor takes the opportunity of explaining things more
thoroughly, that a nurse may get more out of one of these operations than
in the larger institution. I personally feel that the smaller hospitals should
be affiliated with the larger in the third year, hospitals of twenty-five beds
and under. Probably it would be a good idea to have the nurse in the larger
hospital spend a year, in the smaller hospital in order to fit her to meet the
need of the outlying district.
You have more than one-half the population right down here—the
other half might move in, but you have to have these outlying districts.
Your existence depends on the outlying districts. Without the outlying
districts you people here would starve. If an accident occurs up there the
first thing you say is "bring him down to the centre." The hospital is
-essential in these outlying districts. With all your equipment down here
many of our patients will die before they get here. The problem of the
outlying districts is different. You have the wealthy clientele to draw on,
-you have the voters list that backs up your request with the government.
The government has been very considerate to the smaller hospital, but
somehow we get out there, we lose our grip and cannot go to the government every year. If we go every five years we think we are doing well.
I would suggest that some committee be formed to try and meet the solution of the smaller hospitals' need.
Affiliation is a good thing. I feel that the smaller hospitals are'deserving of the very kindest consideration of the larger hospitals. We appreciate,
as a smaller hospital, the very kindly consideration that was given us in
the recent graduation exercises at the Vancouver General Hospital. I
think they went out of their way to mention the hospitals who were in
affiliation. I think that in future years to come hospitals should arrange
to have some of their members come down to graduation. We are not so
sure of the Graduate Nurses' Association, with the Act they have already
and the things they have in the back of their head—a great many of us are
going to feel tired. Personally, I am the oldest practitioner and it is time
for me to get out, yet I think it might be just a little difficult to get others
to come in. I know I am finding it mighty hard to get anyone to help me
out.
38 The smaller hospital has, I think, a claim on the very kindest consideration of the largest centres, and I hope that from this organization we will
have a committee that will go into the thing very thoroughly. We, unfortunately, were not big enough to be visited by the representative of the
Nurses' organization. However, I am sure if we could get some arrangement made by which these smaller hospital needs were taken into consideration we could evolve something which would be up to the present needs.
I feel we have a problem to be solved by the smaller hospitals.
DR. M. T. MacEACHERN, Vancouver—
We are very grateful to Dr. Large for his remarks. We know he has
difficulties. Dr. Wrinch gave us a paper two years ago about the problems
of the outlying hospitals. I think the Nurses' Graduate Association is
interested in solving this problem; the question of shortage of applicants
in the training schools has been so much heard of lately, thus the discussion.
We would like to hear from two who are here with us, Dr. Middleton, of
Saskatchewan, who is assistant to Dr. Seymour, Commissioner of Public
Health, Regina, and Dr. Archer, who' is president or vice-president of the
Alberta Hospital Association.
DR. F. C. MIDDLETON, Regina—
This is a very vital question in the province of Saskatchewan as well
as the province of Alberta. We made our regulations respecting nurses—
I think the standard will not likely be lowered. I think that is an established fact. However, to offset the fairly high standard, arrangements have
been made during the past year to have an amendment put through to the
Nurses' Association Act whereby the smaller hospitals, that is a hospital
which does not come up to the standard of having four medical men and a
bed capacity of thirty and an average attendance of twenty patients per day,
hospitals of probably fifteen to twenty beds—are allowed to engage the
services of young women who may spend a year at that hospital and after
putting in a year in the small hospital then take a course of three months
at the Provincial Sanatorium, then after that there is a special examination
held at the University and they must take that examination. That, of
course, makes the training uniform throughout the province. These women
are given the name of "nursing housekeeper." We have the rural districts—
these nursing housekeepers we hope will do a lot of the work which may be
required when they go back to their respective districts. They go about in
districts that a graduate nurse will not go into. We are just in an experimental stage so far, but we are in hopes it will be developed into something
permanent later on. We have a system of union municipal hospitals, hos-^
pitals which are established in rural districts and two municipalities (municipalities or eighteen mile centres) will co-operate in the forming of a
hospital. We have some ten now in running shape and all giving very good
satisfaction. These hospitals are supported by the two municipalities and
the urban centres contained therein.
DR. R. W. LARGE, Port Simpson-
Have you any unorganized districts?
DR. F. C. MIDDLETON, Regina—
We have no unorganized districts.    In the outlying districts they have
-built three Red Cross outposts consisting of a small shack, three or four
rooms, where a nurse is established.   She makes that her home and possibly
utilizes it as a hospital as  well.    There are three established  in the far
North.
DR. A. E. ARCHER, Lamont—
I did not expect to have the privilege of speaking to you tonight or
discussing in any way this problem which is such a very real problem, but
I am very glad to be here and to have listened to the remarks of Drs. Large
and Middleton. The problem of the small hospital is one which must be
solved. The small hospital is here to stay. The idea that Dr. Large suggested of moving out and allowing hospitals to close, neither he nor any
wm 39 one else would take seriously.   The people are living all over these provinces
here.    I think the conditions are a little different perhaps from the prairie
provinces where the centres  are not as  large and the  population is  more,
disseminated throughout the whole district".   It is the idea that the govern- I
ment   should,   as   in  Alberta,   divide  the   whole   of  the   rural  part  of the
province  into  hospital   districts,  even  as  school   districts.    Eventually the |
whole will be divided into hospital districts and no part of the province will
be outside of the hospital districts; the hospitals will be supported by Has
ratepayers of that district.    How can these hospitals be planned and efficiently conducted?    It has been suggested that affiliation might solve some,
of the problem.    I think perhaps it might.    I have been very glad to hear
how it has been working here, where that plan is in existence.    There is
no  such plan in  existence in Alberta.    The  Senate of the University of
Alberta  has  taken  the  power ■ to  say  what  shall -be  the  requirements  of
training schools and also has the power now and are appointing the Board
of Exaniiners,  which set the" examination papers  for the  nurses  who  are
graduating in all of the hospitals in the province.    Up to the present time |
the committee appointed by the Senate have not reported as to just what
requirements they shall set as the minimum for the obligation of the training
school.   They suggested many things which I think will* shortly be embodied
in a definite regulation.   Up to the present there is no regulation.    It has
been  suggested  as  one  method  that  nurses   from  any hospital  running a
training school in any part of the province might be sent by the hospital
to the university and there within the walls of the university would take a
course,  the  same course no matter  what  hospital  she  came  from,  in the I
theoretical part of her training; this period of three or six months to be
part of her training, and in that way the theoretical part of her training
would(be made uniform, no matter what institution she comes from.    It is
only a suggestion yet.    I would like to know the opinion of those present
as to the value of the travelling instructor in the smaller hospitals.    I do;
not know what you consider the necessary staff in a small institution, say']
twenty-five bed size.   It would not be a large enough field to demand an
instructor giving her whole time to that institution.    I would also like to
hear discussion as to whether ward assistants could be utilized, as to whether]
they  can  be satisfactorily employed  in  larger institutions.    If the  nurses
were relieved of making beds, etc., would it be possible for her to give a
more efficient service?    If so, would that be one of the ways that might
possibly relieve the situation and still meet the requirements of the Graduate Nurses' Association?    Would it be possible without lowering the standard, to relieve the nurse of that type of work, the thing that she has done"
so many times, and which is, to my mind, simply doing work which is of
" no further value to her ?    Could the period of her training be safely short-"
ened and some of,the problems solved by the shortening of that period?   I
believe some of the nurses graduating from the smaller institutions are the
best practising the profession today.    There  is no getting away from the'
fact that some of the opportunities for personal contact with the staff of
the institution and with all the patients in the institution means a great deal
in the development of initiative and thoroughness and in an all-round education in everything excepting the nursing specialties, for which, of course,
we admit the smaller institution is not adequately equipped for giving the
training she requires.
MR. G. R. BINGER, Kelowna—
I asked our matron what she thought of'forming a training school' in]
our hospital, and she did not think it would be fair to the nurse-in-training
as she could not have sufficient variety of work given her, and also, she;
said it would be very difficult, being as busy as the staff generally„is there,
to-give her proper training, lectures, etc., which would be required. She
certainly was not in favor of forming a training school.
DR. R. W. LARGE, Port Simpson—
What capacity has Kelowna Hospital?
MR. G. R. BINGER, Kelowna—
Twenty beds; staff of matron and four graduate nurses.
40 MISS I. COLE, R.N., Vancouver—
. I- would like to know if these nursing housekeepers are capable of
actually doing the nursing during the one-year course and so run that end
of the hospital? S^fes!
DR. F. C. MIDDLETON, Regina—   '
Oh no! There are graduates. We require at all times in hospitals
receiving a grant from the government that a graduate nurse be in attendance. Every hospital should have at least two nurses. These nursing
housekeepers do not take any of the administration work. I do not think
it is the intention of these nursing, housekeepers to do any of the administration or specially technical work.
MR. G. R. BINGER, Kelowna—
I think it will be very difficult to get girls to take up that sort of work
DR. F. C. MIDDLETON, Regina—
• So far we have, I think, about ten hospitals putting on that course.
Most of the hospitals so far have been filled up and quite a number of
applications still on file waiting their turn. I think there will be no scarcity
of applicants.
MR. G. R. BINGER, Kelowna—
Do you think if we wanted one of these we could get her to come
.up here?
MRS. M. E. JOHNSON, R.N., Vancouver—
When these nursing housekeepers are sent into the districts where the .
graduate nurse will not go, will they be under any supervision?   Will there
be any law by which they will "be regulated in any way?   Will these hospitals still have charge of them?
DR. F. C. MIDDLETON, Regina—
I do not know exactly as to that. I do not think there will be any
supervision. It is to do the actual home nursing. Graduate nurses naturally resent, having to do all the housekeeping work as well' as nursing.
These girls will be able to fill both.
MRS. M. E. JOHNSON, R.N., Vancouver-
Have you any of those nursing housekeepers out now?'
DR. F. C. MIDDLETON, Regina—
No, it is just experimental so far.
MISS J. FORSHAW, R.N., Saanich—
Nurses with partial training might be'used for the outlying districts.
I was wondering in what capacity. They have to stay in the homes all the
time, and if they did, under what supervision?
DR. R. W. LARGE, Port Simpson—
: I think we have to consider our own special surroundings. We have
about us a great many ignorant people. Some of these girls are educated
in Indian institutes and they have for Indians a fairly good education. We
have had in the past several applications from bright Indian girls to take
nurses' training, and you can quite understand the difficulty in taking these
in and giving them training with other girls; complications lead to very
great difficulty. If we give them some "type of training, short of a graduate
nurses' training, just simply to allow them to go into the homes of their
own people. I think it applies also to many foreign communities. She
might be able to give a little assistance in sending for a doctor. As far
as the hospital is concerned, I do not think it fills the need of the hospital.
You-will require the two graduate nurses in smaller hospitals besides nurses-
in-training. If we could just get others associated with some of the housekeeping work.
DR. M, T. MacEACHERN, Vancouver—
We would like to hear from Dr. Young regarding 'this subject.
41 DR. H. E. YOUNG, Victoria—
I am afraid, sir, this is a subject I am more interested in listening to.
Many requests are coming to the Department for assistance in regard to
the outlying' districts, but the question of training is one in which the
authority rests entirely upon the Nurses' Act. Whatever decision was
arrived at would have to be dealt with Through the Legislature.
MISS J. F. MacKENZIE, R.N., Victoria—
I think they are of great practical use but very hard to secure at present,
owing to labor conditions. They are of great assistance and relieve the
nurse of a great deal of work which they are required to do. I" think you
simply have to keep them as maids.
MRS. J. D. D. BROOM, R.N., Vancouver—
I do not think you should class them as maids. They might be called
nurse-helpers.
MISS J. F. MacKENZIE, R.N., Victoria-
Make the salary lucrative enough for them to come in.    That  is the
only way you will get them.
DR. M. T. MacEACHERN, Vancouver-
Following Dr. Large's suggestion, it seems to -me that a year might
be a long time to defer it, and at least we ought to have an interim report
of this committee on Saturday morning^.and it might be wise to ask that
a committee of three be appointed to consider the discussion of this very
thing and bring in a recommendation if they can on Saturday, possibly requiring definite action or deferring action; but if this could be all left in
the hands of a committee of three we will be able to have a report which
would be helpful.
DR. H. C. WRINCH, Hazelton—
It was in my mind to suggest or request that the chair should appoint
a.committee to go into this question and try and bring something definite,
before the convention closes, in the way of a recommendation to cover these
questions that are very vital, as is shown by the tone of discussion tonight.
I move that the chair be requested to appoint a committee of three or more,
according to his judgment, to take the subject of this round table conference
up and bring in a recommendation.
Motion seconded by Dr. R. W. Large.—-Carried.
MRS. M. E. JOHNSON, R.N., Vancouver—
At the Executive meeting held in Victoria in January, there were several
recommendations came, in and all submitted to the Nursing Committee, one
of which has bearing on this subject, and on which the Committee reported
as follows:
THAT a teaching scheme especially framed and based on the proyinSi
cial standard curriculum to meet the needs of.small training schools, could
and should be formulated by .this Association, which might assist the
superintendents of small schools in framing curricula, and would make for
greater uniformity in the education of pupil nurses, and that Dr. H. C.
Wrinch's  advice and  co-operation be  requested  in  this  connection.
Moved by Miss E. I. Johns, R.N., seconded by Dr. H. C. Wrinch,
"THAT this report be adopted.   Carried.
DR. M. T. MacEACHERN, Vancouver—
The Committee would have to take into consideration this motion.
It is necessary that we appoint our convention committees.   There is
the Committee on Resolutions, Committee on Officers for the ensuing year
and Committee on Time and Place of next convention. .
Moved by Dr. R. W. Large, seconded by Miss J. F. MacKenzie, R.N.,
THAT the chairman be asked to name the convention and special committees.
Carried.
A reception was tendered to the delegates by the'Vancouver Committee,
which was greatly enjoyed by all, and the remainder of the evening was
spent socially.
The meeting, then adjourned to meet at 9.30 the following morning.
42 MEDICAL SESSION
Thursday, June 24th, 1920—9:30 ajn.
The meeting was called to order by the President, who made several
announcements, pertaining particularly to the clinics, to registration, the
change in the bylaws and to the fact that Mr. Bowman, Director of the
American College of Surgeons, was in the City and would be present with
us during the morning. After this the President called on Dr. H. C. Wrinch,
Hazelton, to preside at the morning session.
DR. H. C. WRINCH, Hazelton—
"Ladies and gentlemen, members of our Association: It is not indeed
with any idea of intruding upon the chairmanship that I am accepting this
honor. It is owing to Dr. MacEachern, as I am willing to do anything
I can to assist him. I am getting a great deal of good from this Association;
I am sure you all are. I hope that our Association grows still larger and
when all other hospitals find it possible to take part in our conventions we
will get more value in proportion to the increased membership.
I am delighted to introduce a hospital official here today that we welcome, the Inspector of Hospitals, who has been recently appointed by our
Government. He is to speak to us this morning on the results of his survey.
-I_would therefore call on Dr. E. C. Arthur for his paper on "Survey of
hospitals in British Columbia."
DR. E. C. ARTHUR, Victoria—
In November last I was appointed Inspector of Hospitals and Travelling
Health Officer for the Province, and early in December I set out to visit
as many as possible of the hospitals in the province, between that date and
the present, with a view to gathering information that might be helpful to
this meeting. Nearly three months of my time were required for other
work; consequently, the most of my visits were more hurried than I wished.
However I visited and reported, more or less fully, upon more than fifty
of the hospitals receiving the per diem grant.
Few, even of the newer buildings are without structural defects, while
some of the older ones are very inconvenient and costly to operate and
one or two are veritable fire-traps. For instance, I have a report of a
frame building of three storeys which has no fire-escape; In a large
hospital in the interior the exit, from the nurses' sleeping quarters to the
fire escape is through a small window. In front of this window stands a
radiator, which projects nearly a foot above the sill of the window. Many
of the buildings that have furnaces in the basement have unprotected woodwork above or beside the furnace. When the Summerland hospital was
burned last December, the nurses escaped with difficulty, losing everything
in their rooms. A hospital of a hundred beds and a single elevator hasn't
a stairway up or down which a patient can be carried on a stretcher. I
should here say that in every case where remediable defects were pointed
out, theJiospital management was very ready to make the necessary changes.
Nearly all the hospitals have an inadequate number of private wards. Very
few have adequate provision for the care of cases of advanced tuberculosis.
Toward such structural defects in future building, I wish someone, preferably the Government would cause to be prepared a set of plans and specifications for a small hospital, say 20 beds, which could be enlarged in units
to meet the requirements of the community as it develops and still be
symmetrical, convenient and economical to operate. To reduce the danger
from fire and lessen the amount of dust, I would wish the heating plant and
fuel room to be placed in a building adjacent to the hospital where the
waste heat of the furnace room could be utilized to dry the laundry. I hope
no future hospital will be built without a nurses' home detached from the
hospital building.
Speaking generally, our hospitals are doing reasonably good work, many
of them under very adverse conditions. In a remote section is a hospital
of six beds—one private—in an inconvenient old building. The staff consists of one med'cal man, a student assistant, and one nurse. The permanent
tributary population numbers about 1000, with approximately an equal
number  of  railway  builders.    More  than  twenty-five  maternity  cases  are
43 booked for the four months, June-September.    Recently a case of gunshot
perforation of the intestines was operated upon, the patient recovering, T.
wish you could see the operating room in which it was done!    Whence is
to come the money 'necessary for the much needed modern building of not
less than twenty beds? s£p$i
This brings me naturally to speak of the financial position of our hospitals. Practically all are in need of additional revenue. One has been
placed by the council of the municipality in the same position as the schools
—the Board of Directors submits its estimates for the year; the council
accepts them, .collects the amount by taxation and turns the money over to
the hospital board. So far as reported, this is the only hospital in the
Province in this fortunate position.
I estimate that the buildings, furniture and equipment now doing general j
hospital work in this Province cost not less than $5,000,000. This is a
conservative estimate in which is included denominational and some private
institutions doing general work. Twenty-two' of these report deficits on
operating account aggregating more than* $100,000. Extensions, replacements
and new buildings in communities needing, but now without, hospitals, would
require two to three millions more to place all in good condition and provide for the increase of population during the next five years. How is
the money to be obtained ?
Second, as to operating deficits. In a few hospitals I think the scale
of charges is too low for ward beds and operating room. I would like this -
meeting to appoint a small committee to investigate the matter of charges
and recommend a scale of fees. My wish is to get a nearer approach to
uniformity of charges and to endeavor to ascertain the actual cost of public
ward patients.
I believe a very considerable saving could be effected by a centralized
system of buying. I will venture the assertion that there is not a representative of a supply house at this meeting who would not pladly exchange
his present position for that of buyer for the hospitals of this province on
a ten per cent, basis, and guarantee a saving to the hospitals of ten to
twenty per cent, of prices now paid. The question of freight charges for
distributing would have to be carefully considered by men experienced in J
freight tariffs.
But these are small economics. I believe that the principal item in
operating deficits is bad debts. There is, (and under the present system there
will always be) a percentage of patients unable to pay. Unfortunately
there is and will always be a percentage of patients who will not pay a
hospital bill if it can be avoided. A hospital has the same right ■ as" any-]
other creditor to collect a just debt and should do so by legal process' if
necessary.    Nanaimo is now doing this with good results.
But even if by various economics all operating deficits could be eliminated there would still remain the larger item of necessary extensions and
new buildings. To provide funds for these some better system than the
present must be found.
^ T read with great interest and have several times carefully re-read-the
papers of Mr. Banfield, and Mr; Day, and the resolution of Mr. Stewart
presented at the last annual meeting of this Association. "When I first read
them I was like Agrippa, almost persuaded. I am still in accord with the
principle, excepting state ownership and operation and, possibly, free public
ward treatment for all.
I now beg leave to submit for your criticism a modification of the scheme.
Hospitals have come to be considered necessary adjuncts of our com- j
munity life, much the same as water supply, sewers and other public utilities. The Government does not supply these, but has provided the legal
machinery which enables communities to provide these utilities for themselves, I think it should do the same with regard to the hospitals. The
topography of this^province has ordained that settlement must chiefly follow
water courses between mountain ranges. Lines of communication must do'
the same. As a consequence, transportation is comparatively slow, and the
bacteriological laboratories which I understand have been established on the
coast, are not sufficient for the interior and remote coast districts. My suggestion  is the division of the "Province into what may be called Hospital
44 Municipalities, in each of which there would be one principal hospital
equipped with a good laboratory in charge of a trained bacteriologist, a
first class X-Ray plant in charge of an expert radiologist, an eye and ear
specialist, and possibly other specialists. The other hospitals of each district would be more or less subsidiary to the principal one. Operating costs
over and above fees collected, to be covered by taxation of the municipality.
A business manager for one, two or three municipalities. New buildings
-and extensions to be provided for by debentures of the municipality guaranteed by the Government. A Commission to have charge of all the hospitals
in the province. Some denominational institutions and company and otherwise privately owned hospitals are obstacles to such a scheme, but I think
not insurmountable ones. At the outset there would be about a dozen
municipalities. Future development would probably necessitate additional
ones. Such a scheme would make easy the introduction of a uniform system
of accounting, the suggested economics in buying, uniformity of closing date
of hospital year, the general use of an efficient system of case records, while
the relief it would afford the Provincial finances should enable the Government to establish and maintain a greatly needed home for incurables.
It would also facilitate the making of proper provision for the care of
cases of contagious diseases. The existing accommodation for such cases
is very inadequate. I think that at least ten per cent, of the beds of every
hospital should be available for the care of cases of advanced tuberculosis—
at present comparatively few hospitals have any accommodation for such
cases. I think that every hospital of fifty or more beds should have a
trained dietitian. As stated at the outset, my visits to most hospitals have
necessarily been hurried, in most cases—too hurried to permit anything
like a proper inspection. In a "Cook's Tour" of a hospital in an hour or
two under the guidance of a medical man or the lady superintendent an
inspector can form an opinion regarding the general cleanliness of the
building and equipment, the adequacy of system of heat, water, light, ventilation, obvious structural defects, the suitability of the operating room
and its equipment, etc., but he can gather no accurate knowledge of how
the records are kept, the nature and suitability of the diet, the discipline prevailing^ whether or not patients have complaints, justifiable or otherwise, in
short he cannot know how the essential work of the institution is carried on.
For this purpose he should spend a day and, in some of the larger hospitals
possibly two or three days, going freely about observing the work and
meeting those who are doing it and those for whom it is done. Ire my next
tour I expect to have the time necessary to do this.
DISCUSSION
DR. H. C. WRINCH, Hazelton—
"You will agree with me that Dr. Arthur has given us food for thought
and discussion for at least the rest of the convention. He has given us a
most valuable report, something which we have been .waiting for for a long
time from an official source. We are delighted to have this report on
conditions of the hospitals in our province. He has spoken of them from
various aspects well worthy of discussion. First of all we would like to
hear from one who has a long experience in hospital work in this province,
also in other countries. He knows the country hospitals as well as he knows
the city hospitals, and there is no one better able to open the discussion
on Dr. Arthur's paper. I refer to Mr. R. S. Day, President Nof the Board
of Directors, Provincial Royal Jubilee Hospital, Victoria.
MR. R. S. DAY, Victoria—
I do not intend this morning to cover all the ground that has been
taken up by Dr. Arthur in his paper, because I think that part which
refers to the financial condition of the hospitals will probably be much
more fully and better discussed at our meeting which will take up the
consideration of that subject. In my paper last year on financing of hospitals I in no way advocated state ownership. It has never been in my
thoughts and I certainly have no desire for it. Dr. Arthur spoke about
the very short time he was able to give to the inspection of hospitals and
he hoped that at some future time he would be able to spend two or three
45   • days in them.   The doctor is probably younger than I am, and so I may
offer him some advice—he should go in as a patient and get a bed.   HeH
will find out more in that way regarding the institution than in any other.
I have visited several of the hospitals in our province.    I make it a
practice when in a town to see the hospital, and I must thank the staffs
for the time they placed at my disposal.   Wherever I went I found on the
part of those in charge a keen desire to make the work efficient.   This was
especially true of the ladies in charge.    They all seemed to be alive to
the necessities of the place and were working for the very best interests of
the institution that was committed to their charge.   They were bringing all
kinds  of pressure to bear upon their directors to  get what they wanted.
The only unprogressive people I found in the upper country were men and
directors.   I found in one of the largest hospitals that there was "ho X-Ray
apparatus, and I remarked upon this to a director.    He professed to see
no  advantage  in Roentgenology  commensurate  with the  cost.    I  recently
called at a small hospital on Vancouver Island—in charge of three nurses
from St. Joseph's Hospital, Victoria.    They were working under consider- j
able difficulty.   They had ten beds and sixteen patients, and a baby two
days old, in a basket in their office.    There was no other place  for him. j
They said the hospital was not in the very best of conditions when they
took chaYge but they had thoroughly cleaned it.    Unlike the larger insti-
tution, this little hospital had a small X-Ray machine capable of taking
pictures  of fractures.    Wherever I went the women were hard at  work.
They were after cleanliness and efficiency.    I went into one of the largest
hospitals in the province last July, and had a trying experience walking up
- a long hill in the middle of July under a blazing sun.    The lady superintendent was engaged with a director, I was told she would be with me in
a few moments.    I  sat for half an hour with the window  open and the
blind down gazing at a blank wall.    When she did come, she was a very j
happy woman.   The director had consented to her list of requirements.   If
the money for these had to come out of his pocket it would have been
cheaper  for  him  to have  married her,  if he  could.    In  one  hospital  the-
matron showed me empty rooms, empty because the Board had no  funds
to clean them.    The municipality does not give them one dollar.    That is
a condition which does not often occur.    Penticton should be blazoned in"
letters of gold because it budgets its hospital as  it does its  school.    In
Victoria, the recently formed Kiwanis Club has taken up as its first great
public   service,   the   rebuilding  of  the   Provincial   Royal   Jubilee   Hospital.
The  interest  of  this  large  body  of business   men  thus   aroused  will  not
remain in the building only, but will surely extend to every phase of the
work.    If we can only get societies of that kind interested in hospitals we
shall get a live force of public opinion behind our movement which will
bring to bear upon the municipality  and the  government  and the  public
generally an influence that will be very effective in helping us to get the j
necessary financial assistance.    Then I think it would not be a bad thing |
if we  could  in  some .way  or  another,  out  of  our  Hospital  Association, j
bring to bear upon the directors, and especially the director^ of the smaujk
hospitals  in  the  province   (persons  like  Mr.   Charles  Graham  and  others
excepted), influence and stimulus along right lines, and I do hope that Dr.
Arthur, in going around the country, will not only look into the hospitals  j
themselves and the staffs of the hospitals and the work that is being done,
but that he will  endeavor to  get meetings  with the  boards  of  directors,  I
take them through the buildings and show the defects and where improvements can be made, so as to get these men to take an interest in their
hospitals.    I realize that we must go to them  and  not wait  for them to
come to us.    This Association  must be  a missionary one  and  reach out
after those who are, outside our fold, and not rest until they have come
within our doors anrL.are taking an active interest in this work.
DR. H. C. WRINCH, Hazelton—
This is your opportunity to tell your inspector what you expect of him.
He is right here.
DR. R. W. LARGE, Port Simpson—
Naturally one looks at his own viewpoint when you have these things
presented, and at once comes the question of the unorganized district.'^*
46 had the pleasure of being associated with our School Board for a time and
I know that when people failed to pay their taxes in those unorganized
districts, it was the pleasure of the secretary, which I happened to be, to
pay the teacher's salary and expenses out of my own pocket, until such time
as money was forthcoming. The Government met that difficulty by taking
over the land that had been delinquent. The result is our School Board
now is rolling in money from the back taxation. That has solved our
school difficulty. In the unorganized district I do not see how we could
get the municipality to assume the responsibility of hospital financing.
Then another point—in a number of sections in this Province we have two
classes of patients, those that receive Provincial Government grant and
those that the Provincial Government will not assume any responsibility
for; the Indian patients I refer to. The Dominion Government in those
cases gives a grant for the maintenance. I do not know how this could
be done unless by some arrangement between the two governments.
DR. G. K. MacNAUGHTON, Cumberland—
I was quite interested in the paper read by Dr. Arthur. From the
title of the paper I had anticipated getting some information regarding the
various good and bad points of the hospitals in British Columbia. I must
congratulate the Government in appointing a travelling hospital inspector
whose duty it is and will be to help boards of directors, lady superintendents
and staff members of the various, hospitals. This will be, I am sure, a
special advantage to the hospitals in outlying districts, where the medical
men and staff and boards of directors have not the time to visit other
hospitals and seeing up-to-date methods so frequently as those in larger
centres. When the inspector came around we did not have the pleasure
of a Very long visit from him, but we take it he is going to be our travelling
Bureau of Information. It has been well said that many of us do not get
away very often and have not the experience that is acquired by visiting
different hospitals, and we trust next year when he comes around he wil*
have the time at his disposal to meet the Board of Directors and Medical
Staff, so that we may take -up with him a number of the problems that we
find confronting us in the smaller districts."
MR. J. SUTTON, Nanaimo—
"There is one thing I would liked to have seen in the report and that
is the Government's viewpoint regarding buildings for hospitals. I think
the time has arrived when there could be in all institutions- that are now
contemplating' being built, a Government regulation demanding that the
institution should be either concrete, brick or cement. I bel;eve that all
wooden hospitals are a danger, not only to those who are practising in
them, but to the inmates. Unfortunately, in Nanaimo, existing conditions
are very much the same as represented by the inspector. We have heating
apparatus from underneath. That has been a source of trouble to us inasmuch as we have not been protected from fire the same as we would desire,
but the board of directors have got together and asked that an enquiry be
made and asking the inspector to give us a complete report on it. We have
been anxious to delay any improvements in view of the fact that we are
hoping to have a new building. At the same time I wonder if we have not
been taking a risk in not carrying out these contemplated changes. I was
hopeful that condemnation would be brought out by the inspector.
DR. H. C. WRINCH, Hazelton—
We are glad to be let off, but it is not the best thing for us. We can
go to our Board of Directors and say "The inspector has said so-and-so,
and we must comply with such request." I would suggest that some report
of the conditions we find in many hospitals where improvement might be
made, should be useful to those who are trying to make the directors more
active in many cases.
DR. E. C. ARTHUR, Victoria-
Just one or two points I would like to mention in reference to the last
speaker and yourself, Mr.  Chairman, about the building.    I do not. know
that it is the place of the inspector to condemn a frame building.   We cannot
do that simply because it is not everything that we would like.   Would it
47 be fair or wise to be too severe on that class of building at the present
time, when the cost of repiacing'by fire-proof building would be so great—
practically prohibited under present conditions? I hope the day will come
when nothing except a building as nearly fireproof as it is possible to make
it, in structure, will be the only kind of hospital building that will be permitted.
Hospital municipalities that I have in mind, Dr. Large, would include
all the territory, organized and unorganized, perhaps in some thousand of
miles in extent in most cases; for instance,—in the two Kobtenays, my idea
would be three municipalities, one for Southeast Kootenay, one for Southwest Kootenay and one for the Northern portion of both districts, including
all the municipalities of the organized territory and all the unorganized
territory, separate municipality, like say, a big country in Ontario.
MR. G. R. BINGER, Kelowna—
Don't you think the municipalities ought to be formed in the districts
-served by the different hospitals?
DR. E. C. ARTHUR, Victoria—
That is approximately the Alberta Act as I understand it. I have read
the Act rather carefully but I cannot succeed in making it fit our conditions
to my satisfaction. Perhaps it would work, but I think it is doubtful, on
account of our enormous extent of unorganized territory. In Alberta
practically all their territory is in municipalities, and they take three r»r
four municipalities in the special district where it is easy to collect the
taxes with the existing organization, as I understand it. We have got to
devise some scheme for a new tax collecting and tax administering body
in order to take in all the unorganized territory. In reference to municipal
taxation—the man you are after is the man" that does not pay any property
tax, the man who does not support hospitals at the present time and does
use them; some measure should be devised to make him contribute his fair
proportion.
DR. H. C. WRINCH, Hazelton—
We cannot get away from the financial aspect; let us have that ready
for tomorrow's session. We will' now have a paper entitled "Survey Report
of Hospital Standardization in British Columbia," by Dr. T. R. Ponton,
Assistant Superintendent and Director of Medical Records, Vancouver
General Hospital.
DR. T. R. PONTON, Vancouver—
At the meeting of the British Columbia Hospital Association, held in
Victoria last July; those of you who were present may remember I gave a
paper-on the Medical Record system of the Vancouver General Hospital,
and made the statement that this system was built up with the idea of using
it, if desired, in smaller hospitals of the Province. At that time, some of
those taking part in the discussion thought that the system was too elaborate and possibly could not be adapted as suggested. During the past year.
Dr. MacEachern and I have undertaken _the Hospital. Standardization
programme for the Province of British Columbia and one or the other of
us has visited every hospital of fifty beds or over, in the Province, and
some of less than fifty beds. During these visits we have attempted to
explain the "Minimum Standard" and to work out a system whereby this
Minimum Standard could be put into practical working effect in the smaller
hospitals. After spending considerable study on this problem, w_e have
come to the conclusion that whilst the Minimum Standard was developed
from study of hospitals of one hundred bejds or over, it can be easily applied
to any hospital. If there- are any present who are not familiar with the
Minimum Standard, copies may be had at any time. I will not take up
you- time by reading it all.
Let us consider the Minimum Standard, point by point, and afterwards
a working plan by which it can be put into effect in the smaller hospitals:—
The first point is the organization of the staff. The word Staff is
interpreted to mean, not the appointed staff on the hospital, but every
medical practitioner who practices in the hospital.
48 £SS The second point has to do with the type of medical practitioner who
should be allowed to practice in the hospital. It is in keeping with the
avowed principle of the modern hospital, to safeguard the interests of the
patient. This clause of the Minimum Standard requires that the medical
men practicing in the hospital should be competent and ethical physicians.
Particular stress is laid on the prohibition of fee splitting. Fortunately,
fee splitting does not exist to any great extent in the Province of British
Columbia and it is up to us, who are vitally interested in the care of the
patient, whether as physician or interested in hospital management, to see
that this practice does not grow.
The third clause of the Minimum Standard provides for staff meetings.
These staff meetings are to be held at least once a month and have two
purposes in view:
1. That the staff should adopt rules and regulations and make
recommendations which will  govern not only their own hospital
.   practice  but will  also  help  the  management  of the  hospital  in
its proper administration.
2. To encourage the staff to do better work by reviewing the work
that they have done during the month preceeding every meeting,
to see where errors have been made; to see where a little extra
forethought and consultation might have saved the patient suffering and possibly disability.
The fourth point of the Minimum Standard has to do with case records.
At the present time we all acknowledge that case records are necessary.
The only point under discussion is how we should get them and how we
should preserve them.   I will take this matter up later on.
The fifth point of the Minimum Standard has to do with Laboratory
facilities. That Laboratory facilities are necessary is also acknowledged,
but in the small hospitals the problem of obtaining these facilities, is a large
one. Complete laboratories are impossible, even though money did not
have to be considered at all. Pathologists are not to be had no matter what
salary is offered them so we will have to be content to have the minor
laboratory facilities in the smaller hospitals with the more advanced bacteriological and pathological work done in larger centres. This point will
also be gone into Jnore fully in discussing the practical working plan.
The following practical working plan is suggested for criticism. It
has been worked up after discussion with the men in Vancouver as well
as the men in the smaller hospitals in British Columbia and I think is
feasible in every point.
Let us consider the first three clauses of the Minimum Standard which
have to do with staff organization. I find that in the majority of smaller
towns and cities of British Columbia, the physicians are either working
in partnership or are working well together. In the cases where they
are working in partnership, I think the spirit of these three clauses is better
carried out than could be done by any formal organization. These men are
not meeting monthly, but are meeting daily and hourly, and discussing
every problem which has to do with both their practice and the hospital
management. They are as vitally interested in the hospital management
as they are in their_own private practice. In fact, it is part of their private
practice. In the case where the men practicing in the hospital are not in
partnership, the matter is almost as easy. The men are generally good
.friends as a matter of actual fact, do meet very frequently, if unofficially,
to discuss problems of practice and hospital management. From this it is
a very short step for these men to make a formal organization and I think
that they will do it if it is explained to them that that organization is in the
interest of the hospital. This very point came up in one of the towns I
visited recently where I asked the men to organize. They immediately
wanted to know the purpose of the organization and when I explained it
to them they replied that they met every day, and sometimes twice a day.
I then put it to them to make the organization formal so as to comply
with these first three clauses of the Minimum Standard. As soon as they
understood that such organization was necessary to get them into a higher
classification, they immediately agreed to complete that organization.      .
The fourth clause of the Minimum Standard regarding case records ts
49 more difficult. The hospital end of the problem, that is, the care of the
case records when obtained is very simple, but the matter of obtaining them "J
is a very different problem. The majority of us in the medical profession
are frankly lazy about writing records of our patients and after almost two
years of constant work with case records I have come to the conclusion that
the unwillingness of medical men to write case records is neglect pure~and
simple. I doubt very much if there is a man in the Province of British
Columbia who honestly has not the time to write his case records. We all
remember the drudgery of our student days when we had to write page
after page on every case that we saw and naturally we shrink from any
such task at the present time. In every case where I have had the opportunity of explaining to the attending physicians that we do not want such
elaborate and verbose case records, they have agreed with me that although
they were busy men, they had sufficient time to write the brief record that
was asked of them. I think that in all the hospitals except the largest, it
can be taken for granted that if adequate case records are to be obtained
they must be written by the attending man himself and that he must overcome this prejudice and indifference of which I have been speaking. Very
few of the hospitals I find have internes, and lacking these internes, no
other medical man is available to write the records, but the record need
he only a brief one since it is written by a man who is experienced in
picking out the important from the unimportant. He knows exactly what
may influence the patient's future life or present illness and so naturally
disregards about 90% of what the student must write because his mind has
not yet been trained to that stage where he can select.
The system of handling these records may be briefly outlined as follows:
Every patient, on admission to the hospital should be given a hospital number This hospital number is a convenient manner of referring to the
patient whenever his name should appear on a document, whether medical
or business. The Register of Patients (M5) or some similar form should
be used to show the serial number and name of the patient together with
what information the hospital desires to be kept. In order that the number
may be easily referred to it is necessary to keep an alphabetical index.
Two forms of this index immediately suggest themselves-either Card Index
or Book Index. The Book Index is suitable where only a small number of
patients are treated, but it is not suitable in the larger hospitals. For
these hospitals, the card index is, I think, the only type that should be
used. It is a very simple matter when the patient is admitted, to write
plain cards, showing his name, date of admission, doctor attending and
hospital number. This card, when filed in the proper card index drawer,
is the simplest of all possible methods of looking up the patient's reference.
In order to make this permanent it may at the end of the year be either
kept in transfer cases or typed and bound. I think the latter is by far the|
best plan and more than repays one for the amount of work there is in
typing.
The forms recommended for use are the Diagnosis Book (M5); a Sum-
mary Card of some kind and similar to (M3) ; a Summary Sheet (M40); I
History Continued (M43); Report of Operation (M71); Maternity Record
(M55); Temperature Chart (M20); Medication Notes (M22); Nurse's
ISfotes (M23); Emergency and Accident Form (M15) and the Death Book
(M13).
These forms could be supplemented~by others if the hospital wishes to
go into a more elaborate system. I do not think it is necessary or advisable
■to take the time for explaining each one of these. The use of each is
apparent.
Having obtained the records on the wards, they should be sent on the
■ discharge of the patient, to the central department which may be in the
smaller hospitals under the charge of the secretary. Here they should be
■placed in envelopes and filed numerically. I recommend filing in envelopes
rather than in folders because from experience we have found that the
folders are dirty and untidy whereas the envelopes are clean and very
• easily handled.
The index of patients has already been referred to. If a disease index
is desired, the form that we use, (M96) answers the purpose extremely well.;3
50 This form is made to be used in loose leaf binders arranged alphabetically
according to the name of the disease and it is a very small amount of work
to enter the patient's hospital number and the result of his stay in the
hospital on the proper sheet in this book at the time he is discharged.
The result of making such entries is that those in charge of the hospital
know at a glance the results of their treatment. I cannot reconcile myself
to the fact that all hospitals in this Province, so far as I have seen, keep
their business entries very correctly but make no attempt whatever to show
the most important feature of their work, the results of the treatment of
their patients. This classification that I advocate is in reality the economic
ledger of the hospital. It shows the gain to the community, the patients
discharged, cured or improved and the loss, in the patients who have died
or who are unimproved.
The Death Book is also recommended because it is to it that we frequently have to refer to find out the very important point regarding the
death of our patients, either immediately after their death or perhaps years
after. It should be accurately kept and should contain a complete description of the patient and accurate statement of his diagnosis and cause of
death.
The fifth point of the Minimum Standard has to do with Laboratories
and under this is included the X-Ray. I find practically none of the hospitals doing any laboratory work beyond urinalysis and rightly so, because,
unless laboratory work is properly done, it is better not done at all. It
is more apt to mislead than help. X-Ray work, too, is neglected in most
of the hospitals because the doctors attending have no time to do the details of developing, etc. To overcome these difficulties, after consultation
with various laboratory men, X.-Ray men and hospital administrators, as
well as doctors in small hospitals, I have come to the conclusion that we
must train technicians who can do the minor laboratory work, who can
take X-Ray plates, develop them and finish them for the doctor attending
to interpret and who would also possibly take charge of filing of medical
records. There are no such technicians at the present time, but I believe
that inside of a year there will be a demand for them. We are prepared in
the Vancouver General Hospital to train technicians for any of the hospitals
in the Province if they wish to send them to us. The present proposal is
that they should take six months in the Laboratory, four months in the X-
Ray and during this four months to do a certain amount of work in the
Med;cal Records Department, so as to learn the principles of filing and indexing. This would provide for everything except for advanced bacteriology and pathology. This must of necessity be done in larger laboratories
because it requires very highly trained people to do it. The time is coming
shortly I think when there will be free Provincial Laboratories. We have
almost got to that point in two of the laboratories at the present time. The
Provincial Royal Jubilee Hospital for the Island and the Vancouver General
Hospital for the Mainland now do almost every type of laboratory work
free of charge. The Vancouver General Hospital Laboratory is willing to
do pathology and such advanced work as is not included under the Government work for any hospital at cost to that hospital. In this way every
hospital in the Province of British Columbia can get pathology and bacteriology done if it is so desired.
It will thus be seen that no matter how small the hospital the expenditure of a very little money and a certain amount of energy is all that is
necessary to bring that hospital under the complete requirement of the
Minimum Standard and I can see no reason after visiting all of the smaller
hospitals in the Province why every one of them should not come under
that Minimum Standard. In fact, the problem is very much easier for the
small hospital than it is for the large one.
The forms referred to are those of the Vancouver General Hospital.
DISCUSSION
DR. H. C. WRINCH, Hazelton—
We want to thank Dr. Ponton for that paper he has given and the very
practical way he has set forth to adopt the principle of standardization.
He gave us a very precise paper on the use of the charts at/ our convention
51 last year. I want just now to express the appreciation of us all to the Van
couver General Hospital for their courtesies and generosity they have given 1
us in the matter of standardization. They have had plates made and allowed f
us to use them. We should thank them for the offer they made today to
do our laboratory work at cost that we cannot do in our own little hospital.
Dr. H. B. Rogers, Medical superintendent Provincial Royal Jubilee Hospital,
Victoria, will open this discussion.
DR. H. B. ROGERS, Victoria—
"I have hot much to say, Dr. Wrinch has practically covered the ground.
From our own viewpoint, we have a hospital in which sixty to seventy men
are practising, situated in Victoria. The Victoria Medical Society, the
members of which send patients to our Hospital, meet twice monthly. We
have ten men appointed by the Board of Directors and the nomination of
the Victoria Medical Society. This Board also meets once a month—the
Advisory Board. Unless you have case records the usefulness of this Advisory staff is nullified—you have no means of reviewing the work. A case
record is absolutely essential. The medical man is lazy. Our men are
alright in some things, but the funniest part is the busiest man writes the
best record. To facilitate writing all these reports we have recently had
to come to the point of having a stenographer, who is placed at the disposal
of these men, to take the dictation, who also does the filing. The reviewing
is done by myself.
DR. T. R. PONTON, Vancouver—
As a rule I take the result which is given by the attending man.   Very   j
often a man comes in with Fracture of Radius and Ulna, sent out in two jj
days "cured."   Of course in those cases I ruthlessly change that to "im- I
proved."
DR. H. B. ROGERS, Victoria—
I think the offer to train technicians is most excellent and ought to be J
taken advantage of.
DR. H. C. WRINCH, Hazelton—
We are very privileged in having with us this morning the highest I
authority on the continent on standardization, Mr. John G. Bowman of I
Chicago, Director of the American College of Surgeons, the head of hos- ,
pital standardization in Canada and the United States.
MR. JOHN G. BOWMAN, Chicago—
"The subject I talk about seems always to be hospital standardization, |
no matter what it is called in the title. I made an effort sometime ago to
look up the history of hospital standardization and found that 600 years
B. C, in the time of David, some writer of a bulletin on hospital standardization stated that through the various problems in Egypt there were many
specialists in medicine, those who administered to the eyes, those who
dealt with plague and so on. The writer pointed out that the trouble with
these many doctors was if they got hold of the patient and he did not have
the particular disease they were qualified to treat, he sometimes did not get
the right treatment. For some 2600 years following that, hospital standardization has gotten along pretty well in a slow, steady progress. There has
not been anything new. We find as far back as 8000 years ago the desire
to take the right care of sick people. For the last four or five years it has
been my work to go around among hospitals, and during the last six weeks
in Canada, coming across the continent from Halifax. I have been in
Canada year- after year for some time back, and I am going to make a
statement I never before made in regard to Canada, that is, that you have
in this country, so far as ethics goes in your profession of medicine, so far
as that ideal goes that knows no discouragement, I think the greatest profession in the world, equal to the idealism of the ethics of the doctors in
Canada. I say that after a good many years of observation. I do not
think there is a. city of 40,000 in the United States in which I have not talked
to doctors, nor in Canada. I have hear'd the discussion, I have been through
hospitals. I have come to that conclusion after a good many years. Nowr
with that as a basis, you have accomplished nearly all there is to accom-
52
_J I plish in hospital standardization.   You have got the foundation right.   Your
I men do want to take the right care of sick people.   They are not willing to
[make a business out of it, they are not willing to turn it into a tommercial
enterprise, and that is really the whole thing in hospital standardization.
With regard to staff meetings—that is where the whole trouble comes.
I think you are going to have a little trouble there because your doctors
are very sensitive, they are easily offended. They get what we call "peeved"
a little bit easily. I thought that over and, over again, and the doctor does
not take criticism and stay sweet about it. If you ask him to explain his
care of the patient he is apt to feel that you are meddling in his business.
The exercise of his privilege is not merely an individual thing, it is a community thing, a group thing; if he does not take the right care he is held
accountable to his colleagues. No one is going to be done an injustice.
To anyone who is asked and makes a satisfactory explanation there will be
nothing accorded him but fair feeling of goodwill.
I do not know your hospitals in British Columbia, outside of Vancouver
and Victoria. I do, however, know the hospitals in the four Western provinces pretty well, and there is no territory on the continent in which more
progress has been made than in the hospitals I have seen. There are
fewer cliques, less ill will, more real devotion to the ideal for which these
hospitals were formed, than in any place else on the continent that I know
about. What I saw in Winnipeg, Calgary, here and Victoria, is an inspiration; it makes me feel that it is impossible to get discouraged. It has
resulted in a revolution. I do not think there is anything to equal it in the
history of medicine. When a little hospital in Calgary can say that "every
patient in this hospital gets the best care that the hospital knows how to
give"-—that ushers into that community a new conception and a new ideal
of medicine, a recognition that never existed before, that every man, woman
and child in our country has a right to be well. That institution will protect
that right. When that idea gets to the public there will be very little trouble
in getting sufficient money to run the hospital on the basis it needs. As I
have said over and over agin, the medical profession in the hospitals have
not sold their ideals to the public. I shall certainly say on the other side
of the line that there is no place in North America that has made the inspiring progress that has taken hold of this thing, the idealism that_ is true
in Western Canada. I have been through Eastern Canada, there is some
progress there, but you have quite outdistanced the Eastern section of the
country, not only in Canada, but also in the United States. If there are
anyquestions I can answer I shall be mighty pleased to do so.
DR. H. C. WRINCH, Hazelton—
We thank Mr. Bowman for that very inspiring, too short, discussion
on this subject. It does us good once in a while to look a little bit higher
than the personal work we are doing.
DR. H. B. Rogers—Victoria—
I would like to ask~Mr. Bowman if he has come across any machinery
anywhere to educate the public as to the value of autopsies.
MR. JOHN G. BOWMAN, Chicago—
I do not think there is any machinery for that; somebody must take it
up as his or her special work. The largest percentage I know of is obtained
in the Montreal General Hospital, running over 80% of autopsies m that
institution. There is one man there who makes it his business to obtain
the consent for the autopsy. It requires also a pathologist who is interested
and will make an autopsy that is worth while, and bring a report before
the staff. There is no criticism so merciless, so fair and so beneficial to
a group of doctors as an autopsy; brought in month after month without
command the facts stand themselves. Many times there will be no discussion, many times there will be discussion. It will keep them from becoming'
hardened to pain and illness, keep them interested; and in connection with
these autopsies there will arise questions that men have got to answer out
of the most serious discussion. The question of getting autopsies is not
a matter of any machinery; it must be done by someone who believes in
the thing and sees what it can mean to the other patients who can convey
53 back to the friends or relatives of the deceased person, who can show that j
person also that that autopsy may mean something to him, her or the
family in the way of protecting themselves from some possible inherited I
tendency there may be in the rest of the family, and the autopsy can easily
be had. If they can get 90% in Montreal it seems to me that 50% is
reasonable to expect in almost any city, but it takes someone with real
devotion to go about it, and of course you require a pathologist to do it.
It is to the advantage of the staff. The one whose case is concerned should
not make the autopsy.   So far as possible it should be made by a pathologist.
DR. H. C. WRINCH, Hazelton—
We will have the report on appointment of committees, by Mrs. M. E.
Johnson, Secretary.
Committee on Resolutions:
Dr. H. B. Rogers,- Victoria
Miss Pauline Rose, Nanaimo
Dr. R. W. Large, Port Simpson
Mr. George R. Binger, Kelowna.
Committee on Time and Place of next Convention and Officers:
Mr. Charles Graham, Cumberland
Mrs.  M.  E. Johnson, Vancouver
Miss G. M. Curry, Chemainus
Miss L. S. Gray, Chilliwack.
Committee on Nursing programme of yesterday:
Dr. H. C. Wrinch, Hazelton
Dr. R. W. Large, Port Simpson
Miss E. I. Johns, Vancouver
Miss J. F. MacKenzie, Victoria.
DR. M. T. MacEachern, Vancouver—
Miss Kinney sends in her regrets—owing to complications in the cafeteria she is unable to take the discussion of Dr. Pearson's paper, but she
told me to tell you .she, as a dietitian, finds herself coming into greater
service and use in the hospital from the medical standpoint, by her knowledge and work in dietetics, by being able to assist the doctor in treating
the patient dietetically, and by her close connection with the Laboratory
in the Metabolism Department.
DR. H. C. WRINCH, Hazelton—
We will now have a paper from Dr. J. M. Pearson, entitled "Hospital
Dietetics
relation to the scientific treatment of Disease"
DR. J. M. PEARSON, Vancouver—
The questions which arise from a consideration of the title of this
paper—a title by the way which was chosen for we are two. First—what
has Dietetics to do with the treatment of disease? Secondly, what has the
Hospital to do with Dietetics? and incidentally with the Dietitian.
It will be possible in the near future to take a healthy infant, and by
feeding such infant through childhood to adult life, along certain definite
lines to guarantee that by the time he is fifty years he will be the victim!
of say a well defined hardening of the arteries, which will presently cut
short his career.
Lest this statement should unhappily acquire currency, let me hasten-
to say that no such experiment is in contemplation nor' is the medical
profession in the habit of making experiments upon the human body. At
worst we try it on the dog. But you will readily grasp the points I wish ,
to emphasize, namely, the increasing knowledge that we are rapidly acquiring regarding food stuffs and food values—dietetics in fact, and the
former we are getting. In applying that knowledge to the prevention or
treatment of disease.
The first duty of a physician is to prevent disease, failing that, to cure,
failing that to relieve suffering and prolong life. Prevention of disease we
regard as the "Summo bonum," and to that end, reluctant legislatures
and skeptical municipal bodies have been driven by the medical profession
(which may be generally reckoned as being on these matters a generation
54 ■ ahead of public opinion) into means for controlling the transmission of in-
[fections and for ensuring at least a measure of purity in our water and
| milk .supply, and in food generally.
In the feeding of patients, in hospital at all events, the modern physician can no longer be content with the general division of diets into "fluids,"
"softy" "light" and "full," and the equally general information obtained from
1 the house that the patient's appetite is good, bad, or indifferent.   He de-
[ mauds something more  accurate.    He  must know how many  calories  his
; patient consumes in a given time and the number of grams of the various
'■ food constituents used to make up those  calories.    He must measure or
'■. estimate whether this amount is sufficient to counteract the ravages of the
disease from which the patient suffers and to afford a maintaining diet for
his body.
A word as to the constituents of food stuffs and their sources and food
of whatever nature and however much affected by national custom or local
habit is fundamentally of the same variety and is the last event capable
of reduction to their chief types, namely, Protein, Fats, and Carbohydrates;
to these must be added certain inorganic principles and some very important
clusice, but most necessary substances, termed "vitamines."
Proteins we get in two varieties from the animal world in the form
of meat, fish, eggs, etc., and from such vegetables as peas and beans, wheat
and grains generally. These are the building stones of the body and from
them we produce growth or maintain our structure.
The term "fats" explains itself. Fat has great food value and is readily
burnt up in the healthy body, but in some diseases such as Diabetes it may
give troubje and the quantity admitted to the diet requires watching.
Carbohydrates or starches (which includes sugar) bulks largely in the
food supply of all. peoples, wheat with Western people, rice with those in
the East, is to be regarded as the principal source.
Inorganic salts, such as phosphates, carbonates and Chlorides of Sodium
and Potassium enter into the composition of all food stuffs and are much
needed in the human economy. One of their functions is the maintenance
of the reaction, of the blood which by means of these salts is kept just on
the alkaline side of neutrality and is one of the most carefully guarded
constants of the body.
The remaining constituents of food to which I shall refer is that group
known as "Vitamines." These peculiar bodies exist in such minute quantities that their number and variety is even yet unknown and such knowledge as we do possess of their existence and vital necessity is an affair of
recent acquirement.
I may give you an instance of their importance. In the tropical disease
-of beri-beri, a form of neutritis, it has long been suspected that in some,
way rice was concerned. Comparatively recently it has been found that if
people whose diet is largely rice, as is the case say with the Chinese or
Japanese, too exclusively eat their food after it has been deprived of. all
its outer coats or husks, being then termed "polished rice," they become
liable to develop beri-beri. The husk contains one of their important
"vitamines" in very small quantity, it is true, but essential to good health.
We do the same thing with our wheat when we make it into flour-—
carefully removing all the husk in our endeavor to get a white commercial
product of good appearance—and with the husk goes the vitamine. Fortunately for us, in our varied diet, we pick up the necessary vitamines in
other places.
The nutrition value of the various constituent of our food is estimated
in the form of Calories—a Calory being the unit required to raise the
temperature of one kilogramme of water through one degree centigrade of
temperature. The number of Calories liberated by the combustion of one
gramme each of the principal constituents of food being Carbohydrates 4,
Proteins 5, Fats 9.3.
In ordering special diets the physician should be prepared to prescribe
definite amounts in grammes of each of these constituents. It is the business of the dietitian to translate these orders into terms of bread and meat
and vegetables and other articles of diet and to place them before the patient
55 in an attractive form.    Not only that but to inform the physician just what
amount of each the patient has consumed or refused.
Let me give you some idea of the class of disease in which dietetics is
a great, if not, preponderating element in treatment. Diabetes is probably
the best known of these. The patient afflicted with this disease has a
great intolerance for all starchy foods and often a difficulty in dealing with
fats. Our problem here, apart from the work of controlling his natural
appetite is to construct a diet on which he can maintain health and strength, -
which will yet contain only such proportion and such form of carbohydrate
as he can utilize.
Wasting diseases such as Tuberculosis, will require the use of the
rnaximum amount of nutrition in properly balanced form that the individual
appetite and. capacity can accommodate.
The same applies to an affection such as Exophtholmic Goitre, where
the breaking down processes of the body under the influence of the poison
are proceeding at an unduly rapid rate.
Typhoid fever calls for the utmost skill in dietary and recent advances
in dietetics have improved our capacity to handle this problem. We are
called upon here, in the face of a disease which shows its maximum effect
upon the organs of digestion, to provide nuti ition not only for the ordinary
body waste, but to provide for the extraordinary waste, consequent upon
high and continued fever. We have learnt that it is possible" to do this and
possible also to bring a patient through an attack of Typhoid without the
accompanying emaciation which used to be looked as a part of the disease.
In disease's such as asthma, gout, and-many forms of eczema, we are
sometimes confronted by evidence or it is sometimes possible to procure
evidence of an intolerance on the part of the body to some definite conj
stituent of the food. This constituent may be responsible for producing the I
disease and our problem is rather one of finding it out than of diet when it
is discovered.
I need not in this hasty survey do more than mention actual disease of
the alimentary tract itself such as ulceration of the stomach or duodenum
or other part of the intestinal tract, and the necessity for a proper dietary
in. their treatment. This is a point, which every man understands and "indigestion" is the one form of disorder in which he voluntarily recognizes
that "something he may have eaten" is the cause of the trouble.
Having thus briefly outlined the part played by dietetics in the treatment of the disease you will readily appreciate the value we attach to the
trained dietitian as distinguished from the mere cook. Every hospital which
pretends to live up to what we are coming to recognize as its duty towards
its patients must regard the dietitian as an important member of its staff,
and the position of the dietitian on the Hospital Staff must be recognized
as at least equal to that of the nurse.
DISCUSSION
DR. H. C. WRINCH, Hazelton—
We have been showri by Mr. Bowman the demands of the hospital on
the doctor; now Dr. Pearson shows us the demands of the doctor on the
hospital. Miss E. Master will discuss it from the dietetic's point of view,
for she has been a hospital dietitian.
MISS E. MASTER, Vancouver-
There  is  no  subject which is  receiving as  much  general  recognition
in  the  field  of  science as  the  S.cience  of  Nutrition.    Experiments  in  research work are being conducted to prove that proper feeding will prevent
many forms of disease.
In the treatment of disease much attention is being paid to feeding the
foods which will be most satisfactory to the patient considering not only
the disease to be treated but also his personal habits and personal
idiosyncrasies. The prescribed diet list is giving way to individual treatment or individual diet list, where most satisfactory results are being obtained. Though a. diet list may contain every desirable food and nothing
undesirable, there are 'few cases where such lists can be used "without
variation, as patients differ in their tolerance for proteins, carbohydrates
and fats.
56 Chemical changes take place in foods during cooking which influence
digestion and assimilation. The trained dietitian knows what these changes
are and is the only one in control of the preparation of foods. The
physician is in touch with the patient watching the symptoms which show
where treatment is effective and where not. Therefore it is essential that
there be the closest co-operation between dietitian, physician, and nurse in
successfully treating by means of diet. Only by the very closest co-operation can this be carried out without very elaborate organization in the
dietary department. The nurse can learn what patients preference is and
with very little extra work the food he craves can often be supplied, rather
than another food which he would not enjoy and would be of greater value
to him.
There is often difficulty in persuading patients to eat the foods which
are best for him. Here is another situation which can best be handled by
the physician as he can persuade them to submit to physical treatment no
matter how painful,- and can persuade him to take most distasteful medicines. Many personal dislikes for food may be overcome in this way. In
rural districts where conservative food habits exist, these difficulties come
up. In a military hospital when influenza was prevalent, the doctor in
attendance told me his greatest problem was to persuade the men to eat
the foods best for them. For example, in their homes they never had eggs
in any form but fried, and they refused to eat them in any other form.
Oatmeal porridge was unfamiliar to them but by the doctor was considered
an essential in right treatment. This situation can best be handled by the
doctor, linking it up with treatment prescribed.
The education of patients to right feeding would be desirable as the
hospital term is usually a very small part of the treatment. This is especially true in the tubercular sanatorium where the patients are receiving
instruction in the proper care necessary to the prevention of the spread of
the disease. It has been my experience in meeting those who have been in
such institutions to find they have had very little training in taking care
of their diets.
In the small hospital which cannot afford a dietitian the matron in
charge should be equipped with some special training in foods, the chemical
changes taking place in cooking and the methods of preparation of foods
in the most wholesome and digestible form. In many hospitals the training
nurses receive does not go sufficiently into detail regarding -changes in
cooking, nor is the administration of foods given the stress that is given the
administration of medicines. Without this training in the small hospital
without a dietitian the matron and her staff of nurses would be handicapped in assisting the physician in scientifically treating disease by means
of the diet
In other small hospitals where dietitians are employed they are very often
made dietitian and housekeeper. In such institutions the best use is not
being made of the special training she has had in feeding the sick. She
has not the time to devote to individual diets nor is there sufficient time
to devote to giving the best training to nurses.
The trained dietitian can be of the greatest assistance in the scientific
treatment of disease by feeding.    She should be a specialist in charge of the
food and released from the burden of administrative work.
' Meeting adjourned till 2:00 p.m.
, AFTERNOON SESSION
Thursday, June 24th, 1920, 2:00 pjn.
NThe meeting was called to order by the President, Dr. M. T. MacEachern.
in the chair.
DR. M. T. MacEachern, Vancouver—
Our first  paper'this  afternoon  is  "Organization  and  Management of
hospitals, and service to be expected in  (a) Hospitals up to twenty-nve
beds;    (b)   Hospitals twenty-five to fifty beds;    (c)   Hospitals fifty beds
and up," by Dr. H. C. Wrinch, Hazelton.
DR. H. C. WRINCH, Hazelton—
I do not quite agree that I was the person .who should prepare this
57 paper, because I know very little about one side of the matter, but in order
to save trouble I consented to take it.
In treating this very comprehensive subject,  in order to establish a,,
relation of sympathy with an audience of hospital workers in the year 1920^.
one must pay deferential homage to the spirit of the day.   There are row
principles that have been of late very much emphasized in all recent writing
and discussion in the broad field of hospital development.   One of these
principles cannot be overworked, but cannot be too persistently drilled into |
the mind and thought and action of every hospital worker.   It is included •
in the simple expression "highest efficiency."    Concerning this principle, no
further comment is necessary.    It is accepted by everyone present, or you .
would not have gone to the inconvenience of breaking into a busy round,
of duties to attend this convention.
The   second   important   consideration   finds   expression   in   the   term-.
"Hospital Standardization."   This also has come to stay, and is becoming
the means of accomplishing much in bringing our hospitals up to the con*
dition of highest efficiency.
It is .the purpose and endeavor of this paper to add its mite to the
development of hospital efficiency. To this end the principle of standardization will be advocated as far as it can be pressed into service, but with the
clear understanding that it is a means rather than an end.
Having thus given pledge as to orthodoxy, the next principle laid downd
is that full recognition should be given to local  conditions  and  requirements, especially wherein they differ from the ordinary.    Even in arrangement   of   accommodation    in   building,    local   requirements    should   be
considered—for instance,  in an  industrial plant where the laborious  style
of male workers predominate with few-women and children in the com- -1
munity, a hospital will he required with principal accommodation of public
or   semi-public   character.    On  the  other   hand   a   hospital   in   a   farming.
community, where population is mixed in normal degree will require mqre.|
private  and  semi-private  rooms  for  care  of  illness,  incidental  to   fami™|
life.
And of course the hospitals to be devoted exclusively to care of special
diseases should be designed and built so as to give" best conditions possible |
for care of such infants.   There may thus be three, or even more, hospitals.|
of equal capacity, but each requiring different internal arrangement to be
best adapted to their particular purpose.
It is a remarkable, and surely an anomalous condition, in_an- age such,
as the present, when governmental control or regulation is brought to bear.
in so many ways in order that the rights and safety of the public should
be safeguarded, that an important service such as that of hospitals should
have been virtually ignored in many cases by "the powers that be."    Certainly there is no service more vital to the well-being of our whole coitir
munity than that in the hands of the hospitals.   And yet, insofar^ as chec^
or regulation by constituted authority is concerned they have been left to
be originated, developed, and carried on, in very many instances, according,
to the ideas of individuals, private corporations, publicly or semi-publicly
elected boards of trustees—m fact in any way whatever as local conditions^
appeared to demand, or permit, as the case might be.   And this refers only
to the negative aspect of the situation—the regulations of such institutional
as  have  been brought  into  existence  by  independent  methods.   Is   it  too
Utopian to conceive of a condition where constituted authority comes into
a community and advises them that population warranted it, and their best
health interests  demanded,  that  a  hospital be established  convenient of
access to them?   An established policy such as that would automatically
prevent the independent action which has in the past, only too often, resulted
in the establishment of small hospitals at points, Or under conditions, which' |
from the first precluded any possibility of success.
Lest there should be any misunderstanding, I desire at this point to
pay tribute to the invaluable services that have been rendered to our communities by the many hospitals by which they have been, and are stilt
being, served. The credit to be accorded to the many persons instrumental
in conducting our hospitals, should be all the greater because of their having.
had to work so much of the time, comparatively single-handed, and having,
58 had to negotiate difficulties innumerable, and break trails for themselves,
when their way might have been made much smoother and many pitfalls
avoided had there been an experienced hospital commission or committee
with power to advise with and direct their efforts.
In the mind of the writer of this paper, the first, and by far the most
important feature in organization and management of our hospitals, big :
and little alike, is the bringinginto existence of a wisely selected committee
or commission on hospitals. That they should be persons of broad hospital
knowledge and some experience goes without saying. They should be ultimately responsible to the local government, although not necessarily directly
appointed by that body. In fact it would seem more reasonable that they
should hold appointment under a council of hospital workers, organized
along lines similar to the medical, legal, dental, and other councils.
Such commission should have authority to inspect and examine closely
into the methods and working of all hospitals, large and small, public and
private, within its territory. It should, above all things be sympathetic, and
constructive in its criticism. It would naturally decide upon certain
standards. These standards would necessarily be graded according to
capacity or special object of each hospital, but should be such as would
ensure to every patient admitted the best possible treatment demanded by
his condition. This might involve transference of certain patients to
larger centres or larger institutions where more highly specialized equip-
' merit would be available. An institution that was found wilfully ignoring
the need of a patient of treatment such as it could not furnish, and holding
him, either by misleading advice or by taking advantage of his ignorance,
would be subject to censure or other pressure by the commission.
It may be claimed that such a course could not, or should not, be applied
to private concerns. It would be an unwarranted intrusion upon private interests. The answer to this would be that private interests must be
secondary to the public good. No one can be allowed to trade in the
greatest asset of the state,—i.e., the health of the subject. The only exception
to the carrying out of this principle would be in the case of the patient
himself, who might refuse to be transferred to another institution. Having
arrived at the conclusion, with the approval of the Hospital Commission,
that a hospital should be opened at a certain point, the question of its
organization in relation to the community becomes the most important
matter. Some would settle the whole .question for all hospitals and in all
time by vesting the entire responsibility, control, and administration in the
Government; but while this would appear to be the easiest way out and- in
many respects the most equitable, there are not a few persons; who see in
the system some very serious drawbacks.
A system that would best ensure the active personal interest of every
member of the community to be served must be admitted the ideal,one.
The local administration should be vested in the people of each hospital
community. A system of appointment of board of management patterned
somewhat after the school trustee system of this province would serve the -•
purpose. The honor of the position and the privileges of contributing to
the welfare' of the community should be sufficient inducement to enlist the
services of the most broadminded persons in the district. An honorarium
for partial or full time of one member of the board who would be responsible for secretarial or other necessary work, where it involved more time
than could be reasonably afforded gratis, would satisfy the situation in
cases where such conditions existed.
In comparison with the above system, the hospital organization under
control of'any philanthropic body, whether religious, fraternal, or otherwise
is handicapped in that it enjoys the active sympathy of only a portion of
the people of any community. No matter how disinterested the motive
behind the hospital project in these cases, there are but few that will escape
criticism, or the imputation on the part of some, that there is some ulterior
motive or some particular interest, of the organization concerned, for the
furtherance of which the hospital has been thrust into the field. A very
httle of such adverse suggestion is sufficient to alienate a considerable
portion of the local interest which the hospital needs and to which it is
fairly entitled, and which it can ill afford to lose.
59 Similarly the institution controlled and directed entirely by the government, with all appointments made by political methods, would meet with
as much or even more indifference on the part of the general public. It
means a very great deal to the success of the hospital that it shall be so
organized that every person in its district may think or speak of it as "our
hospital." To the mind of the writer these conditions are best met when
the hospital is under the direction of a. local board of management, who are
appointed in some manner by the people served by the institution. It can
be readily seen that the matter of financial support also, an all-important
feature, while its discussion does not come within the scope of this paper,
becomes an easier undertaking under this suggested organization than almost
any other method. This organization should be found applicable, in a
modified form to hospitals of any capacity.
As to Management of hospitals there is probably more diversity of
opinion than over almost any phase of hospital work. In this particular
respect, the capacity or size of the hospital must be taken into account.
It is being more and more recognized that the position of a hospital
superintendent is one requiring a more widely diversified range of ability^
or. even talent, than almost any other conceivable work. The superintendent
of a large hospital holds a very important relation to the disbursement of
very many thousands of dollars annually, hence he should be something of a
financier, and be as able in seeing that the best value possible is obtained
for the hospital's money as he is in devising or carrying out measures for
obtaining it. He is in personal relation with a very large staff of employees,
in widely diversified forms of work. In addition to this, which is a part
of the task of the manager of every large business concern, the hospital
superintendent is handling, as his raw material, a mass of humanity in the
most difficult and often unreasonable form in which it can be found.
Further, he should be familiar with quality, value, and market fluctuations
of a very wide range of commodities, in itself no small task. And by no
means lastly, and certainly not least, he should have a working knowledge
of a group of complicated and highly specialized sciences, by means of
which his associated staff are working upon his raw material, in the endeavor
to turn out a finished product of health and happiness in the guise of a
grateful clientele of convalescent patients. Can anyone conceive of a
stronger plea for a thorough training by years of experience for so onerous
a position?
To return to the detail of our subject:—
The Superintendent of the "larger group of hospitals should certainly
be medically trained, and a man of experience drawn from similar successful
service in smaller institutions.
The Superintendent of 25 to 100 bed- hospitals should also be medically
trained. Prior to receiving appointment in charge of such a hospital he
should have experience of hospital administration acquired by a certain
period of service on staff of some other hospital, perhaps as an interne, and
preferably also as an assistant superintendent, or head of some allied department where his capacity as an administrator has been developed and
tried out- As medical superintendent of such middle-sized hospital, he is
in line and succession, and in course of development and training, for the
position-in the larger institutions.
There is a feeling that a special course of training should be institut|p
for hospital superintendents. Perhaps such would be valuable, and without
doubt it would be if supplemented by the training by experience above-
stated. But it is certainly open to question whether the special course of
training without experience of successful work in a smaller sphere would
justify engagement for the larger positions.
A question may arise as to whether there is sufficient work in the
hospital of 25 to 50 beds to find profitable employment for a trained medical
man, for if engaged by the hospital, and with outside doctors on the staff,
he must not engage in private practice. The answer is that in the smaller
hospitals of this group, the medical superintendent who is presumably a
young man, can take over some of the duties performed by internes in the
larger hospitals, or carry out some of the treatments usually given over to
special operators.   Among such duties would be administration of anaes-
i 60 thetics, laboratory work, X-Ray and other electrical treatments, supervision
of case records, etc. Many of the practitioners in attendance at the hospital
would be more than glad to be able to have such work done for them in
the small hospital, as it is in the larger ones, and would welcome a medical
superintendent who would work.in harmony with them along such lines.
The third group, that of hospitals of less than 25 beds, would be hardly
large enough to warrant asking a trained medical man to devote his full
time to their superintendence. Such hospitals are now being very satisfactorily superintended by experienced trained nurses. It is not likely that
this system can be very greatly improved upon. For these positions,
however, it is equally important that candidates for them be prepared by
training and experience in assistantship positions in larger hospitals.
In these smallest hospitals the lady superintendent would naturally
combine with her other duties the direction of the nursing as well as of the
kitchen department. In this way her time could be profitably occupied in
a manner that would not be feasible for a medical superintendent, unless
the latter were a lady. This latter alternative might after all be the
solution of the problem as to how every hospital should be under the
direction of a medically qualified superintendent, which the writer ventures
to believe is the ideal condition.
In the time limit of this paper it is not possible to pursue the discussion
of management into further detail of the various departments,, with their
chiefs and assistants. This becomes a matter of adjustment according to
requirements based on capacity of accommodation. The matter of instituting'
a sufficient number of departments, and having them adequately manned so
that no one individual is either over-worked or idle, is after all only a part
of the duty of the medical superintendent. It is to him the trustees must
look for smooth-running of the hospital machinery, or at least the human
element which enters into it. The board of management that finds itself
continually harassed by friction among the employees or by constantly
recurring difficulty in keeping the responsible positions on the staff satisfactorily filled, may look for the cause in one of three ways,—either (1)
they are not providing sufficient means to secure the best individual for the
various positions, or (2) they are perhaps hampering the superintendent
by not giving him a free hand in engaging and dealing with the employees,
or (3) the superintendent lacks something of the required amount of tact,
personal magnetism, or ability to get the best of loyal, interested effort out
of each and every employee. If they are conscientiously satisfied that the
fault does not lie in either the first or second alternative, then they should
very seriously consider a change of superintendents. It is to him they
must look for the development of a harmonious spirit of loyal co-operation,
with ultimate efficiency the watchword of his institution.
Just here it is appropriate to refer to a method adopted and found
productive of exceeding beneficial results as described in a recent article
in "Hospital Management." In the case described a monthly union meeting
of medical staff with trustees proved a great success in creating a sympathetic atmosphere. The idea is passed on as well worthy of trial.. The
suggestion. being that as many as possible from every department come
together at stated intervals, and spend an hour or perhaps two in considering
means of avoiding interdepartmental friction, and promoting co-operation,
with a view to improving the combined service of the institution.
The question of the service to be expected in the different grades of
hospitals is to be discussed from several aspects in the next period so it
need be but briefly referred to just here. It may be to the point, however,
to remark that the service to be reasonably expected at any hospital depends
less upon the bed capacity of the institution than upon number of specialists,
in addition to the general practitioners, who are practising at points convenient enough to permit them to attend the hospital.
The hospitals in the larger group can, and are of course expected to'
furnish treatment, both medical and surgical, in every form approved by the
latest developments in medicine and surgery. They are able to do this
because they are located at the larger centres of population, where specialists
in all departments are in active practice.    Such specialized forms of treat-
61 ment are  equally available to  the  smaller  hospitals  situated  within easy
access of such town or city.
The service in the two lesser groups of hospitals are necessarily more
limited for the reason that such hospitals, or most of them, are located in
smaller towns and rural centres. In such places it is obviously impossible
to provide the more highly specialized treatments carried out "by specialists.
Thus hospitals are limited in range of service to such as can be furnished
by the general and surgical practitioners on their visiting staff, supplemented
by what can be carried on by the trained members of the hospital staff.
It is quite feasible in hospitals ranging about the 50 bed mark, with
a visiting staff of five or more practitioners who are working harmoniously,
to carry out a fairly wide range of special treatments. It could be arranged
by the visiting staff agreeing among themselves, each to take up a certain
specialty, and then fitting themselves for such specialty by a moderate period
of training of post graduate character.
, The medical superintendent of such a hospital, if a man of tact, could-
show the medical staff the great mutual advantages that would accrue both
to themselves and the hospital by such a course. He would be a specially
effective factor in the development of such a scheme if he would become
responsible for such of the technical work, before referred to, that the
visiting staff would be glad to have done for them. A point to be carefully,
guarded is that the income of the superintendent should be derived entirely
from the funds of the hospital, and not from fees for carrying out any of
these treatments. Any fees for such treatments should go directly to the
hospital funds.
A policy on some such lines as this should be the means of creating
and maintaining such cordial relations between hospital and attending staff-
as would enable them together to render the best possible service to the
community.
DISCUSSION
DR. M. T. MacEACHERN, Vancouver—
Dr. Wilks of Nanaimo and Dr. MacNaughtonof Cumberland, who were
to discuss this paper, are not here.    Mr. Graham will open the discussion.
MR. CHARLES GRAHAM, Cumberland—
I am rather sorry that Dr.- Wilks and Dr. MacNaughton are unable to
be here, as it was only this afternoon that I was asked to take up this
discussion, and I have really had no time to give the subject any particular
thought, so I will have to apologize for not being able to give the subject
the justice it should have.
It seems to me that from the title of the subject "Organization and
management of hospitals and service to be expected"—in the service to be
expected in any hospital I do not think there should be any-variation at all.
The service should be the very best it is capable of 'rendering, whether
large or small. A small hospital is just as capable of rendering good service
as the largest institution. The aim of the hospital should be to render the
very best service that can be given by employing a properly trained staff
and having proper equipment. While the equipment may not be as complete as in the large hospital, still it can be just as efficient.
Organization and management of a 'hospital does vary considerably in
different sizes of hospitals. All hospitals, or almost all hospitals, are
managed by a board of directors. That board takes care of the general
operation of the hospital and the business end of the institution. The
medical end is taken care of either by resident ohysicians in large hospital'
or by medical practitioners in the small hospital. The small hospital has
not the same facilities with regard to medical practitioners. In the small
hospital where there is only one or two medical men it is impossible to
keep a medical superintendent. In the first place there is not enough work
for a medical superintendent to do, and no hospital of that size can afford
it. As far as looking after the care of the patient is concerned, the Board
has to leave that entirely to the doctor. They are absolute!-' dependent on
him for this phase.
The nursing end of it is taken care of in all hospitals by a superintendent, or matron, as. we call them in small hospitals such as ours.  A
62 matron has entire charge of the hospital. She takes her directions in
regard to treatment of the patients from the medical men in attendance.
It seems to me the only feasible way in a small hospital is to have a fully
trained woman in charge, and just like any other business concern, the
only thing to do is to select the best possible and demand results. In the
small hospital the three most important officers are the President, Secretary,
Superintendent or Matron. They should be very carefully selected; the
Secretary especially should be a man of good business ability, a man who
has had a business training, able to conduct the business of the hospital
along business lines. He is really the most important of the two officers
on the Board. The President's position is more of an honorary one—he
comes to the board meetings and looks wise. Then the matron or superintendent in charge—it is to her the Board has to look for efficiency and the
service to be rendered the patients; on her the whole thing devolves and
it is up to the Board when making a selection of superintendent, to see that
they get a medical man, if one is' necessary, or a nurse of the proper
qualifications, one who has had a thorough training in hospital work, who
has executive ability and who is able to carry out all the manifold affairs
that arise in the daily operation of the hospital.
DR. M. T. MacEACHERN, Vancouver—
I think it should be readily agreed that the service to be expected in
any hospital should be firstly,—sufficient facilities and sufficient ability to
cope with all emergencies that may arise in that community; secondly, all
medical work; and thirdly, maternity work. If a hospital can do that it is
meeting good need in the community. From that they can build up their
service. I have one suggestion to make to you all—get your internal
organization clearly defined and working. I know of one hospital where
a member of the Board always transmitted his orders directly about the
garden to the gardener, instead of coming in the usual way, and when
anything about the power house came up he went to the engineer, and there
was. trouble from every angle. The whole question is the organization
being, clearly defined. A ten bed hospital, three phases of work to carry
on; one phase is nursing, one is business and,one is medical. I think that
will cover it all. I do not see how you can cover it with any less. Decide
who is going to be the head of these three departments. You may not be
large enough to have a head for each of these divisions; for instance, the
superintendent of nurses may also be lady superintendent of the hospital or
matron. I understand as lady superintendent she is general superintendent
and superintendent of nurses. Matron is a term which we use for lady superintendent; I think they mean about the same thing. Then as your institution
grows, add your departments. In so doing you will have a clear cut organization and avoid omissions, overlapping or shortcomings of any kind, or lack of
co-operation. We, as a large hospital, have a little scheme we follow, which
can be carried to the small hospital. Every two weeks the heads of each department, the people who are on our staff who have definite responsibilities
assigned to them, meet in our board room, one hour, four to five o'clock,
where we discuss the work of the hospital from each person's viewpoint.
If any person has a grievance against another department he has to table
it, we discuss it and have it out. As a result we have good constructive
CfItm'sm °ffered, we get somewhere. You have somebody in your Board
of Trustees who surely takes more initiative than the other. Dr. Wrinch
mentioned the president, secretary, superintendent or matron. We do not
get together enough with our governing bodies. Our governing bodies are
not paid anything as a rule, they give their services out of love for the
work, and sometimes they unconsciously "butt in" unintentionally, sometimes purposely, and sometimes with the best intentions, but if you get
together and explain things you will find that they will right themselves.
|%!  ■'■believe that in any institution there can only be one person who is respon-
Is'ble to the higher governing body, that no institution can exist where people
are pulling different directions; they should all pull together.   Dr. Wrinch
m h's  paper,   and  Mr.   Graham   in  his   discussion,   have   brought   out   a
u     • ^ bope will be taken up very seriously, that is organization of
Organize them definitely and clearly.   That does not mean
63
your hospitals to put on a great big staff; it means to know where one's duties begin and
-where they end, and have co-operation on every side.
MRS. L. H. HARDIE, Duncan—
As to the point of management—we have a Board of Management
appointed by the governing body of the. King's Daughters' Hospital. It
is made up of women as well as men. We have a house committee composed of women to look after the internal arrangement. They see about
the housekeeping end. We find it works very satisfactorily. We have a
paid business secretary who attends to the business end, and for our income
we are largely dependent on annual subscriptions.
DR. E. C. ARTHUR, Victoria—
I wish some scheme could be devised to get more active personal
interest taken in the hospitals by the majority of the members of the
various boards. From my experience in going about the Province I found
some few boards where the members seemed to take very little interest and
it was left to the matron, sometimes to the secretary—often the secretary
happens to be a member of the board. I might say that two of the best
secretaries I came across were members of their respective boards, but
there seems to be a woeful lack of personal interest in the hospital on the
part of the boards. I was disappointingly surprised to find hows many of
the boards have no regular system of visiting their hospitals.
DR. M. T. MacEACHERN, Vancouver—
I think Dr. Arthur has struck a very important point which I would
like to take up. It is a very important point. Although that is the way
with a great many of the boards, still we cannot say that about them all.
There are some that close their business up and attend the conventions; -
those are the kind of men we want on our boards. Others sometimes take
up the whole evening in acquiring information they should have known from
the last meeting.
MR. P. DU MOULIN, Kelowna—
I have the honor of presiding over our Board. I find the greatest system I
for getting an active directorate is to weed it out, keep in mind people who
are interested, and those who do not attend for three meetings, ask them
to resign and appoint another. In that way the keenest of interest in the
hospital is kept up by them, and they can naturally interest their friends,
likewise the whole community.
MR. J. SUTTON, Nanaimo—
I find the difficulty of lack of interest from the board of directors' standpoint is largely due to the hospital.   I remember our own hospital experience!
—the board of directors obligated to the bank for extra payments or overdrafts upon the bank for the general upkeep of that institution, and that
worked particular hardship, and I can just imagine that no director would
be   anxious   to   take  part   in   the   affairs   of  that   institution   under  those
circumstances.   That was probably one reason why we failed to get good
men, because they realized they had sufficient responsibilities of their own
without  taking  responsibilities that belonged to  other people;   still I am
pleased to think that day has gone.    I think it is very essential, and if 18
can be carried out more in detail as Dr. MacEachern has stated, it woluldM
help the splendid work being done in hospitals.   Our Board is composed of
fairly good executive men of the city.
MR. R. S. DAY, Victoria—
I do not think any director of a public hospital in this Province is*
called upon to put his name upon any note or acknowledgement of any kmjjH
for a dollar, and I have always refused to do so and our Board has refusedH
to do so.   I think if the Government and municipalities will not do it, the,
more we do it the more they will expect us to.
DR. R. W. LARGE, Port Simpson-
How are they able to carry on the business with the bank if.they hav|
an overdraft?
64 I MR- R- S. DAY, Victoria—
The Jubilee Hospital has assets of about $150,000.00 coming in, legacies
I of $25,000.00. We had an overdraft and the manager of the bank called the
honorary treasurer and myself over the coals, said he would sue is if we
j refused to pay, but he did allowus to have an overdraft of $5,000.00.   We did
I get an arrangement at our bank'under such circumstances for $5,000.00 overdraft, but we said we are not going any further than that. What happens
is that our traders are not paid. Then we say to the traders, "Go after the
City, the Government, the public."
DR. R. W. LARGE, Port Simpson—
We have taken the opposite view. Our Board came to the conclusion as
private individuals we pay our accounts collectively, and as an hospital we
should pay our accounts monthly. As I said yesterday, we have to put
our names as individuals on our overdraft.
DR. M. T. MacEACHERN, Vancouver—
The Western Canada hospitals got together in April at Calgary. From
Lethbridge the president of the board came down from the Gait Hospital.
He had with him his secretary. The secretary sat at the meeting" and took
all the proceedings. He happened to be a stenographer and of course got
the notes very well. I went up to him, I thought he was a newspaper man,
but he said, "I am private secretary for the Gait Hospital Board, I am taking
a report." I had to take the report of proceedings to get it ready for publication, and I asked him to send me down a copy. His copy was perfectly
accurate, admirable. The secretaries of our hospitals should be here and a
representative from every board should be here to take these notes and
get them back quickly'to their board.
Dr. MacEachern explained that hospital standardization did not come
from over the 49th parallel, as stated by one of the speakers this morning.
It originated in Canada and the United States jointly, and many men in
our own Province here, and especially in the cities of Vancouver and Victoria, were promoters thereof. He said : "It is the best thing that has ever
come into the medical world for our people. We all know that patients
have suffered and died from lack of proper facilities and from incompetent
care. With the advent of hospital standardization and adoption thereof
such would be impossible."
PART II.
Round Table Conference, conducted by Dr. H. C. Wrinch, Hazelton.
Subject:   "Medical service in hospitals of five to one hundred beds."
DR. H.  C. WRINCH,  Hazelton—,
The first topic this afternoon in the Round Tabic Conference is "The
Clinical Laboratory, its equipment and operation," by Dr. R. H. Mullin,
Director of Laboratories Vancouver General Hospital, and Professor of
Bacteriology, University of British Columbia.
DR. R. H. MULLIN, Vancouver-
It is the experience of almost all hospital executives that the highest
efficiency in laboratory service can be attained only when full time workers
are placed in charge. The recognition of the value of an adequate laboratory has become general and practically all the largef hospitals are so
equipped. As this has resulted in a very considerable curtailment of the
available supply of laboratory workers to such an extent that their number
is not nearly equal to the demand. This scarcity of the supply has another
cause in that the salaries heretofore offered have not been sufficiently high
to encourage many young men to enter this branch of the profession. Those
efforts at hospital standardization now being undertaken, necessitating as
they do, adequate laboratory services, have created a competition for well
trained men with a constant increase in the amount of their compensation.
This makes such an individual an expense greater than the ordinary small
hospital can possibly afford, thereby creating a problem whose solution is
most urgent if the efficiency of the smaller hospitals is to be maintained.
The first solution thought of usually is the employment of part time-
men, allowing them to practise in addition to their laboratory service.   This
65 may work for a time but eventually and usually as rapidly as his practise
grows, there will almost inevitably be a neglect of the laboratory service for
the more remunerative practise. In other words, these part time men tend
to use the laboratory as a stepping-stone to practise. At the beginning,
they are young and of comparatively limited experience, since the older and
'more experienced ones gravitate to the larger centres where greater opportunities of all kinds exist. The net result for the smaller hospitals is a succession more or less of a number of men of varying qualifications who are.
interested in laboratory work only so far as it will afford them a livelihood while they are seeking to establish themselves in practise. This does
not seem a happy solution.
Before-seeking a better one, it might be well to have a thorough survey
of the situation determining just what is required and how such requirements can best be met. It must be recognized that this is a Public Health I
era in which marvellous advances are being made throughout all Canada.
In Public Health work, a laboratory service is essential and this Province
is now supplying such a service through the utilization by the Provincial
Government of the Laboratories of the Vancouver General and Royal
Jubilee Hospitals.
Of what does Public Health Laboratory work consist? In a very
general way, it might be such that its work has to do with any examination
the results of which can be utilized in the control of communicable diseases.)
This would naturally include (1) Examinations of cultures suspected of
diphtheria, for either diagnosis or release and a determination when necessary of the virulence of diphtheria organisms which may be found. In
diphtheria work, the preparation of Riaterial for the Schick Test and antitoxin immunization would be undertaken. (2) The examination of sputum
for the bacillus of tuberculosis. (3) Agglutination Tests in Typhoid Fever,
Dysentery, etc., and the search for the organisms in the dejecta of suspected
carriers. (4) The necessary examinations for determining the presence of
diplococcus meningitis. In cases of cerebral spinal meningitis or suspected
carriers. (5) The necessary examinations in venereal diseases, such as
the Wassermann Test and microscopical examination for gonoccoccus and
the spiranema. (6) Bacteriological supervision of water and milk supply.
(7) Examinations in the rare communicable diseases such as leprosy, actinomycosis, malaria, etc. (8) Manufacture of prophylaxis, such as Typoid
vaccine, etc. Here might be included such things as Small-pox vaccines,
d'ththeria antitoxin, anti-meningitis serum, etc., but these require expensive
plants which could not be duplicated in other provinces since such materials,
can be obtained more cheaply and with less variation from some central
plant like the Connaught Laboratories. This mechanism makes the governmental supervision of such products much easier.
Since examinations as outlined above are being provided through a.
provincial agency, the amount of laboratory work absolutely essential for
individual hospitals is cut down to a very considerable extent and in this
way a mechanism for properly providing for it can more easily be devisedfj-
Under these conditions, individual hospitals should be prepared for the
following work: (a) Bacteriology work necessary for non-communicable,
diseases and the preparation of autogenous vaccines, (b) Routine urinalysis, chemical and microscopical, (c) Blood counts, (d) Gastric
analysis, (e) The newer metabolism chemistry. ■ (f) Surgical Pathology.'
(g) Miscellaneous examinations. It must be recognized that in the
larger laboratories doing work of the character, most of the routine procedure' is carried on, not by fully trained medical men, but by technical
assistants who have been trained by repeated examinations to acquire a
considerable amount of manual dexterity, chemical and Bacteriological proficiency, under the supervision of a medical man. Laboratory technicians
have a very distinct place in every well equipped laboratory. There is no
doubt of the fact that in the work enumerated above they can be trained
so that they will attain a very high degree of accuracy. The'r employment
means that the time of the more highly trained medical man is conserved
for work which requires one with a medical degree for a correct interpretation. In the Vancouver General Hospital, routine urinalysis which include
chemical and microscopical examinations have been in the hands of such
66 a technician for some time and the results have been very satisfactory,
similarly with blood counts. It has been possible to take an individual with
average intelligence and through experience, to have him acquire sufficient
information to accurately enumerate the cells of the blood. The differential
counts and the changes in the red cells may need the supervision of a
medical man. In the tissue work, all of the specimens are run through a
fixative, cut, mounted and stained by a technical assistant. The details of
the technique of the newer methods of the Metabolism Chemistry can also
be acquired readily by such a techni-ian.
Such being the case, it might be possible in the larger hospitals to
train a number of such technicians who would be able to go to the smaller
hospitals and carry out the necessary work there, utilizing the laboratories
of the larger hospitals when these technicians might be in difficulties. This
is not as difficult or cumbersome a mechanism as might at first appear since
most of the material in which they might be apt to find trouble is of a
character that lends itself readily to shipment through the mail. In this
way, a laboratory system more or less co-ordinated qould be devised which
would be of immense benefit to all the smaller hospitals. A technician of
this type would have sufficient training to be able to prepare any bacteriological material or surgical pathology material which would require shipment
to a central laboratory. The value of such a system would greatly be
enhanced if to it were added periodical inspections by trained medical men
of the laboratories in the smaller hospitals which employ such technicians.-
If it is admitted that such a mechanism would be a solution of the
question and therefore that it would be advisable, the next question which
would immediately arise would be the matter of the supply of such technicians. In the Vancouver General Hospital, this has been attained so far in a
more or less haphazard manner, beginning by individuals from time to time
who seem to be by inclination more bent for this line of work. Occasionally
one who has already had some training has been found, but the supply is
by no means constant. It would, of course, be essential that a sufficient
number of such people could be obtained. It must be recognized of course
that it takes time to train them and a hospital desiring such a technician,
under the present circumstances, could not be sure of finding one on short
notice. Consideration of any scheme which would seem to provide a constant supply of such individuals might well be undertaken. British Columbia
in one respect at least is very advantageously situated. The Provincial
University has undertaken, with the aid of certain hospitals the advanced
teaching of nurses. At present, the curriculum consists of two years of
university work, a good deal of which is devoted to the fundamental sciences
such as Bio-Chemistry, Physics, Bacteriology, etc. The following two years
are devoted to Hospital training school work. In the final or fifth year, the
student elects one of two branches, either Hospital Administration and
Teaching, or Public Health work. On account of the demand for technicians,
it might be possible to induce the university to add a third option over the
fifth year, which would include traming in a hospital laboratory in an X-Ray
Department, and in the proper collection of Medical Records. If this were
done, a class of individuals would be provided who would have a fundamental training in Science, in Nursing, and in Laboratory and X-Ray
procedures which would be sufficient to make them very acceptable for
technical services in these lines in the smaller hospitals. I think if such
an idea was adopted in the smaller hospitals, that the service would be
greatly enhanced. If there were inspectors of these institutions, not only
to see that the work is going alright, but to encourage the individuals who
are working and to give them a chance to pick up the newer information
that they perhaps m;ght not get in their own institution it would help
considerably. Might I make the following suggestion:— to see if the idea
is of sufficient value that it would be worth while to endeavor to obtain it
and, if so, a constant supply of these technicians would be available.
DISCUSSION
DR. M. T. MacEACHERN, Vancouver—
What do you consider the laboratory work of a twenty-five hed hospital,
Dr. Mullin?
67 DR R. H. MULLIN, Vancouver—
Up to twenty-five beds the laboratory work will undoubtedly have to
iidertaken by the phys
ther
eh
lies
the
emsel
tendent happens to be one of those nurses who has had this additional I
technical training. In hospitals of fifty beds and up certainly there should]
be a trained technican in every one. There is enough work there to keep
a trained technician in every one. There is enough work there to keep a
technician busy doing routine work, blood counts, and X-Ray work if they
were equipped with an X-Ray. I think every hospital over fifty beds
should be supplied with one of these technical people.
DR. H. C. WRINCH, Hazelton—
Possibly the superintendents of some of these hospitals could have parti
of her training in this technical work, or in another way, a trained technician
could become a superintendent. We will consider the next phase of this
round table conference—X-Ray Laboratory, its Equipment and Operation,
and I will ask Dr. H. H. Mcintosh, Radiologist to the Vancouver General
Hospital, to open the discussion on this.
DR. H. H. McINTOSH, Vancouver—
In the smaller hospitals it is necessary that  some means  be  devised'
whereby their patients may receive to a greater extent the full benefits of the
X-Ray in both diagnosis and treatment.
• About one year ago I wrote to your secretary concerning the teaching
of X-Ray technique as part of the under-graduate training. I thought then
and still think that the subject is too large to be included in the pupil
nurses work, but that it can very well be a branch of post-graduate work.
Also at that time there was the difficulty of uniformity of apparatus to be-
considered. That condition has been largely overcome as I shall explain in
a moment.
What is needed now is co-operation for the Durpose of standardizing]
the equipment and the training of technicians, by a technician I mean one
trained in the technical side of operating X-Ray apparatus. Formerly where
a dozen different hospitals had as many different types of equipment, technicians would have needed instructions in the managing of all these varieties
in order to be able to undertake duty at any hospital where there was a
vacancy. By standardizing the equipment, that is each hospital having the
same type of apparatus, a technician trained in the use of this type would
be able to do satisfactory work in any hospital.
The Medical Corp of the U. S. Army through its Division of Radiology
devised and had manufactured a small portable X-Ray unit which was,
capable of doing all work needed for an army in the field. Since the war
manufacturers have produced similar apparatus which is most useful and
does all work except gastro-intestinal radiography and heavy treatment.
With this type of apparatus the detail of taking skiagrams is worked out]
with mathematical exactness and it is simply a matter of making a setting I
on the machine and running it for the length of time specified for the part
being examined.
In the case of hospitals with other types of apparatus, the use of the
Coolidge tube makes it possible to obtain similar results. The technician
would, however, need to receive a somewhat wider instruction to be able .to
work out for herself the requirement for each t"ie. The general working
principles remain the same for all. The Coolidge tube has revolutionized
the work as this tube never varies and works for long periods without overheating and without change. Work with gas tubes is an art, with Coolidge
tubes a science. When all is said and done, the exeat important factor is
the tube and with the new apparatus and the Coolidge tube the training of •
the technicians is much simplified.
In considering the instalment of X-Ray facilities there are three features
to be considered:
1.   The accommodation of room space for the apparatus.
1.   The apparatus.
3.    Someone to operate the apparatus.
In  planning an  X-Ray department,  too  often the unfortunate  X-Ray
worker is shunted to some dark corner of the basement.   This is a great mistake and X-Ray rooms should be large ahd lofty both from the hygenic
point of view and from the point of view of efficiency. This room should
also be convenient to the wards and to the Operating Room. There should
be plenty of over-head space for the high tension wires and plenty of room
in which to move a bed about, then patients can be properly placed for
examination and the apparatus can be moved to accommodate the needs of
patients who must be examined in their beds. The air in the X-Ray room
is continually being vitiated by the high tension electrical current and
ventilation should be adequate. This is also true of the developing room.
In both the X-Ray room proper and in the developing room absolute darkness is needed so that when these rooms are closed not a single particle of
light should be permitted to enter. The windows and doors are thus air
tight around their margins and arrangements are then made to admit air
by means of a light trap. This is quite simple, but possibly on account of
its simplicity is frequently neglected. X-Ray rooms and dark rooms have
generally been painted black in order to prevent the reflection of stray rays
of light It is much better to have the rooms light proof, then there are no
stray rays to be considered and the rooms can be finished in a light color,
such as buff, which is much more cheerful and desirable in every way.
New apparatus should, I think, be of the type I have mentioned. That
devised by the U. S. Army and which is obtainable from a number of manufacturers. A Canadian Society of Radiology is being formed at the present
Canadian Medical Association meeting. It is hoped that through them
standardization may be arranged and it would be well to follow their advice.
In the matter of hospitals with older types of equipment, extra attachments
are necessary for the use of the Coolidge tube, but these are not very expensive and rather easily set up.
I think that for the kind of work we are considering there is no question
that nurses specially trained would be the most suitable as technicians.
There is naturally not enough X-Ray work in a small hospital to occupy
one person's time and the nurses trained for X-Ray work should also take
a course in Laboratory technique and the keeping of case records. Such a
course should be very easily arranged for as a post-graduate training at
some of the larger centres and possibly in connection with ^the Faculty of
Nursing in the University. Insofar as X-Ray work is concerned the course
would embrace glementary electrical physics, general construction of apparatus, anatomy, X-Ray photography, practical work in exposing and
developing plates and the keeping of ijecords. By the new Canadian
Radiological Society a scheme for standardizing the training of technicians
will most probably be worked out. The intention being that a certificate
of competence will be issued to those so trained. It must be understood
that a technician so trained is not an X-Ray diagnostician nor yet one to
prescribe the quality and quantity of X-Ray treatment. The task of interpreting the plates is not that of the technician but remains with the medical
man. The technician would be able to produce good skiagrams, set the
machine for fluoroscopic work and give the amount of radiation prescribed
by the physician. In interpreting the plates she is not expected to be proficient, nor is she able to decide what cases are suitable for X-Ray treatment nor what quantity should be used in individual cases.
The field of usefulness of the X-Ray in both diagnosis and treatment is
rapidly enlarging and there is no reason why smaller communities should
be at much disadvantage. As there is no room in a small community for
any eye specialist there is likewise no room for an X-Ray specialist. Cases
requiring their advice must still go to the larger centres, but there is a great
deal of most valuable work that could be done in the small hospitals. By
means of triple training, X-Ray, Laboratory and case records, the expenses
are not borne by one branch alone and the extra efficiency of the hospital
more than compensates the small additional expenditure.
The operating expense of the new type of apparatus is very small indeed
and if we have as may be expected from the Canadian Radiological Society
a_ standard for training of technicians and recommendations at least regard-
mg equipment it will be comparatively simple to provide in this province a
number of nurses capable of performing the specialized duties so greatly
needed in small hospitals. ■ I still think that graduate nurses could very readily be given such a:.
course of training.    It would take a little time, possibly 6 months, but it
could be taken in conjunction with the course Dr. Mullin suggested.
DISCUSSION
DR. M. T. MacEACHERN, Vancouver—
What if there was no electric power?
DR. H. H. McINTOSH, Vancouver—
In the army they had the same difficulty.   They used a small dynamo. I
The American army had a gasoline engine and dynamo.
DR. E. C. ARTHUR, Victoria—  '
Could any technician carry out this work? Would his work be
recognized by the Medical Council? Is he to be allowed to work independently?
DR. II. H. McINTOSH, Vancouver—
I do not think a doctor should prescribe X-Ray treatment unless he.
knov j the amount that is to be given. The nurse would know exactly how
much per minute was given off. In the matter of treatment, that will
necessarily be very limited. It is much more of a specialist's work than the
other. There are a few conditions, such as eczema, which are very greatly
helped by it and could be used with great safety.
DR, H. C. WRINCH, Hazelton—
I will now call upon Dr. T. R. Ponton, Director of Medical Records and
Assistant Superintendent Vancouver General Hospital, to discuss the third
phase—Medical Case Records, Importance and how acquired.
DR. T. R. PONTON, Vancouver—
As the necessity for the.medical case record is acknowledged by every
person doing hospital work, I shall pass over that part of the subject without
any reference whatsoever.
The method of obtaining and preserving this record has been the subject
of consideration and planning. In my recent visit to the smaller hospitals
of British Columbia, and after consultation with the various men concerned
, in hospital management, the following has been suggested:— All medical
case records in the hospital should be handled on the numerical system.
This means, first,—that every patient should be given a number on admission
to the hospital.   The best method of doing this is by keeping a register of
■ patients in the admitting office. On admission under the serial number, the \
patient's name, address, doctor- attending and date of admission sshould be
entered. When the patient is sent to the ward his serial number should
be sent with him. The nurse's notes form the first part of the medical
record proper and should consist of temperature chart, medication chart
and nurses' notes. Temperature chart should show pulse, respiration and
temperature in a graphic manner. It is well to note on this chart also
stools and urine. The medication chart contains actual prescriptions and
details of diet orders. Cancellations are shown so that the attending
doctor can see at a glance what treatment he has given and what treatment
has been cancelled. The nurses' notes should indicate each dose of medicine
given, each detail of treatment carried out, and in the last column the
nurses' notes as to symptoms.
In considering the medical record proper there is no doubt that in the
smaller hospitals the attending physician himself will have to be depended
on to make this. On this account it will be impossible in the small hospitals
to use an extended form of medical history, and it is suggested that the.
summary sheet which we use in the Vancouver General Hospital be made
the basis of the history. This contains sufficient space for all the important
items such as heredity, past history and history of present illness, with
treatment, medication and finally, condition on discharge. As some cases
will require more extended notes than the summary sheet provides for, it
will be necessary to use a blank sheet such as the History Continued, to
supplement the summary sheet.   On discharge of the patient this completed
70 medical record containing nurses' notes, case history, reports, such as
laboratory, X-Ray, etc., should all be sent to the central records office and
filed in their serial order. At the same time the admitting office should
be notified of the discharge of the patient so that they can enter in the
register of patients the final diagnosis of the attending physician, date of
discharge and the result of treatment. Some of the smaller hospitals also
enter on the register of patients the total amount of the account so that they
have a financial record as well.
A summary card of some kind should be used for findings in referring
to the chief information required about the patient! The one use,d in the
Vancouver General Hospital is found very convenient. It is made out on
admission and is kept on the ward during the patient's stay in the hospital.
On discharge the diagnosis and date of discbarge is entered and any notes
of particular treatment such as operations, are entered in the appropriate
space. This card is filed and very often saves reference to the full medical
record. The numerical system presupposes an index for patients and cross-
index of diseases. The index of patients should be made daily on admission
so that it is always possible to get the hospital number of the patient whether
he is in the hospital or has been discharged. For the smaller hospitals the
index in book form is suggested; for the larger ones the card index is undoubtedly the best system to use. Whichever is used, each entry should
show the name of the patient, the doctor attending, the date of admission and
the hospital number. If the card' index is used, at the end of the year it
should be typed and bound, forming a permanent index for that year.
Whilst this is a tedious piece of work, it more than pays in the easy reference
that it gives. For a cross-index for diseases I do not know of anything as
convenient as the system we use in the Vancouver General Hospital, and it
is just as adaptable for the small hospital as for the large. The classification
sheet has at the head of the sheet the name of the disease. These sheets
are arranged in loose leaf binders, so that it is a very simple matter to enter
under the proper disease the hospital number of the patient suffering from
that disease and the result of his treatment, as well as the days' stay in
hospital. By adding these figures it is easy to make a statistical report
showing male or female, result of treatment and total days and average
days for each disease treated in the hospital. This cross-index or classification of disease is also bound at the end of the year and kept as a
permanent index of disease for that year. If a patient suffers from three
or four diseases they will show in three or four different places, so that this
cross-index is not a guide to the number of patients treated but to the
number of diseases treated.
DISCUSSION
DR. H. C. WRINCH, Hazelton—
How long would it take to give a nurse a course to qualify her to look
after records?
DR. T. R. PONTON, Vancouver—
We conclude that it would take ten months to train a technician who
was at the present time a trained nurse—six months in the laboratory and
four months in the X-Ray. During that four months in the X-Ray she
would spend a certain amount of time in the Records Department learning
the filing and that style of thing, she would have to do. If she were a
stenographer so much the better.
DR. H. C. WRINCH, Hazelton—
We appreciate very much the help given us by the Vancouver General
lospital in the very practical discussion of this more elaborate work.   I
war going to ask if there are any trained nurse technicians in the General
Hospital.
°R- H. H. McINTOSH, Vancouver—
Yes, we have one, in our X-Ray Department. When I was in Rochester
I found a great deal of the work being done by trained nurses, who have
taken additional training, both in treatment and Fluoroscopic work. In
loronto the work is being done there by nurses.    In Edmonton I did not
71 see any nurses in the X-Ray Department.   What is being done elsewhere
can be done in British Columbia.
DR. H. C. WRINCH, Hazelton—
I will.now call upon Dr. H. R. Storrs, Medical Superintendent St. Paul's
Hospital, Vancouver, to discuss the topic for this round table conference
entitled "The Relation of the Medical Staff to the Hospital."
DR. H. R. STORRS, Vancouver—
We have had two very strenuous days, we have two more ahead of us.
The chairman in asking me to open the discussion today impressed upon me
the necessity of being brief. What I will have to say will be in the nature
of suggestions. The details I think have to be worked out by each individual
hospital.
In the first place, what is a Staff? The dictionary defines it as something on which one leans for support. The word as applied to a hospital
means a group of doctors chosen, as a rule, by the management, composed of
men who take an active interest in that particular institution and who do
the majority of their work there.
Now in the matter under consideration, there are four types of hospitals
to be mentioned, first, the private hospital, owned and operated by one or
more doctors for their own emolument and glory, secondly, the closed public
hospital, in which an elected staff does all the work, to the exclusion of the
rest of the medical fraternity, thirdly, the private hospital doing public work,
such as the Sisters' hospitals, and fourthly, the municipal-owned hospitals.
For the purposes of this discussion we may leave out of all consideration the
first two classes and confine our attention to the last two, namely, the semi-
public and public hospitals.
What should be the relation of the Staff to these institutions?
A hospital to perform properly its duties towards its patients and the
public at large should be organized and the medical men in attendance
should be organized, for if you have no organization you lose half your
efficiency. In a small community this organization need not necessarily
be divided into surgical, medical and the specialties, in fact it is better not,
but'.to have one small group of men working as a harmonious unit. In the
large institutions, of necessity the staff must be divided into units, each
overseeing its own department.
Primarily the Staff is an advisory board. It is their duty to advise
the management of the institution, as to what should and should not be
done to increase the hospital efficiency; always remembering that the management reserves the right to follow or reject the advice given. Very often
there are reasons unknown to the Staff whereby their advice, no matter how
excellent, is impossible of fulfilment.
But acting as an advisory board is not its whole duty. By its contact,
its character and ability, a Staff can make or mar a hospital. I have in mind
a hospital of sixty beds in a community of 6,000, with a staff of seven. The
professional ability of these men is excellent, but their mental viewpoint is
such that instead of working together harmoniously and endeavoring to
make their hospital as efficient as possible, they, are continually employed
in personal and petty bickerings, so that nothing is accomplished for the
hospital's good, and in addition the public is beginning to suffer, and realizing this, go elsewhere for treatment.
Co-operation and Service should be the two watchwords of any staff.
Co-operation with the management, so that the rough places may be made
smooth, and co-operation with each other. Without this last a staff is
useless.
If the pathologist refuses to make a white count on an obscure abdominal
case because he is afraid of not being paid, if the X-Ray man refuses to
function because you inadvertently had hurt his feelings last week, and if
many other such like events occur, then a staff is worse than none at all. I .
The staff should be composed of men not only of high professional
ability, they should each and all be men of clarity of vision and unselfishness. They should give the best that they have freely and willingly, sink
their personal differences, and by so doing- they will see their institution
grow in dignity and efficiency and become a monument in the commuriitjp
72 and its glory will be reflected upon them. A staff having these ideas and
acting upon them will increase its own efficiency and by building- up a
series of clinics each medical man is kept up to the mark, and by this increase of efficiency the service he renders to the community is accordingly
improved. And service to the community is what a hospital is for. This
fact in the past has often been lost sight of, and hospitals have too often
been exploited for the glory and pecuniary advantages of the staff and its
owners.
A new era in hospital affairs is now dawning all over this continent.
The public everywhere is being educated -and is beginning to demand what
it is entitled to. It is the medical profession itself that is opposing these
new developments. It is hard to break down old institutions, old theories,
and old beliefs, especially those connected with medical science, but slowly
and surely the barriers of bigotry are giving way and hospital efficiency is
coming into its own, and with greater unselfishness, with more co-operation
and increase of services on the part of our medical staffs, the new day will
dawn sooner than we imagine.
DR. H. C. WRINCH, Hazelton—
We thank Dr. Storrs for that very useful paper.
There is a new member of the Hospital Fraternity whom I would
introduce to you, Dr. G. S.- Purvis, who has recently been appointed to the
position of Superintendent of the Royal Columbian Hospital, New Westminster. .We hope to hear from him tomorrow.
(Dr.   Purvis  was  introduced.)
Meeting adjourned.
Evening Session—8.00 p.m.
Joint Session B. C. Hospital Association and National Committee on
Mental Hygiene held in the Auditorium at 8.00 p.m. Many interesting addresses vere given by the National leaders in Mental Hygiene and a very
profitable evening was spent by all.
BUSINESS SESSION
FRIDAY, JUNE 25. 1920—10:00 a.m.
Mr. R. S. Day, Victoria, Presiding
MR. R. S. DAY, Victoria—
We will commence the morning session by a paper by Mr. A. A. Cox,
F.R.I.B.A., Vancouver, entitled "Hospital Architecture."
A. A. COX, F.R.I. B.A., Vancouver—
The subject of Hospital Architecture on which you have invited me to
read a paper at your Convention is a rather extensive one, and I find it
somewhat difficult to subdivide or condense it into a form proportionately
with the time placed at my disposal today. I shall therefore ask you to
listen to a few general remarks upon the salient points only, and I hope
they will be found interesting. I regret that I have no materials at hand
to illustrate the subject by plans and diagrams, which are always a great
advantage on an occasion such as this. I am not, however, here to give a
class lecture or make any attempt at teaching an audience so well versed
in the requirements of Hospital Building.     £$*:?. ,.
Having had personal experience in designing manv Hospital Buildings
in Canada, I have always found that there is much to learn from the
Medical Profession, and must say that I appreciate the co-operation and
advice I have received on many occasions from those who have.been closely
interested in the Departments of Administration in Institutions of this
character.
As time goes on gradual improvements and new ideas in planning are
noticeable, and at no period, perhaps, as the recent-past and the present, has
there been such a demand for efficiency in Hospital Design
The war having played such an unprecedented part and demanded unusual requirements in the various departments of medicine and surgery, the
Hospitals of today are calling for an increase of bed accommodation, and
73
n I regret to say that funds for meeting this object are not always keeping
pace adequately with these demands.
' The public sick must however be cared for and our efforts therefore be .
given to providing buildings of a simple design and plan, and all superfluous
ornamentation abandoned in order to meet the handicap which has been set-
on constructional progress by the increasing cost of labor and materials. It is
possible even with the plainest designs to acquire pleasing results and with
a good plan in which utility has been carefully studied, there should be no
cause for complaint or disappointment with external effects. Some of the
plainest buildings existing today are the most attractive and pleasing and
so long as they exhibit their true character and at once indicate the uses
for which they have been designed their success has been achieved.
In connection with Hospital Planning, it is necessary that both Archi-^
tect and the Public should cease to regard a single building as a complete
work. Each Building or Unit in a Hospital group has a duty to perform
towards its surroundings and the whole site. It is not enough that a building be effective in itself only—the point is—How much does it contribute to
the general architectural scheme? It is a mistake to suppose that the best
architecture would appear to advantage in any unsuitable location or place."
The thing to be considered is—Does it harmonize with the surroundings and
suit the character of the purpose for which it is designed—if not—then it
will not be good architecture.
An essential part of architectural composition' consists in striving after
refinement in relation to the individual forms which constitute' the whole.
These in turn lead from one part to another presenting finally an effect
built up of the different Units, especially in Hospitals, and in this way a
distinct rhythm is imparted to the design, and rhythm depends on the
proper dividing up or balancing of the component parts.
.   The internal arrangements and planning of a Hospital should not be
sacrificed for external architectural effects, no matter how complicated the'
plan and grouping may be, the skeleton of the construction in the hands of.
an efficient architect can me made to suit the local conditions and requirements, and generally with satisfactory results.
Architectural composition can only be termed good when it ostensibly
shows the character of the purpose for which it has been intended, for example : a Cathedral design invariably signifies that its object is ecclesiastical
in character.
A Power House, or Factory, or Railway Station, also generally show
their respective characters, and a Hospital Building should also, have a style
befitting its own special purpose without an unnecessary display of ornament. One of the chief features desirable in a Hospital is. ample fenestration, or better known as window surface, and this to a great extent governs
the style of building and gives' a special character to it, and if properly
grouped and balanced, can be niade to compare favorably with the best
examples in other classes of architecture. In many instances buildings in
Europe, as well as in Canada, have been failures from the fact that the
Designers have sacrificed the internal plan and arrangement to the external
effects, and when this occurs it cannot be pronounced good design. Experience only will teach the art of good planning for Hospital Buildings.
Specializing is the order of the day, and Buildings have to be made to
comply with the methods employed.
The next question to arise is: What do we consider the fundamental
aim of a Hospital ? It is to aid and give service to the sick; in other words,
it is the Home for sick guests.
No matter how high its standards may be on paper, or how up-to-date
its laboratories, surgeries, sanitary and sterilization systems, no matter how
imposing, and beautiful its architecture, or how perfect the equipment in
the various departments, or how fine the technique and efficiency of the
staff may be, the efforts will all be wasted, unless all of these activities be
dedicated, arid directed to the benefit of the patients and service of the
community.
Hospital requirements of today are as highly specialized as is the
Medical Profession itself, some catering to one branch, some to another, and
still others to all branches of the Medical Profession.
74 ■ If efficiency and- economy are the ends sought in building Hospitals for
^either general or special treatment of patients, it is of the utmost importance
that the designer should have an intimate knowledge, not only of building
construction, but also of the various activities peculiar to the particular
types of treatment involved, as well as the proper co-ordination of facilities
and accommodation that will best suit the requirements to which the Hospital will be devoted, for the simple reason that the arrangements and
grouping of buildings which might be ideal for a General Hospital, would
not be at all suitable for one specializing in tuberculosis and other forms
of disease.
An architect should not be relied on entirely to judge professionally
about the actual grouping of departments in the plans, the arrangement of
rooms and wards, and the details of them. It is unjust to require that he
should know all about hospital management, or the Medical and Surgical
features of a hospital. One may as well ask that he be an expert in civil,
mechanical, and electrical engineering, an able manager of kitchen, dining-
room, or laundry, or even greater, that he be an able Physician or Surgeon.
The study of each and every one of these professions is needed in a
Hospital. The architect, however, should be thoroughly acquainted with
the general work in a Hospital, and the routine of the Institution, and
general character of the greater number of diseases, and ordinary hospital
cases. To obtain a thorough knowledge of good hospital planning, experience only will teach. Designing and construction are very intricate
problems to solve. They need very careful study of the causes, in order
to procure the proper remedies for failure, as seen in many existing examples
today.
Slavish following of past examples and hospital ideas, "often fads,"
will not lead to great success, and copying of such features is a good solution
of any new building. It frequently happens, that when a new building is
required, a hasty examination of various existing institutions will be made,
with the result that only an extensive collection of indigestible data is
made, while the fundamentary study of the hospital requirements is lacking.
It requires experience and very careful comparison before being able to
judge the good or bad features of existing institutions. Great responsibility
therefore rests on the Board of Management of a hospital, when appointing
an architect, and they should always seek and secure a well-known expert,
and one responsible to carry the works through with intelligence and
success.
In regard to location and site for hospital buildings, there should be
ample superficial ground area, an abundant supply of pure air, and all sunlight possible. They should be sufficiently remote from streets and railways, so that the inmates may not be disturbed by traffic. Nothing is more
detrimental than noise and germ-laden air to convalescent patients, or
those whose vitality may be hanging in the balance, requiring every favorable condition to aid recovery. Beautiful surroundings are most desirable
for patients, especially in the convalescent stages, when they can spend the
time very largely in the open air, under shady trees or groves.
. Every hospital should stand, if possible, in a park, rather than in the
limited area of a City Block. The perfect site should therefore afford air
of the utmost purity, a maximum of sunshine, and perfect quietude. Some
of the larger hospitals in Europe occupy thirty or forty acres and upwards.
They are mostly of the Pavilion type of plan, varying in height. Terraces
on the ground floor storey, level with the floor are often adopted, enabling
the beds to be easily wheeled out of doors into the direct sunlight, or a
shady nook surrounded with singing birds and blooming plants, such
environment means rapid convalescence, not only because of the influence
of such conditions in the body, but also the tranquilizing mental effect.
As time progresses we find a larger proportion of sick persons going to
the hospitals for examination and treatment. Formerly only the very sick
were sent to a hospital, nowadays many only slightly sick go to be treated.
This is perhaps because it is economical to do so, and their chances of recovery greater than if they remained at home. In the modern hospital today the
patient has the advantage of special examination by the X-ray specialist,
and may not only have immediate, ordinary medical and surgical treatment,
75 r
but also obtain such special forms of treatment by hydrotherapy, electricity, -
massage, etc., and there is no doubt that the earlier the disease is diagnosed
the greater the chance of recovery.  -It is therefore advisable that sick or
slightly sick should be admitted into hospital for examination as early H
possible.
As I previously mentioned, mental happiness is the first aid to a patient's-.
recovery. The body suffers or rejoices with the mind, especially when both
are in a sensitive condition. A pleasant exterior, homelike interiors of rooms,
flowers, landscape, decorations, and even ^pictures, are all helpful to recovv
ery, and are therefore important and essential features in good hospital
planning.
The beginning of a new hospital building is usually one of relatively ■
small things in many ways, but it is never small in comparison with its potential future. The constantly increasing demands for hospital treatment
assures the future growth of the institution, and this potential feature is a
very important one, and because of this the most careful consideration of
the possibilities of future development is quite as important as is the study
of the present needs and the method of meeting them.
First and foremost, the needs of the institution, present and future,
should be carefully determined, and plaps should be sufficiently developed
that all cost of the buildings may be at least approximated.
While tentative plans for the entire group of buildings should be outlined, only the plans for the immediate requirements need be furnished in
complete form; but the tentative designs of the ultimate development are
essential in order that the relation of the proposed or immediate buildings
to those of the future ones may be properly worked out as a perfect scheme.
In other words, the real problem resolves itself into how to plan the first
unit or units, so that while serving present or immediate needs, additions
and alterations may be made to meet future accommodation and requirements
at a minimum expenditure. The building must at all stages be a complete
hospital in all its details, and the construction must be effected without
handicapping present service. A proper proportion of patients and service
spaces per unit must, at all times, be maintained, and neither sacrificed for
the other.
The problems of type and capacity of the units of a hospital system are
usually local ones, and the guiding feature in their solution should be not
only to serve the present but to forecast the future needs. It is, I believe,
computed that not over 12% of sick people, on the average, use the hospitals;
all the others are being taken care of in their homes, and to a certain extent
neglected, consequently not recovering as rapidly as they should, owing to
lack of hospital accommodation and proper nursing. Every hospital, therefore, should be architecturally as good as science can produce, and the
equipment of the best type obtainable.
The vital question to settle when establishing a hospital is to ascertain
what sort of building is necessary to meet the local requirements. It should
be designed so as to take care and accommodate any kind of disease that
may come along; for instance, take a mining district, where the greater number of cases may be those with broken limbs, and are to be long and tedious
cases. In such cases the planning would have more particularly to consider
the male surgical ward accommodation, which would be greater than other
departments. Or in a milling district, where patients suffer chiefly from
eye troubles, in its way requiring dark rooms, each disease demanding its
spec;al arrangements. Many other cases being of an ambulatory character,
in which the patients are not confined to their beds. All these varieties of
disease create a different type of building, and the architect should give
special consideration to these important features, and provide arrangements
to meet such requirements. Generally speaking, architecture in its decorative sense enters comparatively little into hospital design; the general construction, selection of proper materials, and good planning being the essential  points  for  consideration.
In this country we are apt to be too economical in regard to land area
for hospitals, for the obvious reason that land is costly, especially in the
large cities where large institutions are necessary. In England for many
years a minimum was fixed at one acre to fifty patients, but at the present
76 day this proportion has been considerably reduced. I think we should establish a rule setting forth the area required for the pavilions, exclusive of that
occupied by the accessory buildings. In Germany and France they are far
more generous in the matter of site areas; for example,
Hamburg Hospital, 37 to 50 beds an acre.
Nuremburg Hospital, 40 to 60 beds an acre.
St. Denis, France, 26 to 55 beds an acre.
Manchester, England, 46 to 50 beds an acre.
New York, U. S. A., 100 to 150 beds an acre.
Vancouver General Hospital, about 100 to 150 beds
Much depends on whether in a city or open country.
Hospitals may be divided into two types of buildings or service, viz.:
(1) The "Medical,"  for treatment of patients.
(2) The  "General,"  for service or administration.
And these are again sub-divided into various groups, viz.:
The Pavilion type.
The Corridor type.
The Combined type.
The first type, or "Pavilion," affords light and air on two sides and
one end of the wing.
The second type has a central corridor with wards and rooms on either
side, and of course gets light from one side only, and sometimes at one end.
The third type affords rooms more or less grouped together, with projections from the main structure, which more or less obstruct light.
It would be impossible for me today to more than mention some other
varieties of hospitals, such as :
Special Hospitals for Surgical' Cases.
Lying-in Hospitals.
Tuberculosis Hospitals.
Hospitals for the Insane.
Clinical Hospitals.
Asylums, Barracks and Tent Hospitals.
Contagious Diseases Hospitals.
Out-Patients Department.
Research Department.
Nurses' Home.
Each of which has its predominating features and requirements, necessitating
special study in planning.
In examining more closely the principles upon which hospital planning
and construction is based, it is hard to lay down any hard and fast rules,
owing to the fact that the requirements upon which the design and construction depends are continually changing and progressing by the aid of
new discoveries and research, and buildings have naturally to be erected to
meet the modern demands from time to time.
Canada has produced in recent years a number of interesting hospitals,
notably:
The General Hospital at Toronto.
The Royal Victoria, at Montreal.
The Vancouver General Hospital, and other smaller institutions.;
When we compare the great pavilions of the hospitals in Europe with
the majority of our own institutions, we are impressed with the greater size
and extent of the institutions in Europe. The following features may also
be observed, viz.: The disconnection of the main kitchen and service blocks
from the patients' blocks, and the grouping of Patients' blocks into definite
departments to separate the diseases, the adoption of sanitary annexes at
the ends of the pavilions, the greater provisions for special treatments, such
as: Hydro-electric; Therapeutics. .Special provision for scientific research
and pathology, and also the spacious and remarkable laying-out of gardens
and grounds. It is a question for the medical profession to say whether our
own hospitals are equal to. or excel, those of other countries, although I
believe it is generally considered that many of our Canadian institutions
often excel in internal arrangements and plan, and sanitary equipment.
An intimate knowledge of dimensions of equipment and fixtures is most
important in planning a hosp'tal, the following items being worthy of notice.
77 Beds are approximately three feet wide, six feet six inches long, and there
1 should be a working space between them of at least three feet. The head
should be set about 16 inches to 18 inches away from the wall. It makes
not quite as much difference as to the width of the central aisles between
the feet of the beds, if sufficient space be allowed for carts and wheel chairs,
and for two persons to pass easily abreast. Eight hundred cubic feet per
bed is considered a minimum allowance of space in public wards, and one
thousand to twelve hundred cubic, feet in private wards. St. Thomas' gives'
fifteen hundred to eighteen hundred cubic feet, average, and two thousand
to two thousand five hundred cubic feet in infectious buildings.
The position of beds is a subject to be considered in laying out a large
public ward.    It is generally accepted here, and in England and France,
that each bed should be placed between two windows, but in German and
Austrian hospitals, and some other examples, the beds are spaced, disregarding this rule and often with satisfactory results;  for  example:   The
John Hopkins Hospital, Philadelphia, has beds grouped in pairs, and windows between each group.    In England the local Government Board has
made the following regulations:
60.0 cubic feet for adults.
960 cubic feet for children.
2000 cubic feet for isolation wards.
1200 cubic feet for military hospitals.
In planning a 'new building it is important that an allowance be made
to the extent of one extra empty ward or room to every twelve occupied.
This will afford the management a margin to empty a ward when needed
for purposes of disinfecting or cleansing.
An ideal hospital would have separate rooms for each patient, but this'
is impossible, owing to cost arid maintenance and service. German hospitals
adopt the large pavilion type of wards, ranging from twelve to twenty-four
beds per ward. French authorities claim that no ward should contain more
than four to six beds, at any rate the tendency in modern buildings in Europe,
as well as in this country, is to diminish the number of beds in the public
wards.
There should always be sufficient isolation rooms for separating patients
suffering with nervous disorders, and those suspected of having infectious
diseases. Sizes of operating rooms are somewhat elastic arid depend in a
large measure on the wishes and technique of the surgeons.
In regard to accommodation, some experts have declared that the neces-
sary bed accommodation should be regulated in the proportion of five beds
to every one thousand of population in c;ties of over one hundred thousand;
smaller cities needing about four to five beds to the thousand population.
These figures are approximate, and would have to be varied to suit unusual
conditions when necessary.
Spacing of partitions is another important factor in laying out of a new
hospital. The spaces between blocks or partitions should not be less than
60 feet clear. John Hopkins Hospital has 60 feet, and rriany large institutions have similar spaces. Manchester, England, 65 feet; Camberwell, England, 90 feet. As a rule an angle of 30 to 45 degrees from the lowest under
cell of opposite building will be a safe rule to follow.
Sun rooms at ends of partitions could be made larger with, advantage
and enclosed in glass in cold weather. They would be of greater use for
convalescents and feeble patients who spend much of their time in these
sun rooms, and should the ward become overcrowded a number of beds
could* be placed in them and serve as sleeping porches, and under such conditions a toilet and sink would greatly simplify and reduce the labor of
the nurses, if located in or near the sun room.
Ro.of gardens are also used in some English hospitals, and are giving
excellent results. They could be adopted in British Columbia with equal
advantage. The climatic conditions are most excellent and there, is no
doubt, as I have stated before, that surroundings and fresh air and scenery
accelerate convalescence to a marked degree. Suite of private rooms or
wards on the roofs with gardens in our hospital would be most attractive
to the wealthier class of patients who'would be only too glad to avail themselves of such charming location during the period of sickness.
78 The cost of buildings, furnishings, and maintaining a hospital has increased very heavily during the last twenty years. The reason for this
increase is not entirely due to the introduction of social needs. It is caused
firstly, by increased land values, price of building materials and workmen's
demands for larger wages and shorter hours; secondly, improvements in
technical equipment and fittings, such as heating, ventilating, and electric
lighting, and other sanitary arrangements, and the installation and maintenance of these necessary improvements.
The public demands for better housing of patients in the hospitals has
also increased the cost considerably, private rooms having a greater cubical
space than that usually given in public wards, means larger and more expensive construction. A two or three story block is no doubt rather less in cost,
cube for cube, than a single story block. Cost of roof and foundation is
about the same; on the other hand, walls are thinner and foundations less,
and no staircases or fire-escapes or elevators are necessary for safety for
one-story blocks, and these are items which go a long way towards the
cost.
There are many other reasons for the variation in cost, such as the proportion of public wards to private rooms. Economy of plan and the expansion of the first unit of construction wherein has to be located the service
accommodation for succeeding units. The operating department which
would be desirable in a fifty-bed hospital'would be ample for a building
with double that number of beds, and so it is readily seen, that a small
hospital costs more in relative proportion than one of larger capacity.
A dozen designs could be made for any hospital, each having points of
merit, but it is safe to imagine that only a few of such designs would be
ideal from every point of view. If you ask the question: Is there today a
typical and accepted or standardized ward limit? the answer would undoubtedly be that we are undergoing a transitional period. The medical profession is classifying and specializing on various diseases, and this, in turn,
demands special attention to planning to meet the newer and modern requirements.
The ventilation of hospitals was much neglected until the latter part of
the nineteenth century. Since that period the subject has received better
consideration, with good results. The question of ventilation, however, is
still an imperfect and unsettled proposition. There are, generally speaking,
three systems in use today:
(1) The "natural" interchange of air by windows, doors, and sometimes
chimneys, and this method is still finding favor, and being employed by
some of the leading architects today in some of the largest and best public,
as well as private, buildings.
(2) The "asperating system" by mechanical means. In this method
the vitiated air escapes from the room or ward through ducts and openings
near the ceiling, the ducts being heated by steam, or hot water coils sufficiently to cause an "updraft," and to .increase the efficiency an electric
exhaust ventilator is placed near the top of the main duct, controlled by a
switch when occasion demands.
(3) The "down-draft" system. That is, the fresh air is introduced at
the ceiling level and forced downward by means of a powerful fan located
in the basement.' The cold air being forced across a system of heaters and
thence into the flues under pressure. With this system all windows^ must
be kept closed and air-proof, or the^ system would be "cross-circuited" into
the foul air vents at the floor level. * .
There are several grave objections to the plan of abstracting the foul
air near the floor.
(1) It is opposed to nature's law of atmospheric pressure, and therefore requ'res the use of special abstracting contrivances.
(2) By drawing down the foul air, it causes it to be breathed over
again, which is a most dangerous proceeding, and should never be allowed.
(3) The fresh air supplied is apt to be forced in overheated, in fact
burned, and so made unfit and unhealthy. >        .....
(4) The long tortuous flues cannot be kept clean, and will therefore
become lurking places for dust and germs. The system. therefore, is not
the most suitable for hospital use where there is likely to be infection.
79 The relative merits of the "upward" versus "downward" systems of ventilation may be estimated from the following considerations :
(1) The natural direction of the currents of air from the human body
is, under ordinary conditions, upward, owing to the heat it acquires in the
lungs specifically lighter than the surrounding air in the room, and this
current is an assistance to the "upward" and an obstacle to the "downward"
ventilation.
' (2) The heat from all gas flames used for lighting tends to assist "upward" ventilation, but elaborate arrangements must be made to prevent contamination of the air by the lights if the "downward" method be adopted.
(3) In the "downward" method in large rooms an enormous quantity.
of air must be admitted, if the occupants are to breathe pure, fresh air, or
about three times the amount which would be found necessary in the "upward" method.
(4) Any method of ventilation which depends upon mechanical or
artificial means for its action cannot be reliable, and therefore is not to be
recommended  for hospitals.
Ventilation is a science, and it requires long study to master all its
complications. There is. perhaps, no other subject with respect to which
there is greater diversity of opinion. It will, however, be advisable that
the system which secures the requisite change of air in the simplest manner is the one likely to prove generally acceptable.
It has been argued by some that because carbonic acid gas is about fifty
per cent, heavier than air, it is desirable to ventilate by a "downward" current in a room, rather than an "upward" one. This, however, is not acceptable by some well-known experts.    Prof. Woodridge states:
"The carbonic acid gas by respiration from the lungs, and passed
through the skin, is as thoroughly diffused in the warm air currents from
the body as is the same gas made by a candle or gas flame in the air cur-
rents ascending from those flames. Carbonic acid gas when once diffused
in air can no more settle downward out of the air and occupy the lower
level of a room than salt, because heavier than water, can settle out of the
sea water to its bottom."
One cubic foot of gas consumes the oxygen of about eight cubic feet
of air. With a temperature of seventy degrees Fahrenheit the temperature
of the air expelled from the lungs is from eighty-five degrees to one hundred degrees Fahrenheit. It is the organic matter suspended in the watery
vapour expelled from the lungs andI exhaled from the body wherein the
danger of disease lies.
The velocity Of the fresh air supply should never be greater than two
feet per second, if draught is to be avoided. Investigations have shown
that the evil'effects of bad air are due, not primarily to any lack of oxygen
in the room, but to excessive heat and humidity.
The principal symptoms experienced in a badly ventilated room are due
to the influence of "warm still air" upon the human system. Such an atmosphere causes a rise in body temperature and pulse rate, and fall in blood
pressure and general feeling of discomfort, and a marked disinclination to
physical exertion. Any temperature over seventy degrees Fahrenheit (except where air is in constant motion) is lowering to efficiency, and injurious
to health. It may generally be assumed that when a room is so crowded
that the floor area is less than two hundred square feet per person, some
sort of special ventilation will be necessary in order to secure a reasonable
change of air.
It has frequently been observed that in the "forced draught" system of
ventilation trouble has arisen from the engineer trying to economize fuel by
operating the fan at a reduced speed, or not at all. Sometimes the fan is
doing its part, while wrong proportioning of registers, and lack of "volume
dampers" deliver the pressure so faultily that the air is changed too rapidly
in one section, and too slowly in another.
In an "indirect" system any desired combination of temperature, moisture, variability, and movement can be obtained, if proper supervision and
attention be given to the operating of the apparatus. Humidity depends on
the difference in temperature between the air as it leaves the humidifying
chamber and when it enters the room or ward.   If the two places have the
80 same degree of temperature, the humidity will be one hundred per cent., but
if they differ in temperature, say, by twenty degrees, the humidity will be
only about twenty-five per cent., showing the importance of keeping the air
at a regular and equal temperature. There is a feeling in the profession
that the most expensive and highly perfected systems of "wasting" the air
have been unsuccessful. The trouble lies, however, in failure to utilize their
possibilities and neglect of humidity and movement at the right temperature.
Ventilation has given sanitariums a long chase. Air has been admitted
into rooms at the ceiling and discharged at the floor level, and vice versa,
forced in at one end and sucked out at the other, and each method has been
more or less approved. Air deflectors and revolving fans and blowers have
been installed, windows have been opened at the top, at the bottom, and in
the middle, windows have been removed, and walls abandoned, and still the
problem of perfect ventilation has not been solved to satisfaction. There is
ventilation with moisture, and ventilation without moisture, and with a moderate amount of moisture. The psychic element, I think, also enters very
largely into the problem of ventilation, and the only real thing that stands
out as of permanent moment is temperature and cleanliness, and there is
no doubt that if in the solution of the ventilation problems we gave more
attention to the regulation of the air, and to the age, condition, and activities of the persons who occupy the rooms, better results would be effected.
In regard-to heating: It is an open question whether the system of
heating by steam and hot water have an advantage over the old style stove,
excepting for convenience of operation. There are at least five main features
to be considered, in order to ensure perfect heating, viz., temperature, humidity, purity,, movement and variability of air, and each is a very important
factor in providing good results. In heating by steam or hot water direct
radiation, it is not easy to obtain a constant, gentle movement of air, which
action is one of the chief factors that make outdoor life so beneficial, and
whereby humidity and variability are naturally supplied. Hot air furnaces
are even worse in action than steam, or hot water systems, the results being
too high a temperature, too little moisture, and too little variability.
To secure purity in the air a disinfecting system should be adopted. In-
connection with the humidifying of air, we perhaps scarcely realize the
importance of the use of moisture in the air, and the extent to which this
system is adopted in buildings other than hospitals; for example: the humid-
ification of air is one of the essentials in cotton mills, wool and silk mills^
bakeries, in the candy, cigar and tobacco factories. How much more desirable, therefore, that our hospitals should have all the benefits to be derived
from such  a  system.
Direct radiation from steam or hot water pipes has the disadvantage of
unfavorable conditions, generating in temperature, humidity, purity, movement and variability.
Indirect system is the most highly developed system of modern heating.
The air is warmed by passing over pipes or radiators of steam, and then
blown or forced into the rooms or wards. With this system the desired
temperature, humidity, ,and movement of air can be secured, if operated by
an experienced engineer.   The apparatus fs sub-divided into four parts:
(1) The humidifying chamber.
(2) The steam-heated coils or radiators, which warm the air before
it enters the humidifying chamber.
(3) The fans which drive or force the air through the building.
( )   The ducts that carry the air to the wards.
Hot water heating for small buildings is the better medium or system
for "direct" radiation in wards. Steam heating, because of its high temperature, and the noise resulting from expansion and contraction, should be
avoided.   Hot air heating system should never be used in hospitals.
Comfort depends to a large extent on the lighting, both natural and
artificial. Every patient's room should have direct sunlight during some
Part of the day. The worst type of artificial lighting in a patient's room is
the ceiling fixtures, for it puts the glare squarely in the patient's eyes when-
lying in bed.   A room never looks so cheerless as when illuminated by light
81 Where wards are
diffused from a white ceiling, for practically then all shadows are elimnM
ated, and shadows are most essential for the satisfaction and repose of the]
eye. In architecture and art, high lights and shadows are the essence of a
design or picture composition. The study of light values is therefore ofj
extreme importance.
Illumination should, therefore, play a vejy important part with sick
patients, in giving comfort to occupants of the various rooms, doing away'
with the garish effect of exposed lights, which are always annoying, even]
to persons in good health. Many schemes have been put forth by various^
architects, and others, for lighting a hospital, and many have fallen shorn
of success. The general tendency today is to conceal the lights as fnuch as;
possible, and keep intensity fairly low.
(1) "Low" intensity of light, to enable nurses to wait on the patients]
at night.
(2) A "medium" intensity for patients' reading.
(3) A  "high" intensity for medical examination  at the bed
(4) Wall plugs can always be used with advantage
very large, dimmers may be used.
Regardless of any special type of construction, no hospital or institu-J
tion of twenty-five or more beds should be without an adequate method fc3
giving fire alarm, and strictly observed fire drill of every able person e&m
ployed in the building. The first requisite in protection against fire is thja
use of all possible care in not letting one happen. The second is in recognizing its existence quickly when it does happen; and the third is to be
provided with readily accessible apparatus for extinguishing it.
Alarm systems are of two cardinal types:   the "automatically" operated,
and the "manually" operated methods.   There are also two ways of convesa
ing an alarm, viz.. visually and audibly.   In order to minimize chances of
fire in a hospital the following provisions are worthy of notice as precaution :'
(1) Eliminate all articles of celluloid, as thermometer backs, toiletj
articles,  etc.
(2) Cheap matches should be avoided—they are dangerous to an alarm-j
ing degree.
(3) Do not use metal polish or cleaning fluids in which the base is
cbmposed of benzine or naphtha.
(4) Do not put off the repair of any disorganized electrical wiring or
equipment; have the wires run in conduits, and terminate in metal junction
boxes.
(5) Do not bask in the delusion that because a building is said to be
of fireproof construction, that you are safe from danger.
(6) If you build, secure an architect who knows what fireproof con-;
struction means. Concrete and metal do not mean "fireproof" construction;
they are merely slow burning, or fire resisting materials, and unless they
are encased in concrete, and the building is designed with attention to drafts
and confinement of fire, and cut-offs, they are very little better than other
forms of construction. Actual cremation causes few deaths in fires. It is
suffocation, panic and trampling that furnish the casualty  list.
While reinforced concrete and other methods of fireproof construction
(so called) have largely eliminated the danger from fire, too great stress
cannot be laid on the danger arising from smoke. A fire may originate in'
the contents of the structure, and without injuring the building itself, but
will generate enough smoke to fill the corridors and rooms completely, causing suffocation, and often w'th fatal results or panic.
Special attention in planning should be given to the sub-division of the,
building, and ample means of exit for the various patients. Where possible it is advisable to have each sta;rway entirely enclosed by a fireproof
partition, or lobby, with lower exit doors, as near the ground level as
practicable, thus eliminating the danger of stair walls becoming filled wifW
smoke.
In hospitals decorative coloring has a much greater therapeutic value
than commonly supposed. Brilliant and violent contrasts have by experiment been shown to excite the nerves of sick patients to a degree causing
actual distress.
82 A few remarks on color and reflected light values will perhaps be
worthy of consideration;  for example:
The dark reds, greens, and browns will reflect only ten to fifteen per
cent, of the light values.
White, cream and yellow, up to orange, will reflect sixty per cent, down
to twenty, according to depth of the color. '
The greens and grays are generally admitted the best for wards and
private rooms, as they are easy on the eyes, and quieting to the nerves, but
there is a limit to their usefulness, based on the amount of uninterrupted
direct window light. For night use the white and cream are best, because
they reflect glaring points of light which are .disturbing to the repose of a
patient.
Time will not permit me today to go into details of equipment of an
up-to-date hospital kitchen. The subject is au interesting, as well as an
important one, and deserves much consideration. I would have liked, had
time been given me, to have made some remarks on the military hospital
kitchens and equipments, many examples varying in size, having been
installed under my own personal supervision during the war, in British
Columbia.
In concluding this paper, let me say that I have ventured these few
remarks and suggestions, relative to the comfort of the patients, and hope
that their enforced sojourn may be a trifle less irksome while detained in
the hospital under treatment. I conceive it to be one of the functions
of hospital service to minister to the speedy recovery of all cases, providing accommodation and surroundings which are best adapted to mental
happiness, as well as supplying hygienic conditions and medical services
of the highest order.
The more up-to-date and perfectly designed and equipped hospitals we
erect the more we serve, the community at large, and it follows in fact that
we are simultaneously improving our province, and indirectly enriching
our country as a whole, as well as strengthening the Empire to which we
proudly belong.
DISCUSSION
MR. R. S. DAY, Victoria—
"I think there is room for considerable discussion on this splendid
paper, and I know Mr. Cox will be glad to answer any questions that may
be asked."
MR. J. SUTTON, Nanaimo—
"I have been asked to open the discussion, but I do not propose to do
so at length. First of all, in my opinion, there should be close co-operation
between the architect, the staff of the hospital and the medical profession,
in order to get out the right plans. There seems to be quite a difficulty
in arriving at a conclusion as to what is really needed today. Modern
requirements, modern conditions, call for the best that can be given, and
it is important in view of the fact that changing conditions are ever taking
place, and what is an ideal today may no longer be an ideal tomorrow, that
the public should be protected, and adequate service given in any plans submitted for construction. There should be a common agreement with all in
order to reach that definite conclusion. Today there seems to be a great
lack of interest as to location and making provision for the future expansion
in buildings. Location is regarded as a secondary matter. In a municipality a hospital can be placed almost anywhere without any conditions.
Reservation is made for land surrounding a cemetery, but no reservation
is made for land surrounding a hospital whereby they may extend their
buildings over a larger area and have silent zones. I think greater consideration should be given along such lines. In all cases the first thing
should be the best place possible to build a hospital, giving it as much
ground as can be allowed. The future development of that institution will
thus be taken care of. I am very pleased that Mr. Cox has suggested in
his paper the need for greater space in the wards. Now, I think today we
are overcrowded and there does not seem to be any possible way of segregating various cases.   The serious case is too often dropped into the ward
83 There is a necessity-'
This entire paper is
where he has to put up with a great deal of noise,
for making more definite provision for such cases,
excellent and has great food for thought in it."
DR.  G. S. PURVIS, New Westminster—
"I have listened to Mr. Cox's remarks with pleasure. There are one or
two things I want to mention. I have had the privilege of seeing a good,
many hospitals between here and Halifax, and a good many in Europe, and
never in any one yet, after completion, you would not find many things
that could still be improved. I am glad that Mr. Cox has recognized the
fact that in building a new hospital there should be close co-operation
between the people who are going to work in that hospital and the architect, and he in turn should not depend on his own resources, but should get
the best opinion from people who are or have been working in hospitals and
who have seen a good deal of hospital construction. I have recently gone
over the New Westminster Hospital, which is fairly new. The architect
is a well-known' architect,' but it seems to me that he must have disliked
the nurses, owing to the design or planning, as for instance, the chart
room should be a room from which the nurses can observe the public ward
corridors. Now, that is a thing I think would he well in any hospital; if-
they could consult the nurses or nurse in charge, because she is the one
who is going to work on the ward and in the corridor, and she is the one
who is going to know what is handy and what is unhandy. Therefore]
I would like to suggest that they take the nurses and others into their con-
fidence, also the medical men, probably more so than has been done in the
past.
There are structural defects in the Royal Columbian Hospital, New
Westminster. We have a hospital of two hundred and fifty beds. During
the summer they turn off the heat, but in case of an emergency operation,
when they have to turn on steam in the operating room they have to turn
it on all over the building. This, of course, can be easily rectified. Another
instance, in which the vacuum cleaner was put in the hospital down the
.'elevator shaft. It has not been in use probably more than two hours since
it was installed. When the machinery starts the roaring comes up the elevator shaft, making it too noisy to use.    It is being removed.
Regarding the ventilation, the architect .evidently got confused about
ventilation or possibly he could not decide which kind to install, so he left
it out altogether. I think in building a hospital it is left too much to the
architect. We would not, however, think of telling the architect how much
cement to use, but I think it would be wise to take into his confidence not
only the medical men but the nurses and others who are going to work
on that ward.
MISS E. I. JOHNS R.N., Vancouver—
In Manitoba, with reference to plans, especially of smaller hospitals,
it was suggested that a committee consisting of an architect, a layman, a
doctor and a nurse, be appointed to outline a standard plan. I think the
suggestion was a very sane and sensible one. In some of the courses now-
being given in the University the nurses are given a course of architecture.
MR. J. SUTTON, Nanaimo—
I thought probably an executive body from this Association might be
appointed to work in connection with the architect. It is very difficult for
a board to come to any conclusion; lack of knowledge of institutional work,
the fact that they have probably never travelled and seen various other institutions. I think it would help if the Association. would go on record as
approving standardized hospitals, and probably select a committee to go
into this.
DR. H. E. YOUNG, Victoria-
Mr. Cox's pap'er is one of the best I have listened to. It is probably
too long a paper for a meeting like this to discuss, in view of the fact that"
there is so much other business. As he pointed out, the two important
things that should be considered first are efficiency and economy; efficiency
in the carrying out of the work of the hospital, and economv in regard to
84 construction and riiaintenance. We generally speak of the cost of the hospital in terms of 'bed cost.' Previous to the war that cost varied from
$1200.00 to $2000.00 a bed. Today you cannot build a hospital on a basis
of $2000.00 a bed. After the war began and our men were being sent home
the Government had to provide hospital accommodation for hundreds of
these men. Mr. Barrs, architect in charge of this work, started and he was
told that haste was essential and economy imperative. Mr. Barrs has written an article recently giving the results of his experience. He has had
charge of all the work in the Dominion, and is giving the results of his
experience and giving some very valuable suggestions to any board contemplating construction. I have a number of copies of his paper and intended bringing them over for the use of the Association, but in the hurry
overlooked them, but if any board wishes a copy of this I will be pleased
to send it if they will drop me a card. It points out that the era of great
cost in original construction is gone. We cannot, in view of present costs,
spend an enormous sum of money in erecting a building of the modern
office building type. He points out that he has demonstrated in the construction of the hospitals for soldiers that the construction has to be something that will provide comfort and shelter, and if you have those two
requisites you can adapt all the needs of the hospital to the building that
will provide that. He says, and wisely so, that many of the difficulties we
are suffering from and financial conditions that are facing the hospitals is
simply due to the sum spent in the erection of the original building. The
necessity of capital cost has eaten up available funds. You have exhausted
your sources of income, you have appealed to the Government, municipalities
and to the public. You have spent an enormous sum of money, and when
you have completed your building you, are faced with maintenance, and
when you go back with further by-laws you are met with the answer that
you have been provided with a hospital, now it is up to you to run it. His
article as a whole is worthy of great consideration by boards of management, and I will be pleased indeed to send a copy to anyone who wishes it.
MR. R. S. DAY, Victoria— ■
I think our time is up for discussion on this paper, and I would therefore ask Mr. R. W. Hunter, of Vancouver, for his paper on 'Standardization
of Hospital Accounting.'
MR. R. W. HUNTER, Vancouver—
The time is long past when we kept our accounts by cutting a notch or
tying a knot to record each transaction. This method is recorded in the
early history of accountancy. Gone, also, are the days when accounts were
written by a chisel on a slab of stone. To trace the various steps in the
development of accounting is not the purpose of this paper, but it is well to
bring before your minds two or three of the methods by which accounts were
kept, and those who kept them in bygone times. By so doing you will recognize that accountancy has been developed, although to a lesser degree
than medicine or surgery. It will suffice to cite three stages inthis development.
Let us look back to the days of Rome, when the crowds gathered in the
market place, baked by the hot sun of Italy, to purchase the slaves captured
in campaigns against far-off lands. Here we have slaves laboriously writing
the transactions, of which careful record was kept, on parchments or .tablets. Let us pass the centuries by till we see before us the old and faithful
clerk of the time of Dickens, standing at his desk, scratching away at the
books with a clumsy quill pen. It is not so far a jump till we can visualize
the London clerk with tall hat and frock coat, wearing his life out in the
day-to-day drudge of- writing his accounts in large bound cash books,
ledgers and journals.
From this stage on accountancy has made great progress. We have
systems where machinery relieves us of considerable work, and gives better
results. We have other systems, which, although mechanical methods are
not employed in them, exhibit as great development. Perhaps mention of
the convenience of the loose leaf ledger as compared with the old bound
ledger, although only one example amongst hundreds, will be most suitable,
85 as it is something with which you are all familiar. The olden times probably did not call for any better system than that in vogue at the time, the
speed at which people lived then being much slower than that at which we
live today, and the financial and economic systems were not so complex.
Business houses, particularly manufacturing concerns, have kept abreast of
the times in the development of their accounting systems, although there
have been many laggards, but even they are now fast adopting the more
modern methods.
Have our hospitals recognized this progress in accounting and given
effect to it in their systems? Cast your minds back to the past days of surgery when amputations were performed without anaesthetic, the days when
the terms "aseptic" and "antiseptic" were unknown, the days when the patient died of what was commonly known as inflammation of the bowels,
instead of being able to regale his or her friends with the details of an
operation for cure of inflammation of the vermiform appendix of the
caecum. What would you think if the medical or surgical side of the hospital were conducted today on these old lines? The point I wish to make
is:   Do the hospitals fully realize the progress made in accountancy?
Do the hospitals realize the tremendous sums of .money expended on
them not only in the aggregate but in individual cases, that call for their
recording in the most efficient manner possible. I am not aware how many
hospitals were in existence in the days when each doctor cut a notch in his
stick to record a visit chargeable to his patient, nor do I know to what
extent the government of the day financially aided such institutions, but
I am convinced that the increase in financial aid from then until now,
although not in so great a ratio as the progress made in the sciences of
medicine and surgery, follows it pretty closely. Have we a similar progress
in our methods of recording and controlling these finances so that the
greatest benefit may be obtained from them? The government in British
Columbia spends about a million dollars a year on general, mental and other
hospitals, which approaches an absorption of 10% of the total revenue of
the province.
To record this huge expenditure so that -it will be of benefit to us in
our operations our accounting systems must be thoroughly up to date. To
efficiently administer the funds involved so that the best results can be
obtained from the expenditure, the Government requires to be in a position
to say to any hospital applying for a grant: Your hospital has a larger per
capita deficit than other hospitals of similar size, if such be the case, and
not only to tell them that the net per capita deficit is greater, but also to
tell them whether the deficit is caused by excessive per capita costs or
deficient per capita receipts, and still further, to tell them which particular
section of the costs is high or which particular section of the receipts is
low. The Government fully appreciates the benefit of standardized accounts
as is evidenced by their efforts to collect the forms in use by the different
hospitals. To be in a position to make such criticisms the accounts and
accounting systems of the hospitals of the province must be standardized.
In my mind this point cannot be argued. It is to be admitted, however,
that the accounts and accounting system of a small country hospital cannot
be standardized in such detail as a large city hospital, and no useful comparison could be obtained by attempting to do so. For the matter of convenience, the general method of keeping the accounts would in so far as it
is possible be the same, but the details would be different. In standardizing
it may be necessary to create two or more groups. The basis of forming
such groups will have to be determined by two factors: First, as to which
particular accounting system will be the most efficient for the hospital involved ; second, as to whether a useful comparison can be made between
that and other hospitals.
It is little realized, except by the most discerning that the standardizing-of accounts and accounting systems of hospitals will have a tremendous
effect on the efficiency of hospitals individually and collectively. In the
same way that a legal document binds the parties concerned to a definite^
course of action, so will a definite standardized accqunting system automatically create a standard up to which the individual hospitals will endeavor
to live.   In the report of the committee appointed by the British Govern-
86 ment to enquire into the reorganization of the whole of the machinery of
government of the British Isles it was stated that a standard is becoming
progressively recognized as the foundation of efficient action. Picture ourselves without any standards of living, what a chaotic state we would find
ourselves in. The state of hospitals without standardized accounts may
figuratively be likened to society without standards of living. I do not
wish you to take from this that I insinuate that hospital accounting is
chaotic, far from it, but I make use of the illustration as the best I can
think of.
Let me give you a few of the benefits which will accrue from standardizing of accounts arid accounting systems.
1. The hospital, be it large or small, will see from its own records,
which will be kept according to the best standard by comparing month by
month and year by year, how it can economize in any particular section.
2. Each hospital by comparing its costs and receipts with those of
other hospitals in the same group will see in what particular cost it exceeds
some hospitals and in what particular receipt it falls below others.
3. The central organization or government department will be able to
bring to bear critical faculties unclouded by local conditions or affairs, and
will be able to offer criticisms based upon its oversight of other hospitals
and not criticism only but criticism of a constructive nature.
4. It will create a spirit of competition between hospitals of the same
group, leading to greater efficiency.
5. It will have a p'hyschological effect on the individual employees—
employees being used in a broad sense to include all kinds of personal
service, be it doctors, nurses, pharmacists, accountants, orderlies, or any
help whatsoever—in causing them to appreciate the fact that the hospital
as a whole is in competition with other>hospitals and will so unconsciously
bring them into  competition with each other.
6. The community in which the hospital is situated will begin to
appreciate the fact that their hospital is as efficient as other hospitals, and
they will be more inclined to support it financially.
Now, each of the benefits, in addition to having a value in service to
the patient, has a real money value, which can be utilized to still further
increase the efficiency of the hospital, and produce further money values.
Each hospital, be it the largest of the city or the smallest of the country,
has one if not more ways in which they could make a little capital expenditure, and by so doing save on their cost of operating the institution, or
produce a greater service to the patient.
-I  hope  that  those  who   did  not   fully  appreciate  the   benefits   of  the
standardization of accounts can now see a glimmering of the possibilities.
There is more in the standardization of accounts than the mere keeping
of accounts under the same headings and in the same way.
There must be a centralization of active control of accounts if standardization is to bear full fruit. In the case of railways the government
orders that accounts shall be kept under certain defined headings, and I
would suggest for the Government's consideration that they order hospitals
receiving financial aid from the Government or Municipalities to keep their
accounts on a defined system rather than endeavor to have them adopt it.
During the war the anti-aircraft defense in Britain became very well
developed. Their method was to have anti-aircraft observation stations
throughout the country, which, by specially constructed mechanism were
able to obtain certain information concerning the approaching aircraft, but
it was only through a central control station receiving all the observations
from the individual stations that they were able to determine the height
at which the enemy aircraft were travelling, the speed at which they were
travelling, and when they would reach certain given areas. After each
attack the central station was able to trace the whqle flight and times at
which the craft were over different places, from the time they left enemy
lines till they or whatever was left of them returned. I suggest that you
consider this and apply the same principle to the control of the accounts
of your hospitals.
Health being a national asset it is a logical conclusion that the State
should  conserve  its   asset.    An   active  centralized  control   of  accounts  by
87 the government must inevitably lead to its active control of the operations
of the hospitals through some such organization as was outlined by Mr.
Banfield at your last convention in his paper "The Duty of the State towards
the Hospitals." This must therefore be borne in mind when it is decided
whether the central organization shall exercise an active control or be
merely advisory. The standardization of accounts with only an advisory
central organization will not realize the maximum benefit.
The central organization should draw up the necessary forms of books
and reports, and from the point of view of economy, have them printed and
issue them as required to the individual hospitals.
There are certain essentials which any system of accounts must contain
to be efficient.   The most beautiful accounting system in the world, from a
theoretical point of view, might be in existence, but it would be failing if it
did not give those in charge of the operating of the hospital:
.   The information they want.
2. In the way they want it.
3. When they want it.
It goes without saying, of course, that the accounts have to be kept in
such a way as to show that the funds are all accounted for. The accounts
of a hospital should be run as if the hospital were a business enterprise
and go in to quite as much detail as if the hospital were being operated
by the keenest of business men. The detail of how these accounts should
be kept in each hospital requires to be worked out by those in charge of
the standardizing of accounts. Suffice it to say that the larger hospitals
will only be able to reap full benefit if their accounts are kept showing each
department separately.
The accounts of hospitals should exhibit the moneys received, its transformation into fixed assets such as plant, buildings, and real estate, into
labor, material expense and the subsequent transfer of the combined product, which is service to the patient, to accounts receivable, and finally
their transfer to cash or uncollected accounts. The processes of transfer
should be more carefully recorded in all their stages.. Even the physical
inventory of the plant should be as carefully kept as the cash book.
It will require very careful study to evolve the standardized forms and
records, and care must be taken to see that no hospital be put in the position
of having to attempt to conform to a standard set of accounts which is not
of use to it. Yet no hospital should say, "Our hospital is different from
any other: we cannot conform to a standardized system of accounts." At
school in Scotland, in our arithmetic class, we had to find the L.C.M.
(Lowest common multiple. I do not know what you call it here.) of certain given numbers, which, it is not necessary to explain, is the lowest
number into which all the given numbers could be divided. If I remember
correctly, this problem was accomplished by finding the factors composing
each number. Accounts are as capable of being scientifically analysed as
samples in the chemical laboratory, and I have no hesitation in saying that
if standardizing be properly carried out, you will be able to erect a monument to your old accounts and inscribe on it the epitah which appeared
over the grave of a none too popular lawyer in his little home town—"Here
lies the body of John Brown—Everybody satisfied."
In order to reap the full benefit from standardized accounts it is esseaBf-
tial that they be properly kept, and tegular returns made to the Central
Organization. In the large hospitals this should- present no difficulty as
there are already trained accountants on the staffs. In the smaller hospitals,
although care would be taken to have the system as simple as possible, I
would suggest that the Treasurer of the Board, if the Institution is too
small to employ even the partial services ..of a bookkeeper, be conversant j
with accounts, and that he keep the records. This, however, is a matter
for each hospital to settle for itself.
Under the heading of "Accounts" comes the laborious and worrying
matter of collecting amounts owing by patients, and in standardizing the
accounts, I would recommend that as far as possible a standard system of
collections be adopted.
I suggest that the responsibility for collections, once the patient is outside the hospital, be assigned to a particular member of the board, who in | the case of a large hospital would have his staff of collectors, and, if the
hospital were small, would make the collections himself. A Central Organization of all hospitals could receive lists of persons owing accounts who
have moved away and would forward such for collection to the district to
which the person had gone. A system such as this would operate to the
benefit of all hospitals.
I have touched so much on the question of Central Organization that
I cannot refrain from making a suggestion, which although absolutely outside the sphere of my paper, is brought forcibly to mind in connection with
the recommendation that books and forms be printed by the Central Organization. My suggestion is that a Central Purchasing Agent be appointed
for all hospitals, or at any rate the smaller ones. This would save a considerable amount of money, as being able to place orders for large quantities
of supplies, they could be obtained at very low prices. I understand the
Provincial Government have found that their appointment of a Central Purchasing Agent for most supplies has proved to be of considerable benefit.
I see by the title of the paper of Mr. Leders, who is following me that my
suggestion does not interfere with the subject of his remarks.
' However, to get back to the subject of this paper, "Standardization of
Hospital Accounting," another point has to be referred to. When I had the
privilege of going through the systems of some of the larger hospitals in
Canada, I learned something new in each one. My greatest education was
in the Royal Victoria in Montreal. There I had the honor of being conducted through the hospital by the assistant matron, and very efficiently did
she cover the ground. It struck me very forcibly that I was looking at
things through the spectacles of an accountant, whilst she viewed them
through those of a matron. This set my mind working in order to discover how many viewpoints there are in examining a hospital. The accountant, to efficiently conduct his department, should not look at matters solely
from the accounting point of view, neither should the doctor's viewpoint
be purely medical. Each should fully appreciate the standpoint of the
other, and in this way only can the full benefit be obtained from accounts.
In the olden days, those chosen to keep accounts in business institutions were not Considered to have the same standing as those who were on
the operating end. The progress of business affairs has, however, changed
this, and the man who now has charge of the accounting end of a business
concern is of a much more highly developed type of mentality. In past days
this was not appreciated by business institutions. Accounting was looked
on by all except the most discerning as a necessary evil, and it was considered that the less money that was thrown away on it the better. As a
matter of fact, money spent on a properly efficient accounting system produces returns out of all proportion to the expenditure involved. I am glad
to say that it is becoming increasingly evident that the value of the man on
the accounts is being better recognized. It is surely a grave omission if
finance is not considered as one of the chief factors in the successful development of business enterprise, and finance goes hand in hand with accounts.
Not only in business enterprise, but in hospital affairs, be the hospital large
or small, must the value of the man on the accounts be properly recognized.
Don't let your accountant be a stenographer to take down the results of
a post mortem on some expenditure. Let him co-operate in the making of
expenditures. One example of the benefit which would: accrue can be
evidenced in the following: It is desired to make a certain capital expenditure. The accountant would examine the proposal with a view to ascertaining whether it was for of three purposes, viz.:
1. Is the expenditure for the purpose of saving money.
2. Is it for the general efficiency of the department concerned.
'  3.    It is necessary from a humanitarian point of view.
Despite the funds being low, the accountant would unhesitatingly
recommend the expenditure if it fell under category one. If the funds were
low he would demur if it fell under category two. If it fell under category
three, he would take it up from a charitable standpoint, and have it financed
from outside sources. As a result, the hospital finances would be greatly
benefitted, and its efficiency inevitably increased. This is only one of
hundreds of ways in which the man on the accounts can be of benefit to
the hospital. oo It may appear that it is outside the scope of this paper to discuss this
subject, but I consider the recognition essential to the proper creation and
efficient operation of Standardized Accounts.
Now in closing may I summarize:—
1. The large amounts of money- expended call for the most efficient
system of accounting.   ;
2. The most efficient system of accounting should be made uniform
throughout the Province.
3. The standardizing of accounts will benefit each and every hospital,
and hospitals as a whole both financially and from the point of view of
efficiency.
4. There should be an active Central Organization in control of accounts, with such subsidiary services as are necessary.
5. The system adopted, if it is to be efficient, must give all the information required by those in charge of the operating of the hospitals.
6. In order to make a complete success of the Standardization of
Accounts, the value of accounting must be fully recognized by those in
charge of the operation of the hospitals.
Just a word of warning:    In standardizing the accounts do not forget
the human element—the factor which as such does not appear on the books
•your guest of honor, the patient.
DISCUSSION
MR. R. S. DAY, Victoria—
The subject is now open for discussion Mr. Withers.
MR. E. S. WITHERS, New Westminster—
I found that a very interesting paper Mr. Chairman. The subject is one
deserving of a great deal of thought. As he says, it has not been given
the consideration in the past that hospital accounting really should have—
the feature of standardization, that is where the benefit is going to accrue.
I believe a couple of years ago Mr. Haddon, managing secretary of the
Vancouver General Hospital, read a paper defining the system in vogue in
that hospital. We know that is not applicable to all hospitals, but in a
modified form it is applicable to hospitals of almost any size, and I think
it would be a good idea if the committee that is already existing in this
association were to get some such system, not necessarily that, and those
in charge of the accounting of the various institutions in the Province
could be sent copies of forms and a general resume of the method in vogue,
and get their opinions or suggestions, and by that method get moving toward
standardization. It has been talked about since the association was formed.
I do not know that there has been any progress at all towards standardization and I do not see why we should not get moving. With that idea in
view I think this committee should get some such forms and distribute
them, then the committee could meet and adopt a form which could be
suitable for hospitals of say, from fifty to one hundred beds. In regard to
having an adequate system—unless you have an adequate system of accounting you cannot give due publicity as to what your hospital is doing, and if
you cannot give due publicity as to what your hospital is doing you cannot
expect to get publicity, and you certainly need that. Some accountants
have rather elaborate ideas which require sometimes a greater staff than
the number of patients to keep it going.   Of course that is not necessary.
The method of collection is a feature which is rather interesting. I
rather like Mr. Hunter's idea of appointing a member of the Board to do
that. I would be tickled to death if one of our Board would do it. One
of the most difficult features in collection at the present time is due to the
amendment to the Provincial Hospital Act, whereby municipalities are made
responsible. You can imagine that there are many difficulties in that respect. If you have a patient in the ward whom you charge $1.50 per day—
he may be in for a week, he may be in for six months. His account becomes
due and payable by the municipality thirty days after it accrues. With
ourselves, we bill the municipality in the thirty days. That patient may
pay his bill and he may not. The municipality may pay his bill and the
man most likely not.   On the other hand, they may both pay; the situation
90 is a very difficult one for the accountant to cope with and is something
which also needs standardizing.
DR. H, C. WRINCH, Hazelton—
I want to thank the writer of that paper for the very practical and
useful presentation of hospital accounting. It is something we, in the
smaller hospitals, at least, need help upon. No doubt the conditions are
somewhat similar in all hospitals. We start in a small way, have very
simple accounts to keep, but as we go along they get more and more complex and involved, each one working in his own haphazard way. Our
Government requires a report on certain portions of our financial statement.
It seems unreasonable that they should require this report without providing
some means as to how we should prepare such a report. I think we should
look to them for some assistance. I prepared a resolution here, roughly,
which no doubt if adopted will come before the Resolution Committee of
the Association:
THAT in view of the fact that the Provincial Government of our
Province requires that reports of financial character be submitted to
them from time to time by all hospitals receiving financial monetary
aid from the provincial treasury, and in view of the difficulty of obtaining such reports when no uniform system of keeping accounts by hospitals has been inaugurated or even recommended by the Government,
WE, The B. C. Hospital Association DO HEREBY REQUEST
that the Provincial Government be requested to have a suitable system
of accounting prepared for our hospitals, and that the hospitals be furnished by the Government with books or forms necessary for the
carrying out of this very essential feature of our work, after such forms
have been submitted to the various hospital boards for their consideration and criticism before final adoption.
My idea is not to have the Government prepare a system and force it
upon institutions that already have a good system and one that they have
worked out to their own satisfaction, but a system that will be prepared in
consultation with those who are already using a satisfactory system, one
that can be made as, simple and generally applicable as possible. I would
like to move that resolution.
DR. M. T. MacEACHERN, Vancouver—
I have -much pleasure in seconding Dr. Winch's resolution.
I want to tell the two speakers this morning that we appreciate very
much their papers. We are sorry there is not a larger attendance, but
there is a representative audience. I am sure both papers are very practical
and useful.
MR. R. S. DAY, Victoria—
You have heard the resolution moved by Dr. H. C. Wrinch and seconded
by Dr. M. T. MacEachern. It is usual to send these resolutions on to the
Resolution Committee, who will consider and bring them up.
MR. P. DuMOULIN, Kelowna—
I would like to ask how these suggestions are brought into being. No
reports have been submitted by this Accounting Committee. What can be
done to se^ that these suggestions are carried out?
DR. M. T. MacEACHERN, Vancouver—
Any suggestions here, of course, will not be lost, inasmuch as they will
be embodied in our report, but to take action on it may necessitate from
our business session tomorrow the appointment of a new committee. The
past committee, I am sorry to say, has never done very much on this. It
has been shelved from time to time. The secretaries of our hospitals, as
Mr. Withers, and I know Mr. Withers from his standpoint has constructive
interests in this, should do some local research work on this problem and
solve it for our province. That is what our Association is for. I think
.e secretaries of our various hospitals should be taken into consultation
with the Government in this respect. We want the viewpoint of the various
hospitals.   If you  desire a  committee appointed you  could bring that  up
91 meeting tomorrow when a report of this committee will be
at the busines
asked for.
MR. P. DuMOULIN, Kelowna—
In the Okanagan Valley Mr. Creehan very kindly audits all the books I
of the various hospitals free of charge, and I think he would only be too
■happy to lay out some system as he does so much of the accounting.
MR. G. R. BINGER, Kelowna—
Mr. Martin, who audits the books of the Kelowna Hospital, said, when
he went through our books, that the system we had was about as good as
he had come across; it was simple, gave all the information necessary and
it was very easy to find the per diem cost. The system is very much like
the Penticton Hospital system.
MR. J. SUTTON, Nanaimo—
The suggestion has been put forward, and I think a very good one, to
go into this work and bring out some definite system. Outside hospitals
are depending on the activities of this Association, and unless there is some
concrete policy adopted we lack the usefulness of this Association—we must
have some definite plans. My chairman pointed out to me the necessity
of bringing back some definite solution to our problems. Your committee
can draw up some definite scheme and submit plans to our hospitals and
probably work out something in the very hear future. I would suggest that
the committee be asked to place in some report, come to some conclusion
upon some standard system of accounting, and this be sent out to the various
hospitals as soon as possible.
MRS. L. H. HARDIE, Duncan—
We all know that coming to an ordinary meeting; in the matters discussed you must either have a letter presented or a resolution—that in order
to bring this to our Board we must have some concrete word either in the
form of a resolution, recommendation or suggestion. There is no use going
back and saying this was discussed. In the matter of collecting accounts,
we find our secretary does our work very well.
Mr. E. S. Withers, New Westminster—
"I might say, as a member of this committee which is receiving so
much adverse criticism, I was not originally on this committee, I was added"
to it. Whether the committee met or not I do not know. I think I can
say for the committee that during the next year we will make some progress.
It is a thing that takes a good deal of thought and I am sure there is a lot
of work, and we as secretaries have a good deal of work to do ourselves; it
is hard to get together, but I for one will do my best to see that we do get
together arid really do something worth while on this matter."
Mr. P. Du Moulin, Kelowna—
"Would it be possible, Mr. Chairman, to have a report of this committee
submitted to the different members of the Association before the "next meeting?"
Mr. R. S. Day, Victoria—
"I see no reason why that committee could not bring in an interim
report to the Executive Committee, which will no doubt meet sometime
during the winter.
We will leave this, subject now and ask Mr. R. B. Leders, Purchasing
Agent for The Vancouver General Hospital, to give his paper."
MR. R. B. LEDERS, Vancouver—
This is a very important subject and I would much rather listen to a
paper prepared by Mr. Guy J. Clark, Purchasing Agent of the Cleveland
Hospital Council, or some other well known buyer, than to be in the present
position of reading my own composition. However, if you will bear with'
me for a short time I will endeavor to handle the different points as they |
appeal to me. I undertake the subject with a certain diffidence,, knowing its
magnitude, both to small as well as large institutions.
92 First of all, the most essential point is that of saving money and
secondly, the buyer's time, which I will deal with later.
Let me first name some of the commodities which are purchased by
contract to advantage—Groceries, Meats, Fish, Eggs, Butter, Jams, Potatoes,
Tea and Coffee for the Commissary Department—Gauze, Cotton, Bandages,
etc. for the Nursing or Medical branch.
Taking Groceries first, my records show monthly savings from $20.00
to $100,000 on an average monthly account of say $3,000.00, quality or brand
and prices being at all times considered. Of course, this is done on specification, for instance, Canned Fruits and Vegetables.
Canned Fruits are an important item in hospital expenditures. The
purchase of this item has been very unsatisfactory on account of a lack
of standard specifications. Much of the Canned Fruit sold is under the
label of the jobber, not that of the canner. This fact in connection with the
position usually taken by a purchasing agent and the natural point of view
of the jobber, has often resulted in a demand on the canner for a pack to
sell at a certain price. Often the goods are sold by the jobbers before being
purchased by them or packed. Their purchases are made to fit their sales
as to_ price as well as to quantity. Suitable labels are prepared to meet
the situation.
Under these conditions advance orders are not a protection in anyway.i
The buyer carries all the risk of fluctuations in labor cost and fruit variation, and the adjustment is made in the quality of the contents of the cans.
This is through the lack of definite specifications in purchase.
To this unfortunate condition the buyer has too often contributed both
the opportunity and the motive, and some times by their attitude at time of
purchase, have made this practice even necessary for a sale. The buyer
has asked only casual indefinite and meaningless questions as to standards
and has presented or required no definite specifications as to quality, but has
been very exacting and demanding as to price. Ignorance as to standards
of quality and the lack of definite specifications to present, are generally
responsible for this.
You will appreciate how this has handicapped the jobber who has
already protected himself by actual purchase of goods of a definite quality of
pack, and really intends to protect the buyer by advance sales. Such a
jobber cannot successfully meet the situation. The sale usually goes to the
one who, knowing he can protect himself later in his purchase, makes the
price just the amount the buyer wishes. The unfortunate point is that the
hospital has had no way in which to determine the kind of deal it is making.
The only solution possible has seemed to be through the establishment
of standard specifications covering a sufficient number of grades to meet
all conditions. The standards are as follows:—Fancy, Choice, Standard
Second or Water and Pie. These range from fruit free from blemishes to
wholesome fruit, unsuited for the higher grades.
You will also find the number of pieces of fruit per can, say peaches,
apricots or pears, will vary. Peaches should contain not less than six or
more than twelve for first garade or fancy; also the syrup is of a higher
degree of sugar.    Cherries, too, can be judged in the same way.
The above, I think, fully explains why I maintain that a definite grade
should be specified.
I use a tender form which reads as follows:    Quantity—Article—Brand
Substitute  (if any)—Unit Price—Total.
The same would apply to barley or articles of that nature, as very
often the jobber will send you not barley instead of pearl, if not carefully
checked up.
The advantages are, the buyer has only two operations to go through,
namely, sendiiig his tenders with specifications, to the wholesalers, and then
reviewing same on return and awarding contract.
The method followed by the Vancouver General Hospital was explained
in my paper of two years ago.
On the other hand, if a buyer had to go to the open market, he must
of necessity call on each individual firm or lose valuable time, over the
the telephone.
93 A definite specification could also be used in the purchase of meats,
beef at a certain weight, percentage of bone, lean or fat; hams and bacon
at an average weight; and a merchant looking for future contracts would
be guided by your specifications and thereby live up to his contract.
A very good argument in favor of contract also, is the fact that on;
this year's purchase of tea and coffee we have effected a saving of some
$1,500.00. Jams, too, are selling now at an average price of $13,00 per
dozen for four-pound tins, which were contracted for at $9.75 per dozen.
Soaps, soap powders and cleansers have advanced and by contractinng
considerable advantage was obtained. Butter could well be contracted for
in September and either taken delivery of at once and put in cold storage,
or arrangements made with the vendor for a definite quantity to be sent in
each week or month as demand warrants. I must not overlook the "King
Potato." I was particularly fortunate in combating this most unheard of
advance. The price towards the end of the season advanced to $110.00.
Yes, and is today $180.00.   I paid on the average of $47.50.
I th;nk I have made my point clear and what I would like to leave with
you is the one thought of studying market conditions, contracting at the
physchological moment, with definite specifications as to quality, per centi
etc.
I could go into details relative to other articles, such as the advisability'
of storing eggs, but I must leave you to study your own local conditions
and be governed accordingly.
DISCUSSION
DR. G. S. PURVIS, New Westminster—
"I think in the smaller hospitals it would be a wise thing to endeavor,-
if we could, to form some association for buying. I used to do a'little in
the drug business myself. Since coming to New Westminster I do not
know what they are paying for green soap. The last we got we pai'd $2.40
for eighty ounces. You can buy green soap from the Royal Crown Soap
Company for 15c a pound. You can bring that down under live steam or
heat by adding ten volumes of water; I figure it out to cost l%c a pound
for good soap. According to that figure it must be a mistake. It figured
out something like 3800%. Gauze, for instance: At the present time if
you'buy a small quantity you pay $13.40 for 100 yards. Chandler & Fisher
telephoned and said they had a shipment in of American army gauze at
$8.50 per 100 yards. We ordered a bolt to try it out, and it is mighty good
gauze, in fact it weighs 8 ounces more per 100 yards than the $13.40 gauze.
At present they have a shipment of 25,000' yards at $8.50. Here is a good
time, I think, at the convention, everybody wants gauze; in fact our hospital
has bought enough gauze to last a year. I think it would be good business
to make up an order and buy the 25,000 yards.
MR,. G. R. BINGER, Kelowna—
How do you contract, Mr. Leders, by the year or month ?
MR. R. B. LEDERS, Vancouver—
Our groceries are bought on the monthly contract.
DR.. R. W. LARGE, Port Simpson-
Are you in any way protected against drops ?
MR. R. B. LEDERS, Vancouver—
We protect ourselves by the monthly contract.
DR. R. W. LARGE, Port Simpson—
For the outlying hospitals that would not be feasible. It would take
us half our time arranging our contracts.
MR. R. B. LEDERS,—Vancouver—
If you follow the system of taking stock on the 25th of each month, and
ask them for the return of that tender by a certain date, then their shipment can be made two or three days following."
DR. R. W. LARGE, Port Simpson-
Are your dealings made with retailers or wholesalers ?
94 MR. R. B. LEDERS, Vancouver-
There is only one wholesale firm that will not sell to us.   I can buy
I from any of the others.
MR. G. R. BINGER, Kelowna—
In smaller hospitals that are supported by subscriptions, one can hardly
deal with wholesalers because the merchants we buy our material from
support our hospitals and I think it is up to our hospitals to reciprocate in
some way.
MR. R. B. LEDERS, Vancouver—
I do not think any merchant should expect to live off the hospital, no
matter whether he is on the Board or not.
MR. G. R. BINGER, Kelowna—
I do not want anyone to go away with the idea that our merchants are
exploiting the hospital.
MR. R. B. LEDERS, Vancouver—
They wont give you the same prices as the wholesaler.
MR. G. R. BINGER, Kelowna—
You couldn't expect them to.
MR. P. DuMOULIN, Kelowna—
We tried to do that in our hospital, we wrote to Vancouver and offered
to pay the freight if they would sell to us at the wholesale rate. We received
a reply turning our offer down.
MRS. L. H. HARDIE, Duncan—
They consider where there are local merchants they should not compete
with them in dealing.
MISS E. I. JOHNS, R.N., Vancouver—
I think the only way would be through co-operative buying. I think
too, the point has not been touched on yet and that is, a great deal of the
buying in the small hospital is done by the man-of-all-wark, the matron.
Might it not be possible sometime to have a short summer session which
matrons could attend, and which their Boards could hero them to attend,
where they might learn something of the prices? We do not teach that in
our schools. I feel they are deserving of some consideration in the matter
of education. Might it not be advisable to have summer schools? I am
perfectly sure the cost would be covered, because then such errors as Dr.
Purvis drew attention to would be eliminated.
MRS. L. H. HARDIE, Duncan—
We are going to have our secretary do the buying to relieve the matron.
DR. H. C. WRINCH, Hazelton—
I started a small hospital some years ago. I had personal friends,
business men; I had to buy for a long period in advance and they gave me
the privilege of buying wholesale. One or two of the merchants said, "We
would like to have your business, give us a chance, but we do not want to
impede the hospital." Once or twice I made out a bill submitted and bought
from them. Again I made out bills of almost the same amount and sent
one to the wholesale and one to the retailer, and I found I could save ten
per cent by dealing with the wholesale. I explained this to the retailers and
they said, "Buy what you can from us," and we have done that ever since.
It is just a matter of taking it up with them. I find the wholesalers are
willing to sell if the retailers do not object I am very anxious indeed to
see co-operative buying. That will eliminate this feature, and I am waiting
to see it brought forward.
MRS. G. B. BROWN, Nanaimo— ^jj||
We have members on our Board who are business men. Any member
who is a business man absolutely refuses to take an order for the hospital.
They never will do it. They never favor the hospital in any way, they consider it is illegal. DR. M. T. McEACHERN, Vancouver—
i I think it is very difficult for the local hospital to pass their local
dealers. On Page 29 of the Calgary Conference report you will find a
delegate brought up the question of the purchasing of supplies. It was fen
the four provinces should have a consolidated Information and Purchasing
Bureau; for instance, if a hospital is going to be built in that province they
go to the Government for expert advice as to site, location, size of building
and all Mr. Cox's paper covered today.
MR. R. S. DAY, Victoria—
Our time is more than up I am sorry to say. May I, before asking Dr.
MacEachern to make a few announcements, express on my own behalf and
yours, our very grateful thanks to the three gentlemen who have prepared
these papers at so much time and trouble and who have put forward such
practical suggestions to us today.
Dr. M. T. MacEachern made some announcements regarding meetings
of Convention Committees.
Meeting adjourned.
PART II
FRIDAY, June 25th,  1920—2 p.m.
ROUND TABLE CONFERENCE
"HOSPITAL FINANCING"
Conducted by Mr. Charles Graham, Cumberland, B. C.
The meeting was called to order by Mr. Charles Graham, presiding.
Dr. MacEachern made several announcements re sessions, Resolution
Committee, luncheon tomorrow, etc.
' MR. CHARLES GRAHAM, Cumberland—
"In common with Dr. MacEachern, I must say that I am very pleased
to see such a representative gathering here, also to see that the sisters have
taken such an interest in this convention to turn out in such large numbers.
My experience has been, in the last three conventions, that; Jhe sisters have
been very regular attendants.
, The programme this afternoon is in the nature of
ference on hospital financing.   It is divided into three
(a) Financial problems of hospitals today :
(b) Sources of revenue and expenditure:
(c) Uniformity of hospital charges,
&s@£:    Ward fees
Special  charges or extras,
Contract charge:
I will ask Mr. R. S. Day to open the discussion on the first subject, "Financial problems of hospitals today." ■
MR. R. S. DAY, Victoria—
I wish, and I expressed that wish to Dr. MacEachern, that he had
asked somebody else to undertake this work, inasmuch as at our session
last year I read a paper upon the subject. Since that time all I have seen
and heard has deepened the conviction given expression to then.
During the year that has passed, in discussing with the corporation of
the City of Victoria the question of hospital finances, it was suggested that
I should go over to the annual meeting of the Union of B. C. Municipalities
and bring it before that body. Dr. MacEachern had advised me that he
had obtained permission from the Union to address them, and the City of
Victoria thought the matter of sufficient importance to ask me to go over,
or rather, I told them Dr. MacEachern had asked me to go over and be
with him on that occasion, and they thought it of sufficient importance to
send me as their representative and very kindly paid my expenses. Dr.
MacEachern and I were privileged during the luncheon hour to address the
Union upon this question. He devoted himself very largely to the service
rendered by the hospitals to the community and I took up with them the.
question of the  support of the hospitals by it,  and we received a very
96
a round table con-
sections,— favorable reception from the gentlemen who were present upon that occasion,*
and an important resolution was passed later.
Now the financial problems of the hospital today are the same as the
financial problems of the hospital last year and of hospitals, I \presume,
ever since hospitals have been founded. Those financial problems, however,
are today intensified by what we may call the still higher cost of living,
regarding which we have no knowledge as to how much higher it will go,
intensified to a considerable extent by recent legislation, inasmuch as the
Government has introduced a bill, to which I think none of us or any
reasonable person anyway, takes any exception. Under this an eight-
hour day has come into force. This necessitates an increase in the working
staff of the hospitals and a considerable increase in the cost. Further,
during the last year the great question of Venereal diseases has been
brought forward and we have the formation of clinics for the treatment of
this trouble, with laboratories here and in Victoria, subsidized by the
Government to do that work, and I think both the Vancouver General and
the Provincial Royal Jubilee hospitals recognize that the Government met
us in a very fair spirit in these matters, arid that the allowance made is
at any rate ample and sufficient for us to take up the work as it stands
today, "and no doubt it will be subject to revision in the future if we find
the subsidy not sufficient or the Government finds it too high. At the same
time the Government has practically turned around to us and said:"You
must take charge of the bed cases," and they are sending in to us bed cases
of these diseases, and in some instances these cases are absolutely unfit
and unsuitable for admission into a public ward. I am one who believes
firmly that we have no right to treat these cases in our public wards. I do
not want my daughter, if she has to go into the hospital, to be up against
the women off the streets who are receiving treatment in the hospital, nor
should any decent, clean living man be treated in close proximity to a man
receiving treatment of that kind. I am of opinion that the public hospital
should take care of practically everything that is' sent to it excepting communicable cases. I do not say that we should not take these cases, that
provision should not be made for them, but I do say that this Association
might discuss as to whether the Government should expect us to put them
in our public wards. I asked Df. MacEachern what he was doing with
them. He said, "We have to take them but we can isolate them." We
have no way of isolating them. Now then, if the hospitals have to provide
for the care of these cases it appears to me that an increased expense is at
once put upon them, first in the erection and equipment of an isolation ward,
and secondly in staffing and maintaining it, against which we can set off
free medicine, a per diem Government grant and- what \ve can collect
Against all this added expense we cannot get any increase in our grants.
Then there is the tubercular patient whom we did not take in some years
ago, but are now compelled to care for. No provision is made for them
except a per diem grant for thein care. We have to take tliem and erect
special buildings. The Government in the exercise of its wisdom and for
the good of humanity, and I do not criticize their action, asks the hospital
to take care of them. So I say, not only the increased cost of living, but
the shorter hours and the development of our work, intensify the financial
problems of the hospitals.
Then we have a growing belief in the minds of the public that the
hospital service is a community service and we are told again and again
that it is the duty of the State to provide for it. By the State they mean
the community. They are not much concerned as to differentiate between
the municipality and the Government, but they do feel that the hospital is a
community service and should be taken care of by the community in some
way or another, and that belief -results in the falling off of personal contributions to our hospitals. I for one do regret and always have regretted
that the personal element is to some considerable extent in this country
lost sight of, and that that large field of voluntary charitable contributions
towards the public hospitals and hospitals of every kind which prevails in
the old country, is practically extinct in British Columbia today.
Now, with all these additions, we have no extra, or at least adequate,
increase in our revenue  from any  of the public sources  from which we
97 •derive it, to take care of the extra cost of treating our cases today. We
have added burdens and we have nothing to show on the other side except
the per diem grant. We had not legislation which would compel the municipality or any group of municipalities, to do more than contribute towards
the cost of their indigent patients until the measure which was passed by
the Government last year, under which the hospitals can send in a bill to
any municipality and claim from the municipality at the rate of $2.50 per
day for every day's stay of any patient who comes from that municipality, ■
having been thirty days' resident previous to his admission into the hospital,
who has gone out and left his bill unpaid. Naturally, the municipalities
do not like that legislation. Naturally, as a citizen, I think it is rather
dangerous, because I am afraid there is, from my experience, a somewhat
considerable number of people, who, if they get that knowledge into their
heads, will probably refuse to pay their bills, "the municipality will have to
pay it." Therefore, I think we have to treat that with a certain amount of
reserve and that it is possibly something that should not be advertised
broadcast over the country.
Under all these curcumstances I think we have before us the duty of
bringing clearly before the public the financial needs of the hospital and
to stimulate it by every means in: our power to bring edaquate and due
pressure to bear upon the authorities to provide financial assistance along"
new lines in an adequate- degree for the work we are doing. I am not one-
of those who wants to fall foul of the Government or the City. I recognize
that the Government has done remarkably well for the hospitals of this
province today, and I do not see that they can do much more out of present"
taxation. I also recognize that some of our municipalities are doing just
as much as they can to help along the hospitals in their straightened circumstances with their present sources of revenue. Then I think we should
also keep hospital work adequately before the great charitable public and
get the wealthy interested through a wise propaganda to influence such
people in contributing towards the cost. I do not believe that our entire
support should come absolutely and entirely from public support. I think]
it would be a very great pity, as I said last year, that our wealthy people
should get into their heads the idea that they should do nothing towards
the support of the hospitals in this province. I am glad to say that I
notice a very considerable tendency on the part of some of them to do something for our hospitals and for our work. Some of us today are in possession
of very substantial legacies that have been left by wealthy people, which
are of untold benefit to us and to the other hospitals, which have shared in
them in the erection of new buildings. Take for instance, our hospital in
Victoria: I have told the business men of our City and our City Council
that we do not use any legacies that are given to us for maintenance. We
put them upon one side and use them for permanent improvements. Without
those legacies we should have been far short of where we are. Those
legacies have helped us very largely—they built our X-Ray department
and provided equipment at a cost of nearly $20,000.00 and in many other
ways have provided the means by which untold good is being done to
hundreds of sufferers from year to year.
' MR. CHARLES GRAHAM, Cumberland—
Our next subject for discussion is "Sources of Revenue and Expenditure," by Mr. G. F. Carver.
Mr. R. S. Day explained that Mr. Carver was unable to attend owing
to pressing business in Victoria.
MR.  CHARLES  GRAHAM,  Cumberland-
Then we will ask Mr. R. A. Bethune, Secretary-Treasurer of the"Royal
Inland   Hospital,   Kamloops,   to   open   the   discussion   on   "Uniformity  of
Hospital charges."
MR. R. A. BETHUNE, Kamloops—
The subject on which I wish to make a few remarks today, namely,
"Uniformity of Hospital Charges in our Provincial Hospitals," is one of
paramount importance to the governing bodies of those institutions.
It is evident that most of the hospitals desire to make some changes in
their rates, but most of them appear very-chary about doing so of their
98 own accord, probably as a change can only mean an increase, which they
are at all times loath to make, both from a desire to assist the sick and from
wish to avoid local criticism.
I would ask the Hospitals to consider the question from a slightly
different standpoint, at the present the cry is "we know that we are going
behind, but the Government or City must help us out if we do." I think
that idea should be forgotten and our hospitals finance themselves as far
they possibly can, on a sound business basis as conditions require; so far
the Government has not seen fit to make any change in the per capita allowances, and as it is now, and until some different system of financing the
hospitals is brought about, if such change is needed, we must try and take
care of ourselves.
I have obtained data from most of our principal hospitals in the Province regarding their rates and a casual glance at the figures will bring
it to notice that there is a considerable discrepancy between the per capita
cost and the basic rate, namely, that charged in Public Wards. My1 idea
on that point is that no hospital should charge anyone less than the actual
cost of maintenance. The range of cost per day is from $2.30 to $3.21,
while the Public Ward rate varies from $1.50 to $2.00, in most cases the
latter amount. It is unfortunately too low and should be at least "cost";
by this I mean cost outside of any Government or Municipal per capita
allowance, as those allowances are given to cover the whole cost of treating
indigent patients, and should not be considered in any other connection.
It may be said that if we charge cost there should be no extra charges
at all; we may be so fortunate some day, but there are many people who
do not and cannot pay, also funds must be provided for improvements to
plant and equipment.
Taking the Public Ward rate as the basis, semi-public and private
ward rates must be based on cost plus the cost of the extra service, etc.,
given, but here again a survey of rates throughout the Province shows a
need of readjustment, and recognition that private ward patients are like
the patrons of the first class hotels and expect to pay extra accordingly,
but our hospitals charge far less than these hotels and give expert nursing
attention and much greater personal service besides.
With regard to rates in semi-private and public maternity wards, I
would not advocate charging any higher than general ward rates, except
possibly a case room charge, which may be considered as a similar extra
to an operating room fee. Private maternity wards should pay in accordance with their extra demands.
The next item is Special Charges. Generally speaking these extras, cost
about the same to any hospital, and it should not be difficult to make the
rates uniform. X-Ray rates seem to be pretty uniform and along the scale
laid down by the Vancouver General Hospital, so no trouble should be experienced in establishing them generally; but hospitals should bear in mind
that funds should be allowed for repairs and renewal of their machines as
well as to cover cost of operating. It appears to be pretty general practice
to charge extra for special medicines, prescriptions, sera, etc., free medi- j
cine being limited to a few standard mixtures. Some hospitals appear to
charge sufficient for special nurses' board, and the practice could easily be
made general. Dressings now form a very large item of expenditure and
sufficient should be charged to cover. Electric bakes, special baths, etc.,
can be put on a uniform basis; the small hospitals are unable to provide
much equipment for laboratory work, but a uniform rate for such examinations can be established easily. Operating Room charges. There appears
to be a wide range of charges for operating room, and it seems that many
of our hospitals are not really aware how much this service is actually
costing them, taking everything into consideration, since charges are often
the same as some years ago, while everything used there has increased
greatly in cost. No doubt a uniform scale can be established without great
difficulty.
The next item is Contract Charges. No doubt there is the greatest need
of uniformity in these rates, those charged now range from $1.50 plus a low
charge for operating room to $2.50 flat. It would appear that the only solution of this question is to charge actual cost, as is paid by the Department
99 of Soldiers Civil Reestablishment at some hospitals. Boards of Directors
are approached from time to time with requests for special rates for contract
accounts, the common argument being that the pay will be sure and so a
lower rate should be granted. No hospital can afford in these times to
charge less than cost to anyone. Hospital boards will be greatly assisted
if a decision is made for uniformity in this.
I believe all these matters can be best handled by a permanent committee of this Association, and I am sure their backing and recommendations will assist Hospitals greatly when rates are under discussion, the
general way is to ask what is being charged at such and such a place; they
had better be written to first, thus decision is delayed but reference to a
central committee would simplify business and also give the Public confidence that the rates were being set by those best qualified to judge.
It should be borne in mind that delegations to the Government, etc,
drives for funds, etc. by which haphazard methods we are all. now financing,
are no good in the long run, and we should get together on this matter and
try our best to at least finance our current expenditures in accordance with
whatever rates of Government and Municipal assistance are in force.
I have prepared a schedule of rates now charged in relation to per
capita cost at a number of Hospitals, and also what may be considered
necessary rates, this I will be glad to turn over should the matter be taken
up in committee.
DISCUSSION
Dr. M. T. MacEachern, Vancouver—
In the report of the Calgary Conference you will find on page 28 the
per diem charges and on page 29 the per diem cost, average, in the four
.western provinces. Dr. Arthur has tabulated some very valuable information which you see on the blackboard here, and which will be printed in
our report.
Mr. G. R. Binger, Kelowna—
Our per capita cost is $3.55.
Dr. M. T. MacEachern, Vancouver—
I do not think our average per capita cost per day in the Vancouver
General Hospital will be more than $3.00. The method of financing hospitals
today is not at all satisfactory. You ask the City Council for assistance but
they send you to the Government, and the Government refers you back to
the municipality. Finally, you must go out on the street and raise the
money by campaign or borrow. This is not a sound business way to conduct our hospitals. There is scarcely a hospital in this Province but what
needs extra equipment and accommodation but cannot get same. It is
serious when we come to such a state as we have arrived at in Vancouver
when a few citizens will say to the hospital people: "No, we think your
demands are quite right and justified but we are going to kill your bylaw
for more assistance, in order to force the question of a more equitable taxation." While such happens our nurses suffer from lack of proper accommodation and the mothers and babies from lack of proper hospital facilities.
It is unfortunate that this issue should be fought out along these lines. My
opinion on the matter is that the financial support we are getting for our
hospitals is such that it will soon come to a time when we cannot make
further progress, our efficiency will have to be reduced, and I know all you
hospital administrators will feel this very keenly and it will be a serious
blow to our institutions. The crucial point before us as a hospital association is the increasing of our financial support annually. The powers that
be are looking for an equitable way of distributing the cost of this hospital
expense and we hope that some practical scheme will be worked out very
shortly. I want to tell you something that will be rather interesting when
you figure it out. We asked for a $500,000 bylaw to meet the needs of a
growing city. Sufficient money would have to be put up by the City
annually to take care of the interest on the whole bylaw and the sinking
fund, which would amount to one-seventeenth of a cent per day- for every
$1,000 of taxable property, that is, it would cost you or I and the average
100 property owner, as a large proportion have assessments not more than
$8,000 to $10,000, one-half a cent a day to give this service to Vancouver,
which amounts to one-half a cigarette or one-fortieth of a cigar. Why,
therefore, should there be any opposition to this expenditure. It is regrettable that our municipalities are not helping the hospitals more than they
are. In the City of Vancouver I am told that they have spent 3 or 5%, I am
not sure which, of their whole investment on facilities for looking after
hospitals and health, while in parks they have spent 13%. The Government
of British Columbia has paid out infinitely more to hospitals last year than
the municipalities and figures will bear me out in this. Nevertheless, the
sum total paid by both governing bodies has been much less than the
required amount. The issue, therefore, is forced on us to get some better
way of financing hospitals, and I hope before we meet next year some solution will be available. We cannot press our paying people to do more than
they are doing. Illness overtakes them constantly and unexpectedly. Our
charges here in this Province are very fair—they are much lower than in
Eastern cities, but the high charges in Eastern cities are for a certain class
of accommodation that we do not supply here. They go in for much more
elaborate accommodation than we do. However, there is one thing in our
institutions, patients will pay for the service you give them; if you give them
a good service, make them comfortable and happy, they are quite willing to
pay. It is pretty hard to have uniform fees but it is not at all hard to have
uniform service. I hope this meeting will do something to solve the financial
problems of hospitals.
Dr. H. R. Storrs, Vancouver—
What class of hospitals is allowed to collect $2.50 from the municipality?
Mr. R. S. Day, Victoria—
"I think that only refers to public hospitals, I am not sure. I do not
know'whether private hospitals can do that or not. That can only be collected from municipalities in organized districts."
Mr. G. R. Binger, Kelowna—
"If we get a patient in Kelowna who has lived in Vernon, arid he
refuses to pay, you can collect from Kelowna. Supposing a man comes in
from outside, from an unorganized district, you only get the Government
per capita grant."
Mr. Charles Graham, Cumberland—
"The Act only applies to those receiving Government aid. They are
the only ones who are compelled to take such cases in."
Mr. E. S. Withers, New Westminster—
"I would like to ask if there is a report on Mr. Day's proposal in his
paper at last year's session, on the per capita tax for hospital purposes."
Mr. R. S. Day, Victoria—
"That was Mr. Banfield's paper."
Dr. M. T. MacEachern, Vancouver—
"There was a committee on that and reported to the Executive."
Report read by the Secretary, as follows:—
RESOLVED that The B. C. Hospital Association believe that the
maintenance of hospitals is a duty devolving upon the community. The
Association recommends to the Provincial Government the appointment
of a committee to investigate the financial position of the various hospitals in this Province, their service and requirements, and to present
to the Government recommendations as to the future management of
hospitals. The B. C. Hospital Association further recommends that
pending the Committee's report that the Government provide for an
'■ increased per capita grant and the Hospital Act be amended governing
the payment of patients' fees by the municipality, said amendment to
call for the full per capita cost per patient, to be assessed against and
paid for by the municipality.
101 Dr. M. T. MacEachern, Vancouver—
"All that has happened since is the adjustment of the Municipal Act"
Mr. P. Du Moulin, Kelowna—
"During the past year we have been in the happy position of having a
surplus of about $100.00. We had to carry forward from previous years
about $4,000.00 bad debts, which I might say we cut in two this year. We
endeavor, before the patient comes into the hospital, to ascertain where they
come from, if they have any friends or relations and their financial position.
We insist on having a promissory note. You can readily understand this is
far better than a bad debt. As to getting subscriptions, this year we
inaugurated a drive to install an X-Ray plant. We purchased one costing
us a little over $3,000.00. Our objective was $5,000.00; we got about $4,000.00.
We also got promises of fruit, vegetables,- eggs and butter. We ask for an
annual cash subscription. By this means we raise a considerable annual
subscription. With this year's revenue we can count on next year's. It is a
great factor to know how much revenue you have ahead of you. We get
subscriptions now and then from people passing through or who have had
a very good year. We find that keeping the affairs of the hospital before
the public is greatly to our advantage. We have a monthly meeting, we
generally try to give a synopsis of that meeting to the press. We publish
all donations and give publicity in every possible manner. The strongest
factor we have is our Ladies' Auxiliary, which supplies and replaces all
linen. If they have any extra funds they give us different appliances for
the hospital, such as an oxygen tank, bedside tables, etc. This year they
kalsomined two of the wards and put linoleum on the hall. The City gives
a small grant in the way of rebate on water and light—last year it amounted
to between $250.00 and $300.00; this year it is more of course. We are
situated differently perhaps, we have ten acres in a very desirable part of
the City, which reaches from one of the main streets down to the lake Iront.
We have no nurses' home, We have a maternity ward with seven beds, which
I think is really the most paying part of the hospital, because these patients
before entering the hospital, have to arrange for treatment. We have our
charges, $3.00 and $3.50; case room $5.00. We have no taxes to pay, the
land was donated to the hospital."
Dr. H. E. Young, Victoria—
"This has been very interesting discussion. It is dealing with the
question that is becoming more momentous every day to the authorities
and to those who are in charge of our institutions. I had occasion to
discuss this question from a different point of view the other day—in the
Public Health meeting, and I might take up one or two of the points that
I discussed there in regard to the extension of health work which is related,
of course, to the hospitals. In my address I tried to present the Government's point of view.   I said in that as follows:—
"The great advance in medical science necessitated the enlarging of our
hospitals at an increase. In British Columbia the Government has nidFy
about reached the point where they cannot consider a further increase in the
contributions to the hospitals from the general revenue of the country.
British Colurribia has been probably the most generous government of any
in Canada in the treatment of hospitals. For the current year there has
been from our general revenue, consolidated revenue, for hospitals, board
of health, charities, maintenance of physicians in outlying districts and the
insane asylums, $1,400,000.00. In addition to that, the Government, from
intimations made by the Provincial Secretary,'will take over the Sanatorium
at Tranquille, an institution which they have practically financed from the
beginning, have paid $350,000.00 by way of capital expenditure, in addition to $14,000.00 this year; and the sum of $75,000.00 or $80,000.00 on erection of the building for the home for backward children at Essondale. A
few days ago Dr. Robertson, president of the Red Cross Society of Canada,
in speaking intimated that there are two subjects in which the people of
Canada will never listen to economy being practised—the expenditure for
- education and the expenditure for health. Taking that for granted, and the
experience in British Columbia, shows that the people of British Columbia
102 have always believed in that by the way they have sanctioned the expenditure for these departments—British Columbia today is spending $1,400,000.00.
The expenditure in connection with the Sanatoriurn and the new institution
they are building will probably be between four and five million dollars for
education; between six and seven million dollars for education and health,
which is about 45% of the total revenue of the Province. It is not that the
Government is not willing and anxious to support these institutions but we
have to take into consideration the fact that we are a new province; there
are great calls on the Government for developmental work of all sorts and
this Government together with other governments, are practically face to
face with the situation where it means, as Dr. MacEachern said, loss of
efficiency, curtailment of the work or the finding of some radical way in
which these expenditures can be met. In Great Britain the hospitals are
magnificiently endowed, but in spite of all that some of those institutions are
practically throwing up their hands and have said to the government: You
must come in if we are going to run our institutions along the line required.
The Government appropriates within the limits of the funds available in
proportion to the demands of each of its activities. It is up to these institutions to constitute themselves into propaganda to educate the people that
upon them must devolve the maintenance of these institutions.
In the period in which we are now entering we have an unparalleled
opportunity to conserve and develop our human power. The critical need
for public health advancement in Canada was never more obvious than it
is now. The phychology of our people generally seems more favorable than
ever before for a Dominion-wide constructive, business-like programme of
public health work.
As public health work affects all the people it appears logical for it to
be conducted essentially as a governmental business. The establishment and
maintenance of reasonably adequate governmental health agencies properly
co-ordinated to function in a common sense, business-like way in every
community in Canada is so logical, in fact, that its realization eventually
may be expected. That the cost of public health activities be met with funds
obtained from equitable taxation of the people seems right. The voluntary
organization upon entering the field of health work should function with
and through official governmental health agencies and carry out its phase or
phases of work with a special view to permanent augmentation of official
health agencies.
The tendency in this country, the present tendency in our State aided
institutions, is to centralize and whenever there is a deficit the immediate
cry is: Go to the Government. On that point I might say that centralization and bureaucratic authority have proved wanting and it is only by the
employment of public health nurses and the co-operation of voluntar"
organization, by the house-to-house visitations, that the people wilt be
aroused to the fact that the care of themselves and their children is theii-
bounden duty and once that idea gx-ts home then thor^ will b?. a Health
Tax imposed, just exactly as we impose a school tax toslrtji
We must depend upon the voluntary organizations for assistance, bur
do not lose sight of the idea, and the Government is alive to the fact, that
this work will pass, and pass very rapidly, to the taxpayer. The underlying principle that must be emphasized at present is this : We must secure
the co-operation of the people by admitting them to the management of their
own affairs, with the handling of their own finances, always with the idea
predominant that this work must be made self-sustaining, and when the
people have absorbed the idea that it is to be self-sustaining they will adopt
the easiest way of making it so by instructing the Government to impose a
voluntary tax which will be known as a Health Tax."
That is my view, Mr. Chairman, of the situation as it presents itself
in British Columbia."
Mr. R. s. Day, Victoria—
"In speaking of the Government, my reference to what they were doing
was in a very kindly manner. The situation appears to be this: we'cannot
expect to increase the charge upon the consolidated revenue, but if we are
103 going to maintain the usefulness of our institutions, if we are going to
meet the growing demand of the people for hospital facilities, we have got
to attend to the increased efficiency if we are going to accomplish what we
set out to do in these institutions, and it will only be by educating .the people
to the fact that these are their institutions, that they are managing them
just as the schools, that the Government will continue its grants up to the
limit of its ability and that the balance must be made up by local municipal
taxation in the same way our Boards of School Trustees do. The people
will know it is their institution, that the State is furnishing all adequate
means to protect their health. They will go there as a matter of course,
but before you can bring about that you will have to educate the people to
that point, and I would certainly urge upon the delegates here, if my views
are accepted, to take these representations to their own municipal councils
and bring about, if possible, a realization by the people what it will mean
as against the expenditure of a slightly increased taxation. It will be one
hundred times the benefit of what it is going to cost. If the people would
get into their heads the fact that preventive medicine is coming, that people
are going to employ the hospital for preventive medicine. If the children
are going to be looked after it is going to relieve the taxpayer of the
burden of the hundreds of thousands of dollars we are spending for incurables, insane asylums, etc. In our relief work it is a simple business problem,
but in order to bring about such legislation the Government will have to be
assured of a. desire on the part of the people for it. It is not difficult to
make a law but you can only enforce it as the people will let you.
In ragrd to the division of the Province into districts or the-working
out of the scheme, that will be a very simple matter. Once the idea is
gotten home that the state must provide hospitalization either directly from
the consolidated revenue or from the municipal tax, preferably from both,
because neither can keep up if the cost is going to fall upon them singly."
Dr. H. C. Wrinch, Hazelton—
"I was wondering if the point has been discussed yet as to whether under
this government directed method of raising money, free treatment is to be
given by the hospitals up to a certain limit, or whether the hospitals are to
continue to make the charge to those who are sick as at present. It would
be very difficult to raise enough to make the treatment free, even to the
extent of the general ward rate. I would like Dr. Young to give us his
views on that, as to whether we continue to make charges on a moderate
basis to those who are sick, then supplement by tax on the property. The
individual tax should be a tax where the individual is not paying property
tax. I would like to know if the treatment is to be free up to public ward
rate."
Mr. G. R. Binger, Kelowna—
"Have the tax levied so as to make the balance come square with what
it has cost us but still charge the patient."
Dr. H, E. Young, Victoria—
"That is a matter that has got to be worked out. Theoretically, of
course, we should carry out the same principle as in the educational system.
Dr. Wrinch knows that the great mass of people, of taxpayers in the country,
do not get an adequate service of diagnosis, if I can put it that way. A
man with an ordinary income probably has one of his family, or himself, who
requires care that will necessitate on the part of the doctor ordering a lot
of laboratory work, a series probably of X-Ray pictures and half a dozen
other of the expert departments—that would be absolutely free in the hospital, those departments would be a direct charge. It might probably be
worked out upon a minimum charge. Others would come in who would
want something a little better, a private patient would want a private
room—charges can be made in proportion; but there should be a level
charge with just as good first-class service and everything that goes for
the protection of the sick man, given to him for a level charge. I have
always maintained that this is going to be the ultimate solution. People
never will give up their right of selecting their own medical man. The State
must step in and afford facilities for providing proper diagnostic facilities.*
104 Mr. R. S. Day, Victoria—
"I think that we owe Dr. Young a debt of gratitude for* the very clear
and forcible expression of opinion which he has given us this afternoon. I
think it has been clear almost from the start of this convention that something, is 'in the wind' and that some of the work which has been done by and
through this Association during the past two years is beginning to bear
fruit. Personally, I am very glad to find that in everything that Dr. Young
has said today I am in complete accord, and that so far as I can see there
is no jot of difference between what he has said today and the principles
which I advocated in the paper which I read to this Association last year.
There are, undoubtedly, things which the Government and the public will
have to take very careful heed of and give very earnest consideration to in
any scheme of this kind. When Dr. Arthur mooted the question of division
of the country into what he called 'hospital municipalities' it at once occurred to me that there is a scheme that will require, if carried out, very careful consideration, because you will find a great many districts in this Province where you have a large urban population with a surrounding farming
population, and the incidence of taxation upon the urban and upon the
farming population is liely to present some difficulty to our legislature
wheh they come to consider that.
There were one or two points I would like to take up. He thought we
should increase the cost of our ward beds and our operating room charges.
In some of our hospitals in this Province now it may be possible to do this.
So far as the Jubilee Hospital is concerned, for instance, and I fancy it
will be found the same with most other hospitals, I think our charges are
on a minimum as compared with the admirably conducted hospital known
as 'St. Joseph's Hospital.' Only two or three months ago we overhauled
our operating room charges. We found in some cases we were not charging as much for our operating room as the Sisters were charging in St.
Joseph's, and we brought our charge up to the Sisters' hospital. I think we
may take it for granted that the sisters are running that hospital with a
view to at least making it pay its own way. I do think I can safely say
that they are not running that hospital entirely with the view of supplementing any deficiencies in it from the broad liberal charity of their co-
. religionists, and I think as a public hospital we can escape any criticism
on our charges being too low. The higher we make our public ward charge
the greater we are going to make, our bad debts and the more likely we are
to have to call upon our municipality or the Government to come to our
assistance. There is a very large class of people in the community today
who can afford to pay something towards their hospital expenses, and in
my opinion it is far better to get from those people $10.00 a week than to
try to get $15.00 for the same service, and falling down in the attempt.
There is a very large class of people today from whom it is impossible to
collect anything.
Another point Dr. Arthur spoke of: he thought we should place our bad
debts in the hands of solicitors for collection. That is a very serious thing
for any hospital to do, even a public hospital. We have to do it. All
accounts that are not paid by a certain date have got to be put in the hands
of a collector for collection. I deplore the necessity of having to do that
in a public charge. Here is where the trouble comes: if you send out indiscriminate collectors you are going to arouse a bad feeling in the community
toward your hospital. If you want to employ solicitors to collect your
accounts you have to use the greatest discrimination. I do wish we had some
machinery, we have no social service worker as you have in Vancouver.
We must remember in fixing our charge, to put down what we can reasonably expect the people who enter our public wards to pay. I think at present it will be impossible for us to get from them just what is costs us to
provide for them.
Mr. Charles Graham, Cumberland—
"I was very pleased to hear Dr. Young's expression of opinion as to
the Government's position. Along the lines we have been operating our
hospital  in  Cumberland:   it  is  an industrial  town  exclusively;   probably
105 H
ninety per cent, of the people are employed by orie company. I have been
President of the Hospital for over two years. After giving it careful consideration I was forced to the conclusion to make it a community hospital, I
to get the people to contribute to it. The men up there have what is known
as a medical fund, they pay into that fund monthly. Out of the proceeds
of that medical fund they pay the doctor so much per man. They furnish
all medicines required, both for the employees and all members of their
families. They furnish hospital accommodation for men who are injured.
Of course we were always sure of receiving payment for accident cases.
We had a number of bad debts, men and their families who had been in the
Hospital. Owing to the fact thst they had been off work for some considerable time they were unable to pay. I took up the question of extending
the fund to pay for the accident cases so it would cover all cases of
accident or sickness of the employees of the Canadian Colleries. It was a
very simple matter to put into operation once you could convince them. We
accomplished that. For the past year the hospital has been operating
whereby all employees are furnished free hospital treatment and all the
necessary requisites on payment of a lump sum. In any case where a
private room is required, in the opinion of the medical man, it is furnished.
If he wishes it himself he pays the difference. We do not furnish any
medicines; those are furnished by the medical fund. There is no charge
for the operating room. The medical fund supplies fifty per cent, of the
gauze and bandages used, the hospital supplies the other fifty per cent
Maternity cases are extra, but they have a rebate of seventy-five cents a
day off the room which they occupy. We have found this works out very
successfully in the Cumberland Hospital. For the last two years we have
had no overdrafts, and it looks to me that that method which we have
introduced is a step towards the solution of the hospital problem. I felt
fully convinced before I took the matter up. I venture to say right now
that we would have a more strenuous time convincing those people it should
not be carried on. I am sure there is no question now of going back to
the old system of private treatment. That, probably, as Mr. Day said,
would be hard to differentiate. The only way would be by a universal fax,
somewhat on the lines of poll tax. To give you an idea of the cost of that:
we have between fourteen and fifteen hundred men, probably about seven
to seven hundred and fifty men with families—a population of three thousand. It is costing those people $700.00 a month, less than fifty cents per
man employed. I think that is a fairly cheap hospital insurance, and as I
said, they are beginning to realize it up there. It is the cheapest thing they
have ever encountered. As Dr. Young said, this hospital proposition is a
community proposition, it is up to them to support the hospital in their own
community. Once you can show them the benefits derived from that form
of hospital support I do not think there will be any difficulty whatever in
putting a proposition of that kind into operation. We have had no trouble
and I do not think anybody will.
Dr. H. E. Young, Victoria—
We are very glad, sir, that you have for us an incidence of the application of this to the people. What I was advising the Association was to get
home to the people this idea, and once this is accomplished there will be no
difficulty. I should have mentioned a concrete example I the Provincial
Board of Health has been working along public health lines and the providing of public health nurses. We began in Saanich a little over two years
ago; today we have four. We have a house, we hold clinics, there is a
small operating room. We are relieving the Provincial Royal Jubilee
Hospital. We have given free work for the examination of school children,
follow-up work which is so essential after the report of the doctor. Last
fall they passed a bylaw setting aside $25,000.00 to build a health centre.
Last week at the meeting of the Municipal Council they went there prepared to take over all this work as municipal work. We are asking them
to defer for the balance of this year as we are using that centre as a training centre in our public health work. Next year the Municipality of
Saanich takes over that work and supports it on the health statutes.   That
106 shows how quickly the people realize the benefits of such work.   We have
the assistance of the Red Cross.
Mr. Charles Graham, Cumberland—
As I said, this medical fund controls all the medical affairs and hospital affairs of those employed by the Canadian Colleries. It costs those
men $1.50 per month to have medical, surgical and hospital attention, for
themselves and their families. It furnishes them with specialists, it pays
their transportation here, specialist's fees, if necessary, furnishes everything
they require. You can readily see once the people get to realize it, how
cheaply that thing can be done when done as a community affair.
Dr. R. W. Large, Port Simpson—
" What representation have you on your hospital board of the people
administered to, and what does your hospital get a day from those patients ?
Mr. Charles Graham, Cumberland—
You mean the medical fund? They haven't got any. The hospital
board is elected at the annual meeting and they do not claim any particular
member of that board, although nine out of ten members are employees of
the Canadian Collieries. One member of the medical board is also a member of the hospital board. There are two committees, the Medical Committee and Hospital Board. The Hospital Board is elected at a meeting of
all subscribers to the hospital.
Dr. H. E. Young, Victoria—
What rate does the Hospital Board charge the medical fund?
Mr. Charles Graham, Cumberland—
$700.00 a month.
Dr. R. W, Large, Port Simpson—
'   What does it work out per patient per day?
Mr. Charles Graham, Cumberland—
It furnishes about $2.00. Our total cost last year was $2.68. Our
Government grant met the deficit. Then we have private fees and maternity
cases. In the case of special nurses—where a special nurse is required the
medical fund pays one-half and the patient pays the other half.
Mr. R. B. Leders, Vancouver—
How do you arrive at your charges?
Mr. Charles Graham, Cumberland—
We have no charges. We figure up cost of operation and employees
and their families .who are attending the hospital.
Dr. R. W. Large, Port Simpson—
Did you find any increase in your attendance when you made that
arrangement? Who determines what is the hospital cost and have you any
trouble with people wanting to get in the Hospital?
Mr. Charles Graham, Cumberland-
It depends entirely on the doctors.   They do not send us in any cases
unless they are hospital cases.
Dr. R. W. Large, Port Simpson—
■ When the doctors have to treat the patients in any case, either at
home or in the hospital, wouldn't there be a little tendency to have the
patients in the hospital ?
Mr. Charles Graham, Cumberland—
There does not seem to have been any so far. We have had cases
there that were hospital cases, but if they had bad to pay they would not
have gone to the hospital.
Dr. H. C. Wrinch, Haaelton—
About how much per month do you get in addition to the $700.00?
You have a certain maternitv rate and rate for extras?   I did not get quite
107 clearly whether that $2.00 per day covers all your attendance or all the
attendance covered by the $700.00 a month.
Mr. Charles Graham, Cumberland—
Yes, this $700.00 covers all our attendance.
Dr. H. C. Wrinch, Hazelton—
How much in addition to that $700.00 do you get?
Mr. Charles Graham, Cumberland—
We probably run anywhere from $200.00 to $300.00. We have no
revenue except from the maternity cases, which we really call private
patients.
Dr. R. W. Large, Port Simpson—
What do you charge a maternity patient?
Mr. Charles Graham, Cumberland—
That depends on the room. We have private rooms varying in rates
from $2.75 to $3,50 per day.
Dr. R. W. Large, Port Simpson—
Do you take any in public wards?
Mr. Charles Graham, Cumberland—
We have no female public wards.   Semi-private, 3 beds: $2.75.
Miss J. Forshaw, R.N., Saanich—
Does this include the physician's charges, or does your Board set the
physician's fee?
Mr. Charles Graham, Cumberland—
For every member who pays into this medical fund the doctor receives
65 cents out of the $1.50. The doctor furnishes no medicine. He does
operations of all kinds. He does make a charge, I believe, for attendance on
maternity cases.
Dr. R. W. Large, Port Simpson—
Have you reports on the Cumberland Hospital available for the different hospitals represented here?
Mr. Charles Graham, Cumberland—
I am afraid not.
Mrs. L. H. Hardie, Duncan—
We, have an arrangement, with the two local camps. We get $1.50
from each man. For that we provide all medical attention, medicines and
everything.
Mr. Charles Graham, Cumberland—
That system is in vogue in many mining camps. In most cases the
doctor simply takes a contract. He says: 'for so much per man I will
furnish all that is required.'
Mrs. L. H. Hardie, Duncan—
Ours is a direct arrangement with the Hospital.
' Dr. R. W. Large, Port Simpson—
How about special diseases that most of us do not take in?
Mr. Charles Graham, Cumberland—
Venereal diseases and alcoholism—those are exempted. A man paying
into/ the fund is not entitled to, treatment for Venereal diseases or
alcoholism.
Mr. R. A. Bethune, Kamloops—
I do not think that would work in a public hospital in a city.
Mr. Charles Graham, Cumberland—
I do not know any place where this arrangement has ever been tried
out. We had thought to cover those who were not in the employment of
the Canadian Colleries but did not.
108 Mrs. L. H. Hardie, Duncan—
• Don't you think all working for one company has a great deal to do
with that? They are on the payroll and you are sure of that amount. It
is better to have a community behind you than a company.
Mr. Charles Graham, Cumberland—
They realize that for one cent per day they can get all the benefits
derived from the Compensation Board. They know that only covers cases
of accident: it does not cover sickness, as well as that of their wives and
families.   They prefer the plan and operation of the Medical Aid Fund.
Dr. R. W. Large, Port Simpson—
All the money is handled by the committee, not the company?
Mr. Charles Graham, Cumberland—
At the end of each month the cheque is handed to the secretary of
the Board of Directors of the Medical Fund.
Mr. R. A. Bethune, Kamloops—
Similar to the system of the C. P. R. Medical Fund—deduct so much
a day and turn it over to the Medical Fund.
Mr. G. R. Binger, Kelowna—
I would like to know how they treat it with regard to the Compensation Board. Do they allow operating room pay to hospitals? We have
been trying to get it for two years but cannot.
Dr. R. W. Large, Port Simpson—
I think that is something we ought to take up. Sometime ago there
was a letter came from the College of Physicians and Surgeons objecting to
nurses being employed to give anaesthetics where doctors should be employed. I took that point up with them and they said it did not apply to
smaller hospitals. I drew their attention to the fact that I had been to
different clinics where they were using graduate nurses as anaesthetists.
In smaller hospitals we get nothing for our anaesthetics and operating room
from the Compensation Board. We have the responsibility resting on the
doctor to see that the nurse is giving that anaesthetic properly; it costs us
just as much for anaesthetics and operating room appliances. I think as
smaller hospitals we are entitled to anaesthetic charges and operating room
charges.
Mr. G. R. Binger, Kelowna—
We have taken the matter up with the Workmen's Compensation Board
on various occasions. This Association has also taken it up with them. I
would like to know if there isn't something we could do. We lost considerable last year, men coming in and not paying.
Mr. R. S. Day, Victoria—
I think it is a shame the way the hospitals are being exploited by the
Workmen's Compensation Board. I took it up with the Government and
they said the Workmen's Compensation Board could do what they liked.
Dr. G. A. B. Hall, Vancouver—
So far as the Workmen's Compensation Board is concerned, there is
evidently a slight misunderstanding. The Board pays for patients who are
in the hospital, for operating room if they are in under a week, anaesthetics
if given by a doctor, even given by a nurse will be paid if the hospital
sends in the bill.
The funds handled by the Workmen's Compensation Board is the men's
own money. They could very well, if they wished, say: we will pay the
men whatever we consider is a reasonable sum for injuries that have been
caused by accident while in the service of his employer, and that money can
be paid to the man. The man could go there and get his treatment at the
_ rate the hospital charged, pay his account and go out and receive his compensation from the Board—whatever they considered was a reasonable
amount; that could be done.   If that was done, where would the hospitals be,
109 f™
would they be anything like as well off as they are today? The Board is
simply paying the hospital because they feel it is to the advantage of the
hospital.
Dr. R. W. Large, Port Simpson—
You know'that the Provincial Government in arranging grants for hospitals, fixed for the first fifty beds a higher rate than they do later on. That
means for the daily treatment the smaller hospital gets more through the
year than the larger hospital. That is to assist the smaller hospital. The
Workmen's Compensation Board works exactly opposite: the larger hospital treats more compensation cases, the larger hospital has the anaesthetics
paid for; in the smaller hospital where the trained nurse gives the' anaesthetic we furnish the ether, the preparation of the operating room, and the
doctor assumes the responsibility for the care of that patient while under
the anaesthetic. The Workmen's Compensation Board does not protect that
doctor.
Dr. G. A. B. Hall, Vancouver—
Why doesn't the doctor send in his bill direct?
Dr. R. W. Large, Port Simpson—
The dressings come out of the hospital,
legitimate that should be paid.
Mr. G. R. Binger, Kelowna—
I really do not think the arrangement is
could be done in order to have our operating
Dr.
It is a hospital charge and
fair at all.   I wish something
room charges paid for.
for  the  hospital  be
let the  men pay the
G. A. B. Hall, Vancouver-
Would  this   conference  request  that  the  money
paid to the men  in  place of the hospital  and then
hospital?
Moved by Dr. R. W. Large, Seconded by Mr. E. S. Withers,
THAT in the smaller hospitals where the graduate nurse gives the
anaesthetic, this Hospital Association request the Workmen's Compensation Board to pay the charges of the anaesthetic.
Dr.
G. A. B. Hall, Vancouver—
We often find where the difficulty-
arises it is from lack of information^
on file to show that the case warranted a
It is simply the dressings"
put before the Compensa-
proper information has not been
special nurse.
Mr. G. R. Binger, Kelowna—
We have never been refused a special nurse,
and operating room expenses, and that has been
tion Board by himself.
Dr. G. A. B. Hall, Vancouver—   j
The view the Board has taken so far, it has been mooted by the men:
why should they pay $2.00 a day when they can go to the Jubilee for $1.00.
Mr. G. R. Binger, Kelowna—
I think our smaller hospitals ought to be altogether separate from cfty I
hospitals; our overhead expenses are greater.
Dr. G. A. B. Hall, Vancouver—
When I was in Victoria I saw the Health Officer there. The Board
made a request to the Council for an additional sum of money. They
thought there were some cases charged that were not paid for, and when
they presented their list it was forwarded to me. I went over it and found
cases posted as city cases that really came from the outside. In those cases
the average days' stay in the hospital was thirty-three days. The average
days' stay of the city indigents was just a fraction less than half that time-
just showing what affect this has on days' stay in hospitals.
Mr. E. S. Withers, New Westminster—
With regard to the man who goes to the hospital for three monthS,-
and leaves without paying his account: I was wondering if there was not
some possible means of giving us warning that that man is not responsible.
110 Dr. G. A. B. Hall, Vancouver—
That does give us as much difficulty as anything, and so far we have
not been able to find any solution to the question. We would be very
pleased to have suggestions. The Act only permits the Board to pay for
cases that come under the Act, real bona fide cases under the" Act. It
frequently happens that a man is injured and not reported for months
after that he is a compensation case. His claim cannot be decided until
reports are in and it goes before the Board.
Mr. E. S. Withers, New Westminster—
On the first of every month you are getting reports of patients who
are supposed to come under the Act. Could not that be checked up and
ascertained?
Dr. G. A. B. Hall, Vancouver—
The only way that could be managed would be if they put the claim
number on all cases.
Mr. E. S. Withers, New Westminster—
If there is no claim number, couldn't you come back to the hospital
and say: we do not know this man.   I think it would be worth it.
Dr. G. A. B. Hall, Vancouver-
Well, so far they have not been able to solve the question.   The Board
cannot pay for a case that does not come within the Act.
Mr. E. S. Withers, New Westminster-
Supposing we sent you in a report, how would it be if we sent you
that report in  duplicate?    You could have  one report  checked over  and
return to us with notes.
Dr. G. A. B. Hall, Vancouver—
I do not know really if that would help.    There would be a lot of
names come in; perhaps a report would not be in from a doctor or the man
has not put in a claim.
Meeting adjourned.
EVENING SESSION
June 25th, 1920, 8:00 p.m.
PART I.
Meeting called to order by Dr. M. T. MacEachern. He being the first
speaker he requested Mr. R. S. Day to take the chair.
Mr. R. S Day, Victoria—
"The first item on the programme is Dr. M. T. MacEacherris report
of the Western Canada Conference; I presume it is a medical conference
on Standardization."
Dr. M. T. MacEachern, Vancouver—
You may wonder why this conference was called. It was called
because there was a desire on the part of many in the four Western Provinces to come together. I had several requests from the other provinces
to have this so I promised them when I was on my way East last fall that
if a sufficient number of people requested it I would call the meeting. They
knew this wave of hospital standardization and greater efficiency was coming over the continent very rapidly and they felt they were not making real
progress. They felt they were not getting very much help from their own
country and they wanted to get together. In the various cities I met the
medical profession and particularly the Fellows of the American College
of Surgeons. In Winnipeg we had a dinner. In Calgary we had a meeting, and in New York we met there and had a conference, so the matter
had been talked of a great deal last October. However, after several
requests I sent around a notice to the various members of the profession
and got back requests from a large number, and a large number of requests
111 came in from the hospitals that they would like to gather together. Of
course distance was something to be considered; we had no finances to pay
the fares for delegates and it was all a matter of our own expense, so
finally we decided to see what would happen. The 26th and 27th of April
was decided on as the date. This was made particularly for the convenience of Dr. M. M. Seymour, Commissioner of Public Health of Saskatchewan, and the question of local arrangements was taken care of by the
Mayor of Calgary and City Council. I might say that they not only found
us a convention hall in the Palliser Hotel but all the expenses of this hall
were paid for and motor cars supplied, and everything to give us an
enjoyable time. We had no time for anything but work. We started in at
ten o'clock Monday and finished at four Tuesday. The meeting was called
primarily by British Columbia, inasmuch as we took the lead at their desire.
They felt that British Columbia had gone through the hospital organization
mill for two or three years and they wanted our assistance. The objects of
the meeting were,—Standardization and Organization of Hospital Associations, but like every other meeting, we drifted into the nursing and financial
problems.
From the Province of British Columbia Dr. R. E. McKechnie representing the American College of Surgeons, and myself, were the only ones who
went to Calgary. Four others were to go but something happened in connection with the Canadian Medical meeting which prevented them from
attending. However, there was a large attendance from Alberta and
Saskatchewan and a representative delegate from Manitoba. I was amazed
and astonished at the tremendous interest people connected with hospitals
put into this meeting. I did not know any meeting outside of our own
where everything was so intensely interesting. To sit there and get the
views of our sister provinces, to hear their problems, you would think you
were at home with your own problems. Perhaps the discussions were a
little keener than they were here, inasmuch as at times they got very interesting, especially on the nursing question. We had laymen, members of
Boards, members of the American College of Surgeons, members of the
nursing profession, members of the medical profession in all branches, and
hospital superintendents. The late Hon. A. G. MacKay was to have been
with us but he died the day we arrived.
The first forenoon we devoted to hospital organization in the various
provinces. We find Saskatchewan and Alberta have organized on practically the same basis as ourselves. Manitoba is making arrangements. Dr.
M. M. Seymour of Regina, gave his address that you see in the report you
have, on Saskatchewan. He gave it in detail and I have had it printed in
detail for you. The afternoon meeting was announced to take up hospital
standardization, and we took particular care to have represented there
everybody that would be in favor and opposed to it. We found no one
opposed to it. Laymen wanted to know everything about it and we were
glad to discuss it with them. The question of fee-splitting aroused the
keenest discussion. Hospital standardization calls for several things, which
are very clearly set forth here. One thing it demands is that fee-splitting
be debarred from hospitals. Fortunately in Canada fee-splitting is not
carried on to any great extent. By fee-splitting we mean that when a
patient is operated on, he pays his bill but does not know why he pays it.
Two men may operate—an inferior operator may bring in a successful
operator, and he collects the fee and divides it with the other doctor. As
an instance of this: a case of appendicitis where the surgeon operating-
charged $75.00, but the one who collected the fee charged the patient
$400.00. That