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''K'iiS^'t%skk- Stillmim Barnard££%*M  REPORT OF PROCEEDINGS
OF THE
Second Annual Convention
OF THE
Hospitals of British Columbia
HELD AT
VICTORIA, B. C.
IN THE
EMPRESS HOTEL,
ON
July 8th, 9th and 10th, 1919
Banrmutrr
G. A. ROEDDE. LTD., PRINTERS
1919  PREAMBLE.
The British Columbia Hospital Association was
formed following the Convention held in Vancouver
June 26th, 27th and 28th, 1918.
The objects of the B. C. Hospital Association
are:-—
(a) To serve as a means of intercommunication
and co-operation between the hospitals in British Columbia;
(b) To establish, maintain and improve standards
of hospital work;
(c) To promote the efficiency of all hospitals in the
province \.
(d) To stimulate intensive and extensive hospital
development;
(e) To make all hospitals of more community service.    PROGRAMME
TUESDAY, JULY 8th, 1919.
Opening Session—10.00 a.m. to 12.30 p.m.
Prayer.
Opening Address—By His Honour The Lieutenant-Governor of British
Columbia, Sir Frank Stillman Barnard.
Address of T,r<>lcome—By the Provincial Secretary of British Columbia,
Hon. J. D. McLean.
Address of Welcome—By His Worship Mayor Porter, Victoria, B. C.
Address of Welcome—By Mr. R. S. Day, President of the Board of
Directors of the Provincial Royal Jubilee Hospital, Victoria, B. C.
Address—"The Ministry of Healing"—By Father O'Boyle, Vancouver,
B. C, Director of Catholic Hospitals of British Columbia.
Address—"The Hospital of Today"—By Dr. M. T. MacEachern, President of The British Columbia Hospital Association.
Business—The appointment of  Committees  for Convention business.
Nursing Session—2.00 p.m. to 4.00 p.m.
Paper—Subject, "The Standardization of Training Schools in British
Columbia"—By Miss H. Randal, R.N., Editor of The Canadian Nurse.
Discussion—Opened by Miss J. F. Mackenzie, R.N., Superintendent of
Nurses, Provincial Royal Jubilee Hospital, Victoria, B. C, and President of
The British Columbia Graduate Nurses' Association.
Paper—Subject, "Post Graduate Work"—By Miss K. Stott, R.N., Assistant Superintendent, Royal Columbian Hospital, New Westminster, B. C.
Discussion—Opened by Mrs. M. E. Johnson, R.N., Superintendent of
the Bute Street Hospital, Vancouver, B. C.
Paper—Subject, "Rural Public Health Nursing"—By Miss J. Forshaw,
R.N., Victorian Order of Nurses, Saanich, B.  C.
Discussion—Opened by Miss I. M. Cole, R.N., Superintendent of Nurses,
Victorian Order, Vancouver. B. C.
4.00 p.m. to 6.00 p.m.
Round Table Conference—Conducted by Mr. Charles Graham, President
Cumberland Hospital Board, Cumberland, B. C.
Public Health Session—8.00 p.m. to 11.00 p.m.
Address—"A Public Health Service"—By Dr. R. H. Mullin. B.A.,
Director of Laboratories, Vancouver General Hospital, Vancouver, B. C.
Discussion—Opened by Dr. H. E. Young, Secretary Provincial Board
of Health, Victoria, B. C.
Address—"Infectious Hospitals for British Columbia"—By Dr. F. T.
Underhill, Medical Health Officer, City of Vancouver, B. C.
Discussion—Opened by Dr. A. G. Price, Medical Health Officer, City
of Victoria, B. C, and Dr. C. McEwen, Medical Health Officer, City of
New Westminster, B. C.
WEDNESDAY, JULY 9th, 1919.
Case Records Session—10.00 a.m. to  12.00 noon.
Paper—Subject, "Case Records in British Columbia Hospitals"—By Dr.
T. R. Ponton, Director of Medical Records, Vancouver General Hospital,
Vancouver, B. C.
Discussion—Opened by Dr. Rogers, Medical Superintendent Provincial
Royal Jubilee Hospital, Victoria, B. C., and Dr. W. E. Wilks, Nanaimo, B.C.
12.00 Noon to 1.00 p.m.
Round Table Conference—Conducted by Mr. Charles Graham, President
Cumberland Hospital Board, Cumberland, B.  C.
5 President of the Board of
Victoria, B. C, and Mr. M.
Nicola Valley General Hos-
-By Dr.
1.30 p.m. to 6.00 pjn.
Entertainment—Delegates and their friends are invited to a motor ride
by the Victoria Rotary Club, leaving Empress Hotel at 1.30 p.m. and returning to the Reception Hall of the Nurses' Home, Provincial Royal Jubilee
Hospital, Victoria, at 4.00 p.m. for afternoon tea and entertainment.
Hospital Financing Session—8.00 p.m. to 11.00 pjn.
Address—"A New Basis of Financing Hospitals of British Columbia"
—By Mr. J. J. Banfield, Member of the Board of Directors, Vancouver
General Hospital, Vancouver, B. C.
Discussion—Opened by Mr. R. S. Day,
Directors, Provincial Royal Jubilee Hospital,
L. Grimmett, President Board of Directors,
pital, Merritt, B. C.
~ Address—"Maternity Hospitals in Relation to Public Health"
A. G. Price, Medical Health Officer, City of Victoria, B. C.
Discussion.
THURSDAY, JULY 10th, 1919.
General Session—10.00 a.m. to 1.00 p.m.
Paper—Subject, "Results of Two Years' Examination of Men Seeking
Employment"—By Dr. A. Henderson,  St. Luke's Hospital, Powell  River,
B. C.
Discussion.
Paper—Subject, "The Relation of the Woman's Auxiliary to the Hospital"—By Mrs. E. Hasell, Vice-President of the Woman's Auxiliary to
the Provincial Royal Jubilee Hospital, Victoria, B. C.
Discussion—Opened by Mrs. Charles Rhodes, President Woman's Auxiliary, Provincial Royal Jubilee Hospital, Victoria, B.  C.
Paper—Subject, "Hospitals and Tuberculosis"—By Dr. C. H. Vrooman,
Medical Director, Rotary Clinic for Chest Diseases, Vancouver, B. C.
Discussion.
12.00 Noon to 1.00 pjn.
Round Table Conference—Conducted by Mr. Charles Graham, President
Cumberland Hospital Board,  Cumberland, B.  C.
Business Session—2.00 pjn. to 3.00 p.m.
Reading Minutes.
Correspondence.
Report of Treasurer.
Report of Committee on Hospital Accounting.
New Business—
Reports of Convention Committees:
Committee on Constitution and By-Laws.
Committee on Development.
Committee on Time and Place of Next Meeting.
Committee on Officers for ensuing year.
Other committees.
3.00 p.m. to 4.30 p.m.
Round Table Conference—Conducted by Mr. Charles Graham, President
Cumberland Hospital Board, Cumberland, B. C.
Entertainment—4.30 p.m. to 6.00 pan.
Delegates and their friends are cordially invited by the Sisters of St
Joseph to visit their Hospital.
8.00 pjn. to 11.00 pjn.
Delegates and their friends are cordially invited by Miss Jessie F. Mackenzie, R.N., Superintendent of Nurses of the Provincial Royal Jubilee Hospital, Victoria, and the Board of Directors of the Provincial Royal Jubilee
Hospital, to attend the Graduation Exercises of the Training School for
Nurses, to be held in the ball-room of the Empress Hotel, and dance following.
Note.—Additional Round Table Conferences will be held if time permits..
6   REPORT
Tuesday, July 8th, 1919.
The Delegates and Visitors to the B. C. Hospital Convention assembled in the ballroom of the Empress Hotel, Victoria, at lO a.m.
Tuesday, July 8th, 1919.
OPENING SESSION
Dr.  M. T.  MacEachern,  President,  in the chair.
President—The  Convention will now  come to order and I will  ask
Rev. H. T. Archbold to open our meeting with prayer.
Prayer by Rev. Mr. Archbold.
PRESIDENT—
As announced, this Convention is being held under the patronage of
His Honor the Lieutenant-Governor of British Columbia, who has consented to give us a few opening remarks. I will now call on His Honor
the Lieutenant-Governor of British Columbia, Sir Frank Stillman Barnard.
OPENING ADDRESS
By   His   Honor   the   Lieutenant-Governor   of   British   Columbia,
Sir   Frank   Stillman  Barnard.
Mr. President, Ladies and Gentlemen:
It gives me very great pleasure to be present here today at the opening session of the Second Annual Convention of the Hospitals of British
Columbia, particularly as it affords me an opportunity of congratulating
all those upon the spirit that they have shown in entering upon this very
important work. From the recently published Report of the First Annual
Convention which was held in Vancouver last year, it is apparent that
greater interest has been taken by the members of the Medical Profession
and by laymen connected with Hospitals, in promoting the objects for
which this Association were formed. The thanks of the people of British
Columbia is due to all those who so earnestly devoted their time to perfecting an organization intended to be of a most useful character and
which will be of the greatest assistance to all those engaged throughout
the Province in improving the standard of our Hospitals.
I therefore beg to extend to the delegates here a welcome to the
Capital, and I trust that they may enjoy their visit and that their delibera-
ions for which they are present will result in further promoting the cause
which brings them here together.
PRESIDENT—
I am sure that we all most sincerely appreciate the privilege conferred on our Association today in having His Honor the Lieutenant-
Governor of British Columbia with us, realizing as we do the many
demands on his time in his important office. We are all pleased to have
with us the Hon. J. D. MacLean, Provincial Secretary, who will give
us an Address of Welcome.
ADDRESS  OF  WELCOME
By the Provincial Secretary of British Columbia, Hon. J.  D.  MacLean.
Mr. President, Your Honor, Ladies and Gentlemen:
I assure you, indeed, that it affords me a very great deal of pleasure
to be present here with you this morning. It affords me also a very
great deal of pleasure to give an official welcome to the Capital City of
7 the Province of British Columbia. I have not only much pleasure in
welcoming our own people—the people from our own Province, but it is
a very great honor and pleasure, indeed, to welcome those of you who
are present from beyond the confines of British Columbia. It is, indeed, a
very high compliment to the Hospital Association to have delegates coming here from beyond the confines of our own small Province. The attendance here this morning, for a meeting of the Hospital Association,
is a large attendance; it is a representative attendance, and it augurs well
for the future of the hospital work in this Province when we find men
and women sacrificing their time and their money to attend a Convention of hospital workers.
Last year at your Convention you were good enough to appoint or
select me as the Honorary President of this Association. On this, the
first public occasion of which I have had the opportunity to extend my
thanks, I now tender you publicly my appreciation for the honor that
you did me on that occasion. Naturally I do not regard this as a personal credit, but I think it augurs well when you find that the Executive
of the Hospital Association gives evidence by selecting a member of the
Government as their Honorary President. They do give evidence that
they intend to co-operate, and they are intimating that they expect the
co-operation of the Provincial Government in all their undertakings for
the betterment of hospital conditions in the Province. I think that is as it
should be. There should be the closest co-operation between hospital
corporations and the public servants of the Province  generally.
Now on looking over the agenda for this Convention we find that you
have a long and interesting programme, and I think that I can predict
for you that your visit here will prove of the utmost benefit to hospital
organizations in this Province. You are here to discuss hospital service;
you are here to try and improve the hospital service of the Province of
British Columbia, and I feel that no more important work could occupy
your attention than the improving of the hospitals of the Province, the
institutions that are placed there for the care of the sick—no more im-
porant work, and it reflects credit on the patriotism of the men and
women in this Province to come to the city of Victoria and spend two
or three days discussing problems which will lead to the benefit of our
hospitals in this Province. The old idea of the hospital was that it was
a place in which sick people were treated and were cured. That was the
old idea. Now it seems to me that at the present time that idea has developed; has become enlarged—a hospital, to my mind, should not only
be a place where people who are sick are restored to health, but it should
be a centre from which all health information should radiate; it should
be a health centre for the community in the same way that a University
or a Collegiate Institute or a High School is the educational centre for
the whole community. I think a hospital should be a centre which should
radiate regarding matters of a health nature. That being so, every interest in the community should be centred in our hospital welfare. It
should be the endeavor, as it is the endeavor of all Hospital Associations,
to interest not merely a few, but.to interest the whole community in the
welfare of the hospitals, because the hospital is the one institution above
all others that from time to time ministers to the welfare and to the benefit
of the people in the community; consequently you need have no hesitation
in endeavoring to enlist the support of all public bodies, municipalities
and provincial governments as well as private individuals who show their
practical sympathy. Insofar as our hospital work is concerned, we in the
Province of British Columbia practically since the inception of the Province, have dealt very generously with our hospitals. During the past year
the Provincial Government has contributed a sum in excess of one-half
million dollars to the general hospitals in this Province. It has contributed a larger sum than that to the Mental Hospitals in this Province,
so that taking both classes of hospitals, the Provincial Government has
expended over one million dollars during the past year in the support of
hospitals in this Province, and when you consider that a million dollars is
one-ninth of our revenue—in every year the hospitals of this Province
have absorbed one-ninth of the revenue—I think you will agree with me
8 that as a Province we are doing very well financially. I venture to say
that there is not another governmental community in the British Empire
that is contributing to the same financial extent that the Province of
British Columbia is doing at the present time, and has done for a number of years.
Now we have in this Province seveflty-one public hospitals, with a
population, I venture to say, in the neighborhood of four hundred thousand
so that you see from the point of view of numbers, we are very well
served insofar as each hospital is concerned. Though there are seventy-
one hospitals with a population of about four hundred thousand people,
the question is: are they fulfilling the whole of the obligation to the people of the Province insofar as hospital service is concerned? In some of
our larger centres we have probably some of the best hospitals on the
Continent of America. In some of the large centres in this Province we
have some hospitals that are second to none. Some of our smaller hospitals in the Province—I speak from experience—are doing excellent work.
The work that is being done in some of the small hospitals in outlying
districts in this Province would reflect credit on first class organizations.
But all of the small hospitals in this Province are probably not doing as
good work as they could do under different circumstances. Now it is to
improve the work of these small hospitals that we are gathered together
this morning, and those who are representing outlying districts will profit
immensely by this gathering.
Now, in order to have a successful hospital, there are many features
to be considered. There is first your Staff, your Staff of Medical men,
there are your Nurses, there are your Buildings and there is your Administration and all the other features which enter into the life of the
ordinary hospital. Now, of all these features it appears to me that the lest
important at any rate is not your staff of medical men, because, unless you
have highly trained, intelligent, well-equipped, sympathetic, medical men
on the visiting staff of your hospital your hospital is bound to fail. You
can have everything else, but that is one of the things that is absolutely
necessary. In the past in some parts of the world, as we all know, young
foolhardy medical men have undertaken to do surgical work which they
never should have undertaken. It has not been fair to the patient, it has
not been fair to the community, it has not been fair to the hospital, and
it seems to me that in the years to come that all our hospitals must be
so organized that that kind of thing will not be possible. No one should
undertake to do the major work, the great surgical operations, unless
they have had special training in that work, and it seems to me that
this action and the development that has come in many places, must come
in all places before the hospital will become the factor in the community
it is intended to become.
Then there are other features in your hospital, one or two of which I
intend to refer to very briefly. One of them is the question of the accounting of your hospital, the accounting system in your hospital life.
I have given some attention to that, and as the head of the Department of
the Government that has something to do with hospitals, I have been seeking information and getting advice from the various hospitals with reference to their system of keeping their accounts, and after we have secured
that information and after we have laid before the various hospital boards
what we think would be a good system, and after we' have received the
criticism of the various hospitals regarding that proposed system, and
when we have got a system of accounting that will appeal to the ordinary
hospital, then we will endeavor to get that one system adopted throughout
the whole Province, so that the small hospitals will be able to know
whether or not they are making a success financially. It is no more
reasonable to expect a hospital to conduct its affairs without keeping a
set of books and keeping them properly, than it is for a man who is engaged in business, because after all a hospital must have a business
management, and in order that it may have a business management it is
necessary that a system of bookkeeping should be, primarily, what every
person can understand. Then another matter we have in mind, so far as the Government is
concerned, is a trained Medical man who will visit the various hospitals,
not in the spirit of criticism to find fault, but will visit the hospitals in
the spirit of co-operation, so that if there is anythng to be found in the
hospital administration which does not appeal to him as being conducive
to the welfare of the hospital, he will, in the kindliest way possible point
out and give ideas to those in charge of hospitals, with a view to assisting
them rather than with the idea of promoting criticism.  •
Now with these few remarks I will not take up your time any longer.
I hope that you will have, as I know you will, a pleasant and profitable
meeting.
PRESIDENT—
I am sure this address will stimulate us to greater enthusiasm in our
Convention. We will now have another address of welcome from His
Worship,  Mayor  Porter,  of Victoria.
ADDRESS OF WELCOME
By His Worship, Mayor Porter,  Victoria, B.  C.
Mr. President, Your Honor, Ladies and Gentlemen:
It also affords me a great deal of pleasure to welcome the delegates
of the B. C. Hospital Association here to our city. I quite agree with
the previous speaker, that there are no matters of greater importance
than matters pertaining to the welfare of hospitals. Sometime ago I had
the honor of serving on one of the local hospital boards, and I quite appreciate to some small extent the responsibilities connected with that
work.
Ordinarily it would be my duty today, Mr. President, to tell our
visitors here of the beauties of our city, as a desirable place to come and
live in, but as you have explained, you only have three days to devote to
this important work that you are here to discuss, I feel that it would not
be possible for me to do so; our city possesses so many beauties that it
would take up the whole three days of your time and you would have
no time to devote to the work that you came here to attend to. Therefore
I will conclude by saying again that we have very great pleasure in having you here with us. If some of you, which I am sure you will, decide
to remain with us now we will appreciate it very much. Those of you
that will find it impossible to stay now, I hope to see back in Victoria
in the very near future. I extend to you the welcome of our citizens.
PRESIDENT—
I do not think his worship need tell us very much of the beauties of
Victoria. We all realize what a beautiful place it is, and I feel sure we
will all enjoy our sojourn here. We will now have an address of welcome from Mr. R. S. Day, President of the Board of Directors, Provincial
Royal Jubilee Hospital, Victoria.
ADDRESS   OF   WELCOME
By Mr. R. S. Day, President of the Board of Directors of the Provincial
Royal Jubilee Hospital, Victoria, B. C.
Mr. President, Your Honor, Ladies and Gentlemen:
You have heard from His Honor the Lieutenant-Governor a welcome
that comes from the Executive head of the Province, but to my mind it
is more a welcome from a representative of the British Empire of which
we are all proud to belong. We have heard from Dr. MacLean a more
typical provincial welcome. We have heard from Mayor Porter a real
Victoria welcome—a municipal welcome. It only remains for me to give a
real hearty welcome home, for I represent the Hospitals of Victoria. I
am not here simply because Dr. MacEachern put my name down. When
he put my name down on this programme he told me that I had to do
this work. I felt it would be a piece of impertinence on my part to
speak for the hospitals without having the authority, but I am happy
to say that I have that authority, and therefore, on behalf of the Provincial Royal Jubilee Hospital and St. Joseph's Hospital, I am here today
to give you this welcome and to extend to you on their behalf a very
hearty welcome to Victoria and to- our hospitals.    You will  see on the
10 programme that arrangements have been made for you to visit these hospitals. I hope that we shall have a large representation of the delegates
there in order that they may receive that personal welcome which our
hospitals are ready and willing to give.
I wish_ the Convention every success  in its  meeting and I am sure
that we will have a still  better time even than we  had  in Vancouver
last year.
PRESIDENT—
I will ask Mr. Charles Graham, President Cumberland Hospital Board,
to reply in a few words.
MR. CHARLES GRAHAM—
Mr. President, Your Honor, Ladies and Gentlemen:
I wish to extend the thanks of the Executive Committee and the
members of the B. C. Hospital Association to His Honor the Lieutenant-
Governor of British Columbia, the Hon. J. D. MacLean, His Worship
Mayor Porter and Mr. R.  S. Day, for their hearty welcome to this city.
I was also very much interested in the remarks of the Hon. J. D. Mac-
Lean regarding the co-operation of the Hospital Association with the
Provincial Government, and I am certainly very pleased to see that the
Government is  doing so much work for the hospitals of this  Province.
Now as we have heard Dr. MacLean touch on very many questions
which we hope to discuss, and to arrive at a better understanding of the
problems  which  are  confronting the  hospitals  of  today,  I  will  not take
any more of your time.   I wish again to thank those gentlemen.
PRESIDENT—
This is the Second Annual Convention of British Columbia Hospitals,
which has just been opened. Last year, as you will' all remember, we had
a very successful meeting in Vancouver, resulting in the formation of a
Provincial Hospital Association—and I think the only real live and active
association of its kind in Canada. The Canadian Hospital Association
is somewhat inactive since the war broke out, but I hope may be revived
again. We intend to do things at this Convention and to accomplish
real work. We intend to accomplish something each session. We are
not here to do a lot of talking and make fine speeches, which we all like
to hear, but our discussions will lead to something, and as President of
the Association I would like every delegate to get right into the spirit of
the Convention first and foremost, and be ready at every opportunity to
openly discuss the various questions as they come up.
We have with us today many distinguished visitors from the East,
and two of these are going to speak to us today. I am therefore going
to ask Father O'Boyle to defer his address for a few minutes till we
hear from Miss J. Gunn and Miss E. G. Flaws, of Toronto, who have been
attending the National Convention in Vancouver last week. It is rather
unique that British Columbia should have convened within its confines
three national conventions last week, and meeting in the city of Vancouver. We have with us today the Presidents of two of these conventions.
viz., Miss J. Gunn, President of the Canadian National Association of
Trained Nurses, and Miss E. G. Flaws, President of the Canadian Association of Nurse Education. I was fortunate enough to attend many
of their sessions and heard the two leaders speak on several occasions.
I also attended many of the social functions and was responsible for
having them speak on such occasions, for which I am not, I'm afraid, in
their best graces at present, and thus desirous to keep up my reputation
I insisted that they should say a few words today, telling us something
of what they did in Vancouver last week. I have, therefore, much pleasure
in calling on Miss E. G. Flaws to say a few words.
MISS E.  G.  FLAWS, President of the Canadian Association  of Nurse
Education, Toronto—
Mr. President, Ladies and Gentlemen:
I did not expect to speak at this meeting, but Dr. MacEachern insisted
that I should do so. Let me tell you I am more than pleased to be present, and to note the advancement the people of the Province are making
in Hospital Work and in Training Schools, in which I am deeply inter-
11 ested. Much to my amazement, on my arrival in Vancouver, I heard that
you had three great problems solved that we have been, struggling with in
the East for many years. I refer to Nurses' Registration, the Eight-
Hour System and University Affiliation. I congratulate you on your advancement.
I am very particularly interested in Nursing Education, and we are
pleased that Training Schools are insisting on a higher educational
standard of admission and a more thorough training within. We find
great need for a broadened and thorough foundation for the training of
today, especially as the field of nursing has enlarged so much in the
past few years, now comprising all forms of Public Health activities,
Social Service, Laboratory Work, School Hygiene, Industrial Hygiene,
District Nursing, etc. This very much enlarged scope of nursing means
a greater demand for more young women and young women with a
broadened training. To this end many of our Training Schools throughout Canada and the United States are drawing closer and closer to the
Universities, and I am glad that British Columbia is taking the lead in
Canada.
We are particularly anxious that more publicity be given to the
Nursing Profession and that an active campaign be inaugurated among
our high school students to induce them to continue their education and
take up nursing on the completion of their matriculation or their academic
education. I think an effort will be made to reach all these young girls
early and lay before them the field that is opening up. Our high school
girls must continue their education instead of dropping out after the
first or second year, and must at least complete their matriculation.
There are many speakers to  follow and I  am not going to take up
your  time   further,  but   in   closing,  I   want   to   wish  you   all   success   in
your  convention, in your hospital work,  and  I  hope you may accomplish
much to put nursing at all times on the highest possible level.
PRESIDENT—
I will now call on Miss Jean Gunn for a few remarks.
MISS JEAN GUNN, President of the Canadian National Association of
Trained Nurses, Toronto—
Mr. President, Ladies and Gentlemen:
As Dr. MacEachern has just intimated, we have finished a week of
conventions in Vancouver, and the greater part of that time was utilized
in endeavoring to work out some plan for a National Nursing Service.
I think this morning that it might be of interest to the members of the
B. C. Hospital Association to tell you something about it, because if we
can get some plan worked out that will meet this national need, some of
you may be asked to co-operate. I will therefore outline in as brief a
way as possible what we are aspiring to accomplish.
The Canadian National Association of Trained Nurses has felt for a
long time that we should have some organization of the trained worker
and the volunteer. We have felt that when we need a volunteer worker
she comes into the field unsupervised and untrained, to a very large
extent, and we have not had a proper linking up of the trained worker
and the volunteer. We realized this to the fullest extent during the
epidemic last year, and throughout Canada there was great need for the
volunteer. In Canada we will never have, unless conditions change very
materially, a sufficient number of trained nurses to meet the cases of
national emergency. Indeed, it would not be economical to have such a
large body of trained workers who would only give service at certain
times. Therefore we feel that we should have a national service for
emergency work, a National Nursing Service which would naturally
divide itself into two branches, namely, the trained worker and the
volunteer. We intend to suggest to the Canadian Red Cross that they
make some plan along this line; not in any way mapping out a policy
for a national scheme without taking into consideration all the existing
organizations. We feel, for that reason, that a good deal of the work
will have to be mapped out or arranged provincially, because, as you
all know, the Provincial Board of Health in each Province has different
powers,  and  a   scheme  that  would  fit  one   province   would  not  fit  an-
12 other probably. For that reason we will have to have a scheme worked
out by the Province, but with a national leadership, and we felt that
the Canadian Red Cross was the leader which could link up all the
existing organizations. This plan took up a great deal of our time
and discussion in Vancouver, and naturally divided itself into two
branches—the trained  worker and  the volunteer.
It was suggested that the Canadian Red Cross form a Nursing
Service, enrolling in its ranks fully trained nurses as members. During
ordinary times these nurses would pursue their customary duties, but
would only be called upon in time of any national disaster or any local
need in any of the provinces. We had one example of this in Ontario
last year when a forest fire occurred in the northern part of Ontario
and they needed nurses at once, but we had no sort of service or organization to send them on. We got nurses and sent them on in a sort of
hit-and-miss fashion, but no one responsible for them, and the conditions
under which they worked were not very satisfactory. We had another
instance in the Halifax disaster, where the American Red Cross were
called upon to send nurses into Halifax because we in Canada had no
organization to cope with such an emergency, and the American Red
Cross had to do the work that we should have done as a Canadian association. I do not need to dwell on the great need for organization all
over Canada, as was demonstrated through the disastrous epidemic of
influenza. I am sure that you were all thoroughly impressed with the
need at that time for some organization to take hold of the situation and
supply the trained workers and the volunteer. We felt, particularly in
the East, during the epidemic, that our trained workers were not very
well distributed and that there were patients in hospitals who had two
special nurses perhaps that might have had an operation for appendicitis
where we had pneumonia patients dying for the lack of nursing care, but
we did take hold of the situation and distribute the nurses to the best
of our ability finally.
In regard to the volunteer worker, who forms a very important addition to a National Nursing Service, much can be said. As you are all
aware, the St. John's Ambulance trains volunteers for service during war,
and they also give courses of instruction. They have done great work
during the war. However, I think I can safely say that they do not
give sufficient training to their volunteers to make them of very much
value when they are called upon in case of a national emergency, as
occurred in Canada last year, and we feel that the St. John's Ambulance
should give better training to the volunteers. Nurses feel that the volunteer could be intimately connected with the trained worker under such an
organization as the Canadian Red Cross and have the necessary instruction and courses necessary to make them useful to serve when required.
Then when the need arose for the volunteer to serve, she would naturally
work under the trained nurse, and all would serve under the national
organization controlling both, giving each one her proper place and
proper responsibility. In regard to the improved training of the volunteer,
St. John's Ambulance have recognized that the trained volunteer needs
very. much more extensive training than she has had in the past, and
just before our convention in Vancouver we had a letter from St. John's
Ambulance asking us, as a national body of nurses, to co-operate with
them in giving volunteers under the St. John's Ambulance a three or six
months' training in general hospitals—this not only to give them the
lecture course which they had in the past years, but linking up with that
some practical work. We took that question up thoroughly and the
Nurses' Association agreed as a whole that the volunteer worker should
have some practical training, but we also felt that she should not have
that training in hospitals that were conducting Training Schools for
Nurses. If we could use other hospitals it would serve just as well and
would not lead to complications which would surely arise between the
training of the volunteer and the training of the pupil in the one school.
If we take a number of volunteer workers to give them the training required, we are likely to deduct from our probationers' training;_ in other
words,  it  is  divided  between  the pupil nurse and  the pupil training for
13 volunteer, which would not work out at all well in a practical way. The
suggestion therefore is that the Nurses's Association co-operate with the
St. John's Ambulance in giving the volunteer worker a practical training
in hospitals not conducting Training Schools. Of course we have a
great many of these hospitals throughout Canada. That is our answer
to St. John's Ambulance on the question; whether they will approve of
that or not remains to be seen, and possibly they will not consider that
it is a feasible plan at all, but as a nursing organization we would not
co-operate in giving volunteers training in a general hospital. The result, if we can accomplish this, would be that we would have a national
organization responsible for the nursing service of the whole Dominion in
time of emergency and they would have funds necessary to provide this
nursing care and they would have the authority and we would have the
trained body and volunteer in close co-operation.
There are further needs in Canada, and I refer to a second type of
nurse. We need nurses who can do a great deal of home nursing or
who can do household work as well as the nursing service required in
the home. In the United States the different states are working along
some plan for the training of this second type of worker, and this year
at our convention we took it up and I will tell you what conclusion we
arrived at. This second type of nurse we would call either a "nurse's
aid" or a "trained attendant," either of which names seem particularly
suited "to her service. We must distinguish between the practical nurse.
the under graduate nurse and the short-term nurse. Taking the latter
one first, the short-term nurse usually means giving a short training of
one year in some hospital then starting her out to do nursing. We, as an
association, disapprove of such, and consider it a very poor policy. We
think there is great danger in giving a short training to any pupil, and
we do not consider it necessary or advisable. We do not approve in
any way of a short-term nurse, and this is one point I would like to
make very plain. The under-graduate is a nurse whom we have in the
East, and think you have in the West, who at one time was a pupil coming in to train and then for some reason or another, she may be asked
to leave the school or she may decide that it is unnecessary to get
training as a nurse. If she has been asked to leave the hospital because
she is not a suitable applicant to finish her training, she is not a very
desirable nurse in the home. If she leaves the hospital of her own accord to take up nursing, after having pledged herself for a three years'
course, she is not a very desirable nurse in the home, either. The undergraduate, therefore, is an uncertain quantity. Next comes the practical
nurse whom we all acknowledge has done a great deal of good in Canada,
but to make her efficient we are advocating some kind of training for her.
The practical nurse at present is usually a woman who wants to earn her
living, she likes nursing, she starts out and gradually becomes a practical
nurse. We, as an association, approve of a trained attendant or a nurses'
aid, but we think, however, that she should be trained to do the work
she starts out to do, and we are advocating the six months' training.
The six months' training we would advise should not be given in any
general hospital conducting a training school, because we have the -same
factors to contend with as already mentioned, but should be trained in a
hospital that does not conduct a school for nurses. She should also have
some training with visiting organizations, for we are training her to do
work in the home, therefore she should be trained in the home. If you
train her entirely in the hospital she is apt to get the wrong idea.
However, before we train these attendants or nurses' aids in any
number, we have to have legislation for her activities. In the Eastern
provinces we have not any very active registration for graduate nurses,
and in some of the provinces we have not any legislation at all for
graduate nurses as you have in British Columbia. In the Western provinces you have legislation, so coming down to your own Province, you
would need to have your Registration Bill amended to cover the nurses'
aid. When we are speaking to audiences on this subject who are not
connected with hospitals, they immediately feel that it is a fine arrangement, not only from the standpoint of the graduate but from the stand-
14 point of the public. If she is trained and qualified to give a certain
service in the community, she should be given the status that is due her.
The public on the other hand, should have some way of knowing whether
they are employing a fully trained nurse or a trained attendant. We have
throughout the whole of Canada, practical nurses, and a lot of these
women have been doing a great service for a number of years, and we
feel that any scheme advanced for trained attendants should include the
practical nurse, giving her her proper dues, so that in amending any
legislation for nurses, it should first consider whether she is a fully trained
nurse, a trained attendant or a practical nurse without any training at all.
They should all be registered. Any woman who is nursing for pay should
be registered and her status should be assured.
We feel that this training of attendants should be very carefully
undertaken and very carefully worked out, and for that reason we feel
that some national body should take charge of them, and we hope within
this next year to find some way of working out that plan, and some of
your hospitals may be asked to co-operate in the training of the volunteer under the St. John's Ambulance and in the training of the trained attendant or the nurses' aid. I think the general opinion—I remember in
Toronto they had a conference of quite a number of national organizations, some of which were connected with nursing, and I happened to be
present at that conference and was speaking of giving the volunteer a
better training. They said they thought graduate nurses were very much
opposed to any type except the fully trained nurse, and were much surprised to hear any national nurses body expressing itself as feeling the
need of assistance, and that opinion, I think, is fairly general and is a
very wrong one. I do not think that any one in any community has felt
the need throughout Canada any more than the graduate nurse herself,
and I do not think you will have any one that will be more willing to
help out, to bring this service, that is so much needed for our citizens.
As I said before, the need of having these attendants properly trained
and properly supervised and licensed to work, those three things are the
important factors in any scheme that we advance.
I would like to emphasize that all I have told you this morning is
just a suggestion. The plan has been referred to a committee that was
appointed by the National Nurses' Association to try and present some
plan to meet this need, and this is what we have agreed upon. Whether
we will be able to carry it to completion, whether we will find that the
Red Cross is in sympathy, whether the St. John's Ambulance will cooperate, remains to be seen, but I think what we need in Canada is the
getting together of all organizations employed in Health Work and to
draft some scheme in which each organization will be prepared to give
a little, take more responsibility than in the past, and to fall into some
plan that is going to meet the need. Of course this plan cannot be carried out without the co-operation of the hospitals. Hospitals are the subject in this whole scheme and the training will have to be linked up with
hospitals, and unless we have a sympathetic atmosphere when the hospitals are approached we will not be able to go very far towards a happy
conclusion of this whole scheme. It is important work, very much needed,
and it is a very big work and will take a great deal of effort on the
part of anyone to bring it to any kind of success. Before I conclude, I
would like to say that we devoted quite a good deal of our time to
Public Health Work and we have had for sometime a standing committee
on Public Health. We had a survey made of all the provinces, and it
was surprising to see the amount of health work that is being done, and
when we had the report of all.the different provinces we really felt that
we were doing a great deal along Public Health lines, and our nurses
are taking up more and more of that branch, and the need is coming
more and more. This year we formed a Public Health Section of the
Canadian National Association of Trained Nurses, giving to that group
of workers an opportunity of bringing up their own questions and working them out to the best of their ability. I do not think there is anything further I can tell you, excepting that we feel it should be made
possible  for  our nurses  to  have  post-graduate  work  in  Public  Health.
IS A great many nurses after graduation are not in a financial position to
undertake further study. We find that after three years they have to
earn their living, and if it could be possible, in as many of our Canadian
hospitals as possible, to grant Scholarships to the nurses to take further
post-graduate work in Public Health, they would not be only doing a
great service to the nurse herself, but doing a very great service to our
nation at large.
MR. DAY, Victoria-
It has been very good of Miss Flaws and Miss Gunn to come here on
short notice and give us the results of their experience and tell us of
their hopes and aspirations. I have much pleasure in moving a very
hearty vote of thanks to Miss Flaws and Miss Gunn for their interesting
addresses this morning.
MISS HASKINS, Vancouver-
It affords me great pleasure in seconding Mr. Day's vote of thanks.
The Convention heartily approved.
PRESIDENT—
Miss Flaws and Miss Gunn, I have very much pleasure in presenting
to you the hearty thanks of the B. C. Hospital Association for your
addresses, and I want to  add my personal appreciation and thanks.   .
We will now have an address from Father O'Boyle, of Vancouver,
recentfy appointed Director of Catholic Hospitals for British Columbia,
on "The Ministry of Healing."
"THE   MINISTRY   OF   HEALING"
By Rev. Father O'Boyle.
This week the leading practitioners and professors of medicine in the
Province will meet in your beautiful city, the sanitarium of Canada, to
discuss problems of life and health and to interchange ideas and experiences on subjects of supreme importance to the public welfare. Medical
science will surely profit, and what tends to the improvement of medical
science is fraught with blessings for all of us.
While I am neither a practitioner nor a professor of medicine, nor
yet a nurse, I feel that in my calling as physician of the soul I am in a
true sense a member of the big union. Together we go through life
among the mangled bodies and aching souls of those we love, intent on
the wage situation, our chief problem being the reduction, not the increase, of the wages of sin, which is death. My presence here is largely
due to Dr. MacEachern, who had me appointed Director of B. C. Catholic
Hospitals. We happen to belong to the same Victoria County Old Boys'
Association, of which he was just as efficient a president as he is today
superintendent of the vast hospital work under his jurisdiction on the
Mainland—even though he was succeeded in the presidency of our Old
Boys' Association by an undertaker.
My theme is "The Ministry of Healing," and I must speak of the
physician and his role. With the physician I include that extension of
his personality—the nurse. 'Tis a most high and sacred calling, not a
trade, not even a profession, but a vocation involving high vision, philanthropy and self-sacrifice. He is guardian of the life which God has
given, and in a true sense shares dominion over life with the Creator—
he is custodian of the tabernacle of an immortal soul—a high and noble
responsibility. He is our guide through mysteries—mysteries of which
Huxley said: "The mysteries of the church are but child's play in comparison"—the mysteries of nature, matter force, life, mind and personality.
Confronted and at times baffled by mystery, he must acknowledge that
medical science is but a broken light of the complete and comprehensive
knowledge of an infinite God. Hence reverence is his chiefest characteristic and humility is his hall-mark. I am speaking now of the real
physician, not the narrow specialist, the materialist of fixed idea who
ignores God's plan and acts very much like an artist trying to piece together the wrong side of the tapestry. This reverence and humility is
religion.
16 mm  Galvani said: "A little philosophy leads men away from God, but a
good deal of it brings them back." This is quite evident today in the
swing of the pendulum back from the dogmatic materialism of the past
century, bankrupt in its profession to explain the riddle of life, to the
realm of psychological investigation which means the soul and God.
The physician who does not realize that he is God's instrument cooperating in His plan, is not a scientist who has drunk very deeply of the
well of science, but once this relationship to the Creator and Preserver of
life is grasped, once he feels that he is a delegate as regards this
guardianship of life, then a vast responsibility takes hold of him, because
he is palled upon to watch the dawn of that life, to guard helpless infants,
to ward off contagion, to adjust and keep moving the delicate bearings of
the vital functions, to relieve pain and duel with death. He is called to
watch the interplay of mind and body, of spirit and matter; he comes in
close contact with the frailty of human nature, he is daily witness of the
trust placed in him by patients who hang on his word, confident in his
wisdom and integrity. He cannot but feel that his conduct, his words,
his character, the very principles which animate his life, consciously or
unconsciously influence his patients not only for the healing of their body,
but for the developing or the stunting of their spiritual lives as well.
Were his human clients rated but machines devoid of an immortal spark,
then a sufficient motive for integrity would be desire for temporal gain
and fear of human tribunals, but if there is a higher law, the natural
law imprinted on the heart of every one of us that God is the giver of
life and God alone can take it away, then he has a higher motive than
mere   professional   etiquette   or   human   convention.
The greatest of your profession have acknowledged this. The spirit
of faith is not scientific. Religion has no quarrel with biology; it merely
asks that you do not leave out of your speculations man's moral nature
and spiritual yearnings, that you forget not the dignity bound up in an
immortal destiny. Pasteur was not "cribbed, cabined and confined" by
his belief in God and his faith in the supernatural. He was renowned in
biology, chemistry, physics, medicine and surgery. No man penetrated
more deeply into the mysteries of nature and the origin of life—yet he
never complained of the paralysis of faith. On the contrary, he said:
"Posterity will one day laugh at the sublime foolishness of modern
materialistic philosophy." On his monument are inscribed words which
are his own: "Happy the man who bears within him an ideal of divinity,
an ideal of beauty and obeys it, an ideal of art, an ideal of country and
an ideal of the virtues of the Gospel." The man who thought thus went
further than mere belief in God, and sensed, as he did so well, other
phenomena, the great fact that with the coming of Christ the outlook
of man on his fellow creatures was changed, that until He came, few
were conscious of the truth that, as all human beings have the same
origin and destiny, none can be indifferent to the lot of other members of
the race from their birth into this world to their departure to the world
beyond. He saw that in the light of a great atoning sacrifice this feeling of mutual interdependence and responsibility grew in Christendom
until the natural human relationships were raised to a higher plane, and
around them cast a new and all-embracing chain. This bond is the
spiritual fellowship that sees the Christ in the least of his brethren according to the words: "I was sick and you visited me." Now, I take it
my dear friends, that is the spirit of the medical profession of British
Columbia.
In choosing your vocation, no doubt family circumstances, scientific
bent of mind, worldly success, keen philanthropy and other, more vague influences conspired to set your path before you, and serve yet as incentives
to overcome difficulties and to drive your taients and energy to service.
But these indications of God's will in your regard did not blot out the
hand that traced them, and when you saw in your vocation an honest
livelihood it was in no mercenary spirit. You were inspired by the only
fully adequate aim of your great calling—the happy destiny of the race.
The world recognizes this when speaking of reward. They do not use
the word "wages" which  applies  to  laborers,  nor "salary" which  applies
17 to intellectual pursuits, nor "fees" for professional service; they speak
of "honorarium" which connotes a tribute to a benefactor whose role,
whose responsibility, cannot be measured or compensated in a material
way. So long as the principles of medical ethics and jurisprudence are
inspired by a sense of this responsibility, so long will you fulfill your
glorious function, not alone of protecting life in the individual, but of
fostering the life of human society as a whole. For without this sense
of responsibility, the sanction of morality will tend to disappear, the life
blood will leave the heart of civilization and it will sink into selfish and
pagan degeneracy.
From this responsibility follows, not alone such practical conclusions
of ethics and medical jurisprudence as, the need of technical knowledge
and of judgment, the need of diligence and devotedness, the demand for
safe methods of experimentation whether with knife or drugs, but especially the right to life of defenseless humanity, and as well as a kindly
regard for the poor and disinherited, a respect for the mortal remains of
our kindred, and a care for preparation for the peace and hope of those
passing to eternity. Along these lines medical practice views cases as
persons, not merely numbers listed in an institution. And that is why I
claim that healing is a ministry inasmuch as it cannot properly be divested
of its spiritual side.
I am not qualified by training or experience to speak learnedly to such
an audience as this on the purely technical side of medical practice, although
I could possibly enlarge on the topic of mental therapeutics, the influence
of mind on mind, which comes within the scope of pastoral medicine. I
hold, then, when experimental knowledge of the laws of the mind shall
have received as much attention as the laws of physics and chemistry, the
ministry of healing is bound to advance another and an important stage.
But while I have accentuated already the psychological aspect of the patient, I have no patience with the exaggeration just as gross as materialism
that sees nothing but mind, and dispenses with the human methods approved by common sense. I believe medical practice will become a more
exact science, will tend more and more to ward off contagion, to help the
vital energy to throw off disease rather than to drug, to open more windows
and less patients, and to see that real food is fed with one's meals. I believe that medicine is to enter on a far wider field thar/hitherto; that it
will concern itself with the production and preparation of food, the study
and improvement of education, and the rational adjustment of hours and
conditions of work. The dominant note of world movement today, not confined to labor, is human dignity. No community can afford to allow a
child born into it to grow up without a full supply of food, air and liberty,
and a sound working knowledge of the machine he has to work with, knowledge how to supply proper energy, how to watch its bearings, regulate its
gears and make repairs. A large proportion of our medical specialists will
be concerned with the social prevention of disease and there will not be
so much demand for what is known as "the wrecking crew." The complete
socializing of medical science, however, would tend to destroy initiative
and introduce the curse of politics.
Speaking of preventative methods and of food suggests dietetics, and
the best of all laboratories are the kitchen and the nurse. In reading the
other day I found the sober statement that men make the best cooks, instancing the chefs in big establishments. The reason given was that the
critical male taste is more exacting in its demand, that the brutes know
better what is good, being more highly developed gastronomically. However, I do not regret that my mother did the cooking at home.
When it is a question of the "ministering angel soothing the fevered
brow of pain," there is no question of woman's peculiar vocation. As a
natural outlet for the desire to serve, nursing has the suffrage far distanced. Christianity early consecrated to it those free of family cares.
This calling means even more than for the doctor, faith, simplicity, aim,
love and self-sacrifice, and with the maternal instinct a more jealous protection of life. With chastened temper and Christian grace the highest
expression of it is in those who have consecrated their lives to it and now
share the name "sister" with all who care for the sick under doctors' orders.
18 I have not said much of hospitals, for it is not buildings so much as
the brains and the hearts of those connected with them that count. Let
me here express appreciation of the kindly and generous feeling that exists
and is being promoted between the Sisters' Hospital and the State Institutions. It means that we have every factor brought into play to secure
best equipment, business methods, and at the same time maintain the ideal
that the hospital is God's hotel. This co-ordination of work, rating of
excellence, and general public co-operation is essential for the fullest
measure of good if the hospitals are to be for the people, and it means
the establishment in the favored corner of the world of a mighty medical
school, and ?n all-round comprehensive preparation for the care of generations to come.
I am glad to report that the hospitals at Rossland, Comox, New Westminster, Vancouver, and Victoria have adopted fully the recommendation
of the Commission as regards the establishment of staffs, the preservation
of Case Records, and, although with a certain hesitation, a programme of
publicity. I have assured them that the rule of humility, by which the left
hand must not know what the right hand does, is not intended for doctors,
much less for surgeons.
In conclusion, let me remind you that, despite antiseptics, antitoxins,
hygiene and tanlac, we all have to die. While nearly all acute diseases
and infections are rapidly decreasing, are not other diseases of civilization—Bright's Disease, Neurasthenia and Insanity—seemingly increasing?
It may be that these are no more common than before, but are more readily
diagnosed. However that may be, we all have to go, and in view of the
inevitable, let me revert again to Pasteur:
"There are two men in each of us: The scientist, he who starts with
a clear field and desires to rise to the knowledge of nature through observation, experiment and reasoning; and the man of sentiment, the man of
belief, the man who mourns his dead children and who cannot, alas! prove
that he will see them again, but who believes that he will and lives in that
hope—the man who will not die like a microbe, but who feels that the
force within him cannot die."
PRESIDENT—
I feel sure, Father O'Boyle, that everybody has enjoyed this masterpiece address very much. The next address on the programme is my own.
I will ask Mr. Day, Vice-President, to take the chair.
ADDRESS—"THE HOSPITAL OF TODAY."
By Dr. M. T. MacEachern, President The B. C. Hospital Association.
This year we meet under different circumstances than last—the great
European war is over and the reconstructive period is on. The Hospitals
of B. C. are here assembled to reconstruct. Our Association, of which we
are justly proud to be members, is but one year and a few days old, and
was organized at the meeting of B. C. Hospitals last June in Vancouver.
Though young in years, we are now a real active and live organization,
and this week in session in the charming City of Victoria will make important decisions concerning the future policy and carrying on of hospital
work in this province. Our ideals are excellent and should always be
kept in mind. Through our Association we endeavor to do the following:—
(a) To serve as a means of intercommunication and co-operation
between the hospitals in British Columbia.
(b) To  establish,   maintain   and  improve   standards   of  hospital
work.
(c) To promote the efficiency of all hospitals in the Province.
(d) To   stimulate  intensive  and  extensive  hospital   development.
(e) To make all hospitals of more community service.
No higher ideals can be set forth for any hospital organization, and
we must accomplish our task.
It has fallen to my honor to be the first president of the B. C. Hospital Association, an honor I most highly regard and for which I trust
you will accept my sincerest appreciation. During the year I have faithfully endeavored to  discharge the  duties of my office, but  have felt a
19 considerable difficulty in accomplishing all I would like, owing to the
distance which the various members of the executive are apart, making
it impossible to get them together as often as I would like. The programme this year is therefore arranged somewhat differently to that of
last, inasmuch as we have divided the time into particular sessions so as
to finish up each subject at that session and secure final decision if possible of the convention on all resolutions which might arise out of the
papers or discussions. It is the desire of our Executive, and I am sure
heartily approved by all, that this Association accomplish real work at
our Convention. So often at such meetings fine papers are read and discussed and great oratory runs uncontrolled and splendid enthusiasm
apparently, but nothing follows. That is not to be our policy, but every
moment in session we must accomplish real work, real constructive administration and progress. To do this we want the serious thought of all
on the various questions, their opinions, their sound judgment. This
Convention is a clearing house for all your troubles, and do not hesitate
to  unload  them  on  us.
During the recent European war the world has witnessed the greatest
medical service organization that there has ever been, and that will likely
ever be in war times, at any rate. The most important part of the service
was that played by our hospitals. In peace times such an efficient service
is also needed and our returning soldiers, having been accustomed to it,
will want it for themselves and their families. A new era is therefore
rapidly looming up for our hospitals in regard to administration and
development, and the hospital administrator who is giving serious thought
to his of her work must feel a pleasing inspiration in their work. Thanks
to the American College of Surgeons—a fine international body of men,
among whom are several representatives from the Province of British
Columbia—for stirring things up in the hospital world of today, and we
all realize that there is great advancement and development coming. Now
the avalanche of efficiency, the true measure of any hospital, will sweep
out of existence for evermore the innumerable "sick dumps" or "boarding house" types of hospitals throughout our land. We are not, however,
in a destructive period, but the reverse—a constructive period, the keynote
of which is "one hundred per cent, efficiency to the. patient," a condition
that all hospitals must meet.
The demands of society today make it essential that hospitals be established in all communities of a population of two thousand or over, and
in some cases, less. It is evident that people are agreed therefore that
there is an advantage in having such institutions when illness overtakes
them, and this is undoubtedly true. I do not intend to go into the past
history of the growth and development of hospitals, but I -will deal more
with the present-day phases of the subject in question and incidently
that which is required of the future. The growth and development of an
institution as a hospital is only commensurate with the use such institution is to society, what it can give in return by way of service in the
science of healing. It is very true that some people pass through the
world, living a somewhat passive existence, eking out such an existence
along lines of easiest resistance, leaving the world no better, if not worse,
when they pass on. In some cases it is not the person's fault—it may be
due to arrested mental development or unfinished education, or in short,
may be the result of uncontrollable or controllable circumstances. The
other day I was handed a poem of two verses entitled, "Which Are
You?" In a pleasing rhythmical maimer these verses portrayed very
vividly two classes of people, one class being the people who "lift," the
other the people who "lean." This applies to our hospitals of today and
has application just as much as in the human being. The hospital is
an institution which runs a career much the same as the human being.
It is born into existence and has to be carefully nursed through its early
difficulties which are numerous. The progress is usually slow, but with
careful guidance goes on and on through the various phases of development, just as a person does. The child is born into the world, carefully
nursed and cared for, taught to read and write and gradually more and
more being thus  equipped  for  days  of maturity.    So  also  the  hospital
20 but I must be brief
proceeds, and lucky it is if as in the development in the child proceeds
systematically to a finished state or condition. If this was the case we
would have fewer institutions suffering from arrested development and
inefficiency and those that "lean" instead of "lift." Of course, the child
to develop into manhood of highest type must have the guidance of good
parentage and teachers and thus likewise the institution can only become
great by careful guidance and by wise administration. The hospital administrator today can, to a certain extent, make or unmake the institution,
and if he is holding his job down because he thinks it is an easy one
and expects everything to run smoothly, then I would feelingly advise him
to seek new fields and to engage his contended and optimistic disposition
in other fields, in no way reflecting or thinking disparagingly of optimism,
for I believe it is necessary to have when properly guided.
The successful development of any hospital depends on certain conditions and factors, which may be ascribed to several sources, of which
the chief are:
(1) The  Governing Board.
(2) The Executive Head.
(3) The Staff.
(4) The  Auxiliaries.
(5) The Public.
(6) The Press.
(7) The   Institution   itself.
Volumes could be written on each of the above,
and summarize rather than amplify.
A brief restrospect of my own personal experience makes me wonder
how a co-ordinated success could arise, but I believe it is possible, I
conscientiously feel we can accomplish it here in our Province. To deal
with this more fully it is necessary to consider each phase more or less
separately.
The Governing Body of the hospital may be known by different names,
but their duties and responsibilities are all the same. They may be called
governors, directors, trustees, etc This body must assume supreme control and responsibility and are usually capable, representative, broad-
minded business men or professional men, systematically selected. The
successful governing body must be chosen according to certain basic principles of choice and there are certain important qualifications necessary
to make a good governor, director or trustee. They should be men or
women of good standing in the community and who can afford to lose
their time, as their services are gratuitous. They must be broad-minded,
fair, firm, tactful' and resourceful. They must have a keen sense of
community spirit and public confidence. In short, their motto must be
"service," and each director or trustee should be as familiar with the
institution and take as much pride in it as if it was his own personal
property. It is unfortunate that we have so many trustees or directors,
today who are holding down their positions oh such boards of hospitals,
merely for the honor therein, and who never come near the institution
excepting once a year—to the annual meeting and therefore know nothing
about the hospital they represent, and have no more interest in the institution than becoming elected from year to year. These men must not
sk on the Boards of Trustees in British Columbia hospitals in the future.
Analyze your boards critically find out if they are giving the best service
for your hospital. On the other hand we are fortunate in having in
many places members of boards who are of the keenest and best possible
type, and we have them right here in this convention today. They are
good citizens and real hospital workers and of the first rank. They are
our hospital builders of today.
It is unnecessary to emphasize the importance of the executive head
of the hospital—the Superintendent The necessary qualifications of such
a person is so approximate to that of the "angel" type that I feel it is
rather unwise for me to detail such in word picture. He or she must
have ability, tact, good judgment, initiative, _ perseverance, diligence, patience, etc., and most know what real hospital service is. There is no
Superintendent who knows all the details, technical or otherwise, of the
21 various departments, but must surround himself or herself with good assistants or heads of departments and they must know when proper results are being obtained. The Superintendent has a large number^ of
people to satisfy, not only the entire staff and the patients, the Medical
and Nursing profession, but also the public. The associations and relations are far-reaching and intricate. The Superintendent is responsible
to the Board for carrying out their orders, so far as is possible, and for
taking the lead in the development and progress of the hospital. Therefore the utmost co-operation is necessary. The selection of the Hospital
Superintendent should be based on efficiency or ability to serve as above
indicated and not based on influence or "pull" or ability to create hospital
surplus—as we have seen in some places.
The Staff of the Hospital consists of various classes as maids, orders
lies, cleaners, cooks, etc. Then again are the doctors and nurses.
"Esprit de corps" is necessary and can be readily kept up if such a staff
is used considerately. The kindly and well treated staff, with a fair deal
to all, will mean a strong, loyal aggregation. Some superintendents are
too important to speak to any of the domestic staff or the ordinary
workers. This is very unfortunate. Endeavor to regard each and all as
filling very essential and important posts and forming cogs of the great
hospital wheel. Treating all with respect and courtesy and endeavoring
to make their social life pleasant will bring about a strong co-operation
between all. The smaller the hospital the more apt to have disensions
and lack of harmony.
Of great importance and advantage to any hospital is the work which
can be carried on by the women's organizations or any auxiliary attached thereto. There are a number of activities in which they can devote their energies and can do a vast amount to increase the usefulness
of the hospital and its efficiency. We are all agreed that without our excellent auxiliaries of women and girls our institutions would suffer greatly.
It keeps a large number of more or less influential people in the community interested directly in the hospital, and this is a great advantage.
Our institutions, to be a success, must have active working auxiliaries to
assist in their work.
The public or the people of the hospital community are not as interested in the hospitals as they should be. They are in many instances
hypercritical of the institution, though it is their own in many instances;.
There is a great need of publicity and education of the people in each
community along such lines. The community must be sympathetic to the
hospital in its various activities. There is more unjust criticism, and
let me say, "absurd" criticism, about hospitals by the public, than of any
other institution I know of. There was no criticism, however, during
the epidemic of influenza; in fact, the hospital was regarded as the only
institution existing at that time. If we could have spared even a few
hours, how many of us could have gone out and raised hundreds and
even thousands of dollars for hospitals at that time. The epidemic, however, is now over and the hospitals may now be more or less forgotten
by many. I remember so particularly several instances of the above, but
one I am going to tell you of: A woman whom I knew very well stated
openly on the streets of Vancouver that she would not go to such-and-such
an institution if she were dying. Inside of a month she was a victim of
the dreaded influenza, as well as her family, and from the very moment
she took ill demanded being sent to the hospital she had openly condemned.
The institution was filled to overflowing, with no beds or bed space, but
nevertheless she called the ambulance herself and came. She was glad
to sit around even for a couple of hours till room was made. She now
appreciates hospital service. It is most distressing when one analyzes
'the devoted service of the nurses and staff of the hospitals, that the
public should criticize^ so. If the public were subjected to the same
service from our hospitals as is given them daily in large commercial
institutions of our country, we would have a rebellion on our hands.
These corporations have their roles and regulations and you have to
live up to them, whereas in hospitals people think roles and regulations
are for breaking at all times, especially such roles as those applying to
22 visiting. We all have seen people waiting in line for hours to get into
a theatre, picture show, an exhibition or hockey match. If you keep
them waiting five minutes to get into your hospital there is a howl.
However, this whole question has such ramifications I cannot deal with
it in detail, but just mention one other point: I suppose many of the
hospitals represented here, and particularly the larger, have trouble collecting the patients' accounts. People today think the services rendered
by a hospital should be more or less free, but do not realize that such
an institution must live. The question is so serious now that we hope
to hear a great deal of discussion on that point at this convention. The
public in many instances today are not good contributors to the hospital,
or are they as good at paying their own accounts as they should be.
They must be awakened to the sense of their responsibility and it behooves us to do so through our various agencies and activities.
To accomplish a great deal in the way of publicity for any hospital
or institution the sympathetic support of the Press should be solicited.
Today the Press throughout our country are most sympathetic to such a
cause, and the publicity that can be given by this means will be of great
value to hospitals. I hope the Press of this city will give our work
in the convention good publicity so that it may reach every home. We
do not realize what a splendid educator the Press is when the material
therein is based on fact and good opinion. So far as I am concerned
personally, for the past six years I have secured the greatest assistance
possible from the press in my work in Vancouver, and I know for a fact
that it has done more for hospital work in Vancouver than we can ever
measure. Therefore, interest your Press in your work and give them good
hospital news. Tell them what you are doing and what you want to do.
Your institution must take the lead in your community and therefore
get all factors going which will lead to such a state.
Coming now to the institution itself, we find that there are volumes
which can be written about it, which would be helpful in such development. We are hearing a great deal about Hospital Standardization,today,
and the first review of this continent has already been made. There
is an impression that this only applies to large hospitals, but such is
not the case by any means. The hospitals from the various communities
represented here must be standardized institutions. There is a difference
of opinion I find in regard to what is really meant by Hospital Standardization, and I have been asked several times lately to explain what it
means. It does not mean that every hospital should be similarity equipped,
organized and operated, for there are conditions, everyone knows, which
make it impossible, owing to the diversified local conditions, but in the
briefest language means—"one hundred per cent, efficiency to the patient,"
and today I wish every hospital in our Province would put over their
doors the following inscription and live up to it: "This Hospital Stands
Only for One Hundred Per Cent. Efficiency Service to Each Patient,"
and any hospital can do it if they practice their art with a conscience
guided by the best ideals. This one hundred per cent, efficient service is
not restricted to any particular class, but reaches from the poorest and
humblest to the richest and most aristocratic. It must not be a regarder
of person or persons; it must stand for the highest possible grade of
"Diagnosis" and "Treatment" with the best results obtainable. The
human mind or intelligence and the human hand are not by any means
infallible, but it must be admitted today that the innocent suffer at the
hands of people supposed to be efficient but who really are not. How can
the bluffer get away with his "camouflage" whether it be a human being or a hospital. The day has come when the public will demand facts
and results.
No longer can our hospitals be run in a sort of routine and mysterious
fashion. We must put real life into our hospital administration and let
efficiency be the real measure or our result. Our hospitals must one and
all get down to real business and accomplish the ideals we enumerated
already. Those that guide the institutions must realize this responsibility,
and I wonder do our Boards of Directors or Trustees fully realize the
responsibility   for   the   many   hundreds   of   cases   now   on   their   beds   of
23 languishing and pain in our Province—in our Hospitals. The Board of
Director or Trustees must realize this responsibility to the very fullest
extent. Their real value to the institution can only be measured by the
service thus extended to the patient. You may now ask: how do you
know that the patient is getting service? To give proper service you
must have organization. You must have equipment and facilities—but to
measure your service you must do so by the end results—and this can
only be recorded by Case Histories or Records, and here unknowingly,
and somewhat unconsciously I have mentioned the three great phases or
principles of Hospital Standardization:
(1) Organization
(2) Facilities.
(3) Case   Records
In the analysis of Hospital Standardization the above three play an
important role.
If every listener to this paper will seriously take to heart my rambling
remarks, will analyze his own conscience in respect to his own work, a
greater good may arise than I anticipate, not only in the one specific
direction which we are dealing with here, but in the many and diversified
callings of life. This will mean better citizenship, a better country and a
more  harmonious  existence  for our people.
(Chair resumed by President).
PRESIDENT—
It is necessary that we spend a few minutes before closing this session in disposing of some business matters. You have all had copies of
last year's Report of Proceedings, containing the minutes of our meeting
at that time.   What is your pleasure?
Moved by Dr. McPhillips, Vancouver; seconded by Mrs. Broom, Vancouver, that we take the minutes as printed in the Report.    Carried.
PRESIDENT—
During the year we had two meetings of the Executive. The Secretary, Mrs. M. E. Johnson, Vancouver, will read these minutes.
Reading of Minutes of two meetings of the Executive by the Secretary.
Minutes of Meeting held on November 23rd, 1918, at the Bute Street
Hospital, Vancouver. Present—Dr. M. T. MacEachern, Dr. C. H. Gate-
wood, Dr. F X McPhillips and Mrs. M. E. Johnson.
A resolution, moved by Dr. F. X McPhillips, and seconded by Mrs.
M. E. Johnson, was passed authorizing the President and Treasurer to
sign cheques for the paying of bills for the current expenses during the
year, and it was further ordered that a copy of this resolution be sent to
the Bank of Montreal.   Carried.
The Treasurer's Report showed $387 on hand in the bank.
The Meeting adjourned.
A meeting of the Executive Committee of the B. C. Hospital Association was held in the Board Room of the Vancouver General Hospital,
March 22nd, 1919, at 8 p.m. Present—Dr. M. T. MacEachern, Vancouver;
Dr. C. H. Gatewood, Vancouver; Dr. F. X. McPhillips, Vancouver; Mr.
Charles Graham, Cumberland; Miss M. P. Macmillan, Nanaimo; Miss
L. S. Gray, Chilliwack, and Mrs. M. E. Johnson, Vancouver. Correspondence was read and ordered filed The Treasurer's Report showed a
balance of $2.98 in the bank.
Moved by Dr. C. H. Gatewood, seconded by Mr. Charles Graham,
that all the hospitals who have not paid their dues or joined the Association, be written and urged to do so. Where institutional membership was
not desired, possibly individual membership would be taken oot   Carried.
Moved by Mrs. M. E. Johnson, seconded by Dr. C. H. Gatewood,
that the President be asked to go over to Victoria to confer with members there in respect to the Annual Convention, and if, for any reason,
Victoria should not want the Convention, as we had not heard from
them, that an invitation be extended from Vancouver to have the meeting
here.    Carried
Moved by Mr. Charles Graham, seconded by Miss L. S. Gray, that
July 8th, 9th and 10th, be the dates for the next Convention.   Carried.
24 The following matters arising out of the Proceedings at last Convention were discussed:
First—The suggestion of Mr. H. T. Devine that a committee be
formed and arrangements made to put into force "A B.C. Hospital Produce Day for the donation of fruits, produce and other food supplies, together with the collection and distribution of same on a pro rata basis."
After discussion of this it was moved by Dr. F. X. McPhillips and seconded by Mr. Charles Graham, that the Executive recommend that each
district or Hospital community take this matter up as a local matter
and that the third Monday in September in each year be set aside as
Hospital Produce Day in B.C., when hospitals would receive donations of
fruit, vegetables, etc.   Carried.
Second—Motion of Mr. G. Haddon, Vancouver: "That a Committee
be appointed by this Convention for the purpose of considering and devising a system, if possible, tending towards uniformity of Hospital Accounting, and to report at the next meeting of the Association."
Dr. Gatewood stated that Mr. Haddon had been appointed Convenor
of a Committee to deal with this.
Moved by Miss M. P. MacMillan, seconded by Miss L. S. Gray, that
the Secretary be asked to notify Mr. Haddon to have a report ready for
the next Convention in July.   Carried.
Third—Moved by Mr. Mordy, Cumberland, seconded by Dr. Rogers,
Victoria, that this Convention call on the Provincial Government to furnish Isolation Hospitals in rural districts and provide for the maintenance;
also compel municipalities to maintain them in their particular district.
Moved by Dr. C. H. Gatewood, seconded by Dr. F. X. McPhillips, that
the above resolution be laid over till our next meeting.    Carried.   .
Fourth—Moved by Mr. Mordy, seconded by Dr. MacEachern, that this
Convention fully believe they should have accurate and systematic Medical
Records in their Hospitals, and that they ask the Executive Committee to
draw up standard forms of reports which shall be suitable for all the Hospitals in British Columbia, and that these be standard.
Regarding this, Dr. MacEachern reported that Dr. T. R. Ponton, Director of Records, Vancouver General Hospital, is working on this, and would
present the entire scheme at the next Convention.
Subjects for programme for next Convention meeting were discussed,
and it was finally moved by Mr. Charles Graham, and seconded by Dr. F.
X. McPhillips, Vancouver, and seconded by Mrs. Broom, Vancouver, that
President's hands.   Carried.
The meeting adjourned.
After reading of the minutes by the Secretary, it was moved by Dr. F.
X. McPhillips, Vancouver and seconded by Mrs. Broom, Vancouver, that
the minutes as read be adopted.    Carried.
The President then affixed his name thereto.
The question of Committees for Convention  Business was discussed,
and the following Committees named:—
Committee on Resolutions.
Committee on Time and Place of next Convention.
Committee on Development of Association.
Committee on Officers for ensuing year.
Moved by Mr. Charles Graham, Cumberland, seconded by Father
O'Boyle, Vancouver, that the appointment of Convenors for these Committees be left to the President
Meeting adjourned to meet at 2.00 p.m.
TUESDAY, JULY 8th, 1919.
Nursing Session.
Meeting called to order by the President at 2.00 p.m.
PRESIDENT—
I am going to ask Mr. R. S. Day, Victoria, our Vice-President, to preside this afternoon.
25 MR. DAY—
The first paper on the programme this afternoon is "The Standardization of Training Schools in British Columbia," by Miss Helen Randal, R.N.,
Vancouver.
THE STANDARDIZATION  OF TRAINING SCHOOLS IN
BRITISH  COLUMBIA.
By Miss Helen Randal, R.N., Registrar Graduate Nurses' Association of
B. C, and Editor of The Canadian Nurse.
Mr. Chairman, ladies and gentlemen:
In selecting the title for my paper I have taken up a much hackneyed
and over-worked word, which, with re-construction, is one of the words of
the day. Nurses' Associations, both provincial and national, have for many
years considered the standardization of the Training Schools, but I feel
that they have gone about it in perhaps a roundabout way, and that it
would be better to bring this to the attention of the Hospital Associations,
as in that way we shall interest the Hospital Boards in a matter in which
they have the greatest interest.
The glib way in which people refer to standardization of Training
Schools as they might to the standardization of sterilizers or other part
of hospital equipment, shows that they do not realize the tremendous difference there is between the needs of a hospital of one thousand beds and
that of from fifteen to twenty. In order to explain fully why the need of
standardization comes before us at this time, we must go back to the old
idea of the origin of hospitals. This word was used in the term "hostel"
or "home," covering shelter for patients, and the hospitals in this province,
as in all parts of Canada, have practically arrived from that original idea.
The small town would feel the need of having a place for sick patients to
be taken care of, and the most interested people in the vicinity would choose
some site, generally some place that was already built, and arrange as best
they could for the accommodation of the sick of that town. This in many
cases formed- nothing but a shelter for patients, the modern hospital idea
hardly coming into play at all. The Training School evolved itself from
the fact that the patients required care. The consultation of the powers that
be thought graduate nurses were out of the question, owing to expense of
salaries, even if they might be obtained in numbers sufficient to take care
of the patients, and the Training School was started. One can easily see
how, with limited finances and the need staring them in the face, that this
condition should arise, but we have no right to feel that we may leave this
condition as it now exists. In order to judge fairly of conditions one must
be able to look at the point of view of the patient, the hospital authorities,
and last, but not least, the pupil nurse.
When we come to hospital standardization, as far as the building is
concerned, that was taken up very fully last year at the Hospital Convention, and it seems to me that something definite should be arranged for by
the Provincial Government, that no hospital receiving provincial financial
aid should be allowed to put up any building or occupy any building whose
plans have not been seen by some competent architect. In that way many
of the fire traps, inconvenient and inadequate hospitals would not exist.
Looking at it from the patient's standpoint—what may they expect as
a standard? They should be able to expect to find in a hospital to which
they go, proper equipment, not too extravagant, but the needful equipment
for their proper care; they should expect to find a building that is sufficiently sound-proof so that their rest is not disturbed; they should expect to
have sufficient supervision by the medical men that they should never at
any time be left without a resident physician; they should expect to find
definite supervision of the pupil nurse by a properly competent Superintendent of Nurses, and they should also expect to find sufficient nursing help
so that their general nursing care can be undertaken by the hospitals themselves, without, requiring the use of specials.
What should the hospital authorities expect? They should expect to
have as a standard their Superintendent and their Superintendent of Nurses
both equipped for their work. Before going any further I should go back
to a point which may be rather a shock to a good many of you, and cer-
26 tainly will be a surprise to some, to know that in our estimation for standardization of Training Schools the Hospital Board finds a place. In how
many of our hospitals do we find men elected to serve on Hospital Boards
who, during their term of office, know nothing whatever of the work of the
hospital, with the exception of its finances. In the East where the Hospital
Boards are elected year after year, sometimes serving throughout an entire
lifetime, they may get to know something of the workings of the hospital,
but unless each man definitely feels that it is his responsibility in accepting this position, not only to understand how the hospital is run financially,
but also to understand fully that they must know more about the actual
working conditions, about everything in it, that they must know whether
the patients are getting what they require, and also whether the nurses
are getting what they are led to expect that they should have. I would
like to see each one of the members of the Hospital Boards here present
go back with searchfhgs of conscience and ask themselves if they understand as much as they should and have paid the attention they should to
the work they have undertaken to do.
After the standardization of the Board comes the standardization of
the Superintendent. To how many Boards does the question come when
they require a Superintendent of a Hospital, as to whether that man has
any other qualifications for the position other than that of being a medical
man? If they have a nurse as Superintendent of the Hospital and Superintendent of Nurses, how many times does the question of salary form the
only basis or criterion of her value? It is a positive fact that, as far as
B. C. is concerned, Superintendents of Nurses have been taken into hospitals where they have never even asked the hospital from which they graduated, if they have had experience or if they come up to a definite standard.
The chief point of view of the Board is, does so-and-so manage the hospital that there is not very much of a deficit? As a standard the hospital
should insist that a man or woman occupying the position of responsibility
as Superintendent of a Hospital, should know and have some experience
along executive lines, particularly along the institutional lines such as they
are undertaking to do. As for the poor unfortunate woman who may be
selected, as is so often the case, as both Superintendent and Superintendent
of Nurses, what should be said of her? She is expected to be a good financier, to understand thoroughly the equipment of the hospital, engineers,
plumbers, laundry, have a motherly eye over the housekeeper and other departments, to supervise the teaching and training of the pupil nurse and to
see that the patients are well taken care of. What do the Boards demand
as a standard, and what salary does she require?. Boards should realize
that their demand should be for a woman, experienced and competent, and
then pay the salary which will encourage those fitted to accept the position.
May each member of the Board here present take this question home, as to
the requirements necessary for Superintendent of their Hospital.
For the standards for teaching we have to take into consideration the
fact that there is a definite agreement made between the hospital and the
pupil nurse or probationer. She enters the hospital with a definite viewpoint, she has come there to get her training or her equipment for her professional life. She gives her services to the hospital in return for the training and the education she gets. In how many cases is that educational
training adequate? In how many hospitals do we find that any amount of
equipment is cheerfully given to the Operating Room or other departments
of the hospital proper, but is it not almost impossible to get a suitable equipment for the teaching of the pupil nurse? How many hospitals, can truthfully say that they have suitable library, demonstration equipment, or, in
fact, any real definite scholastic equipment for a hospital claiming to give
a training to pupil nurses? The pupil on entering feels that she must devote her life to her profession, and she naturally considers the matter in
this way—or should consider the matter in this way—does this hospital
which I have entered give me a recompense for the labor which I am giving? The work of the pupil nurse is practically of no value to the hos-
pital in the early days, but there is a definite contract entered into by the
hospital by which they take this untrained material and by using her constantly improving skill for the hospital, they also definitely place themselves in the position of giving her a  definite training.   The university
27 course of The Vancouver General Hospital is a step in the right direction.
It is something of which I am very proud, but I feel that so far as the
standardization of the Training Schools of British Columbia goes, The
Vancouver General Hospital and Provincial Royal Jubilee Hospital, Victoria, when they arranged for affiliation with the smaller hospitals of the
province, did more for the standardization of the hospital than in any other
way. The old trite saying that "the chain is no stronger than its weakest
link," comes in when the small hospitals must be considered in any scheme
for standardization. The large hospital can safely look after itself, but our
constant effort must be to help the small hospital to come up to the rights
and expectations of the pupils. The small hospital benefits again by affiliation, because they can turn out honestly and truthfully young women as
graduate nurses of their hospital, feeling that they can take their place with
any other. In the second place they gain by being able to get better material, by encouraging the young women of that vicinity to enter the small
hospital with the knowledge that a part of their term will be given them in
the larger and more interesting Hospital Training School. I have been
pleased in this last year to see several hospitals asking for probationers,
stating that they are affiliated with The Vancouver General Hospital or the
Provincial Royal Jubilee Hospital in Victoria. The question comes up in
the smaller hospital as to what teaching facilities they need, and that rests
largely with the standard that they set for their Superintendent of Nurses.
The wards of any hospital furnish a very large field for education of the
nurse if the material there is properly used.
So far as the hospital is concerned, I have told you what the student
has a right to demand from the hospital. What must we ask from the pupil
herself? The standard of admission, so far as education is concerned, can
hardly be raised too high if it were possible to get the young women with
the higher education to enter. A certain amount of high school education
should be the minimum qualification, whether one year or the full course,
is a question which cannot be too hastily settled. In California this spring
they made a decided departure from the usual way of providing standards
of admission, which are usually put up in each individual case to the Superintendent of Nurses to decide. In this new scheme all pupils desiring to
enter California hospitals, send their names in to the Central Registration
Board, and they decide who is eligible and who is not She can then choose
whichever hospital she prefers to enter, but her standard must be settled
by the Registered Nurses' Association of California, which is actually the
State Board of Health.
So far as our Curriculum goes, that has to be worked out in detail, but
these things we must demand—that the nurses have proper facilities for
the theory and practice of the Anatomy and Physiology, Dietetics, Contagious Diseases, Medical, Surgical, Obstetrical and Gynaecological work—
Contagious work should be, perhaps, optional. No yoong woman, however,
in my estimation, is thoroughly qualified unless she has had Contagious
practical work, but one cannot always give that in smaller hospitals, but
it might be easily arranged for by affiliation. The public are asked to
support the hospitals, and they have the right to ask and demand that their
daughters and sisters should be given a suitable chance to get a proper
education along nursing lines. To the average person a graduate nurse is
a graduate nurse, but to our sorrow we know that many nurses have been
taken in to these so-called Training Schools, who have not had anything
like the training they should have had for the three years' service they
have given. If any hospital feels that they can neither affiliate with the
larger general hospital nor give the training that is required, they should
in all common honesty give up the name of Training School and undertake
to nurse their patients by means of the graduate nurse.
What are our ideals, and what is the future of the Training School?
To our mind we see the Training Schools of British Columbia all united
in one effort to give a standard education to the young women entering
their doors. That this can be done we feel absolutely sure, if the common
ground of the minimum curriculum be taken and the common attitude of
giving and taking between the large and the small hospital in affiliating
be understood. Then, and then only, can we feel that our hospital has done
its duty—the small ones in sacrificing a portion of the three years they
28 expect to have the pupil nurse, in order to give her a training in the larger
hospital, and the large hospital in assuming a slight extra amount of work
in the arrangement for the taking in of these affiliated pupils. In my experience of British Columbia hospitals for the last seven years, I feel sure
that with the enthusiasm and the high ideals of the past, we will be able
to accomplish all that is hoped.
MR. R. S. DAY—
Miss Mackenzie will open the discussion of this paper.
MISS J. F. MACKENZIE—
Miss Randal has covered this paper so fully in all its details, that there
is nothing left for me but to get down to the curriculum.
It affords me a great deal of pleasure to at last begin to realize that
we are going to have our Hospital Training Schools standardized. Dr.
MacEachern said "We are going to do things." In consequence of that
remark I sincerely hope in three months we will be standardized. It is
well over a year since we had registration. In three years from last April
the pupils of our Training Schools will be called upon to take provincial
examinations before they can get registration. If we cannot standardize
and our pupils have not the same text and reference books, we cannot possibly give them any conception of what they must study in order to be prepared for our provincial examinations.
I was appointed Convenor of a Committee to work out a practical
Course of Study, or, in other words, a minimum Curriculum, for our
Schools. This has not all emanated from my brain—I made a collection
of all printed curriculums, from which I worked this out, and added a
great deal of detail which possibly would not be necessary in the large
Training Schools. I will not take this Curriculum up in detail, but I feel
we should take a decided stand at this session, and I hope a good Committee, acquainted with Training School curriculums, will be appointed to
investigate this Curriculum, and if it is not approved as a whole, it will
at least be a skeleton for a beginning. I want Dr. MacEachern to investigate it thoroughly.
A SUGGESTED COURSE OF STUDY FOR THE HOSPITALS
OF B. C.
Requirements for Credited Schools of Nursing.
The Hospital.
Training Schools connected with a general hospital of at least fifteen
beds (or a special hospital which is affiliated with an approved general hospital), the Principal and Night Superintendent of which are registered
nurses or eligible for registration, giving a three-year course of instruction
and providing general training in the following departments of nursing:
Medical, surgical, obstetrical and pediatric nursing, and which schools are
registered by the Council under this Act as approved Training Schools.
Training Schools which do not provide adequate opportunities in all the
above departments, shall not be registered as approved Training Schools,
unless they first become affiliated with institutions approved as giving such
opportunities.
It shall provide proper and adequate facilities for class instruction,
such as a working library, in which is included the modern text and -reference books, a skeleton, a manikin or charts, and such additional auxiliary
apparatus as the hospital may be able to afford. The class-room must be
well lighted and provided with a student's table, chairs and a good sized
blackboard. There must be a demonstration room and demonstration equipment as outlined in the pamphlet "Elementary Nursing Procedures." It
shall provide a diet kitchen and the necessary equipment for teaching purposes.
It shall provide the necessary laboratory equipment for the teaching of
elementary bacteriology and analysis of urine.
Admission.
Candidates for admission to Training Schools for Nurses should present the following evidence:—
1.   High school.
29 2. Home training and influence fitted to form good moral character,
and lay the foundation for the future work of the nurses.
3. Good physical condition. A complete physical examination must be
made by a physician before application is accepted. Physical and mental
development shall be taken into consideration in connection with the age
of the candidate, but in general it is advised that a pupil shall not be under
twenty years of age or over thirty-five years of age.
4. It is recommended that students shall be admitted in classes at
stated periods during the year.
Course of Instruction.
The course of instruction, theoretical and practical, must cover a period
of three years in the Training School.
When schools can not provide opportunity for practical experience in
any one major b^nch, they must affiliate with other approved schools giving the required experience.   The studies must be as follows:—
Practical Experience.
1. Preparatory course     4 months
2. Medical nursing    4
3. Surgical nursing    4
4. Operating room, dressing rooms and dispensary    4
5. Obstetrical  nursing      4
6. Children   _    4
7. Contagion         2
8. Dietetics  _ _    2
9. Night duty    4
10. Vacation      2
11. Elective time  _ _    2
In the instruction of male nurses, hospitals shall provide lectures and
practical experience in genito-urinary diseases, instead of obstetric nursing.
Graduates of Training Schools complying with the above requirements
who have completed with the three years' work outlined, and have received
the diploma of the school, will be eligible for examination by the Provincial
Board of Health. Candidates who pass successfully this examination will
be entitled to the Certificate of Registered Nurse.
Recommendations.
The Council recommends the following considerations with a view of
raising the educational and technical standard of Training Schools:
1. When a school is so situated and endowed with the facilities as to
be able to enlarge the curriculum, it is unhesitatingly recommended to do so.
2. There shall be a study room provided where there shall be absolute
3. There shall also be a recitation and lecture room.
4. There shall be a special instructor of nurses in each school.
5. Teaching requires time for preparation which the Superintendent
of Nurses, who may also be the Superintendent of the Hospital, is unable
to give it.
6. The class-room shall be properly correlated with the practical opportunity offered in the wards and rooms of the hospital.
7. Good reference libraries shall be established, and a definite outline
of required reading on subjects allied to nursing prescribed during the
course.
8. Social diversion as offered by opera, concerts, musicales and lectures
shall be encouraged, and special forms of recreation should be provided in
the Nurses' Home.
9. Nurses' Home—Proper living conditions must be provided for the
students. These must include a building erected for the purpose, or, where
this is not possible, one suitable and adequate. Dormitories in upper story
or basement of hospital will not be considered. There must be a sufficient
number of airy sleeping rooms; individual rooms are recommended; there
must also be special provision for night nurses' rooms. The diet must be
simple, well-cooked, and ample.
30 10. Faculty—A sufficient force of instructors must be maintained who
are competent to conduct the instruction herein specified, and shall consist
of:—
A Superintendent or Director of Nurses, who is also principal of
the school.
A Graduate Night Superintendent, who is capable of assuming responsibility, and of teaching the students under her supervision.
A full-time Nurse Instructor in a school of over twenty-five students;
Graduate Nurses' Supervisors of all departments (Medical, Surgical, Children's, Maternity, Operating Room, etc.).
A Dietetian, who may or may not be a graduate nurse.
A staff of medical and other lecturers.
11. Records—There must be a good system of keeping records, showing in detail qualifications for admission, physical condition and character,
instruction and attendance at lectures, classes, demonstrations, practice and
efficiency in class and bedside work. This complete record of each student
must be kept from time of admission to time of graduation.
12. Affiliation—Hospitals unable to meet the requirements of capacity
and daily average number of patients, or /the requirements of experience
in any one major subject, namely, medical nursing, surgical nursing, obstetrical nursing, and the nursing of sick children, will affiliate with accredited
hospitals giving the required experience.
Suggested Course of Study..
The system of instruction outlined is intended as a guide in planning
course of study for Schools of Nursing in the Province of British Columbia
which will form a basis for accrediting regulations in the future. Revision
will be necessary from time to time to meet the increasing demands upon
nursing. By establishing a uniform method of instruction it is hoped to
build up a sound educational system for students of nursing in British
Columbia.
FIRST YEAR.
Preliminary Period—Three Months.
This course is arranged to enable the student to obtain a knowledge
of the fundamental principles underlying the work of nurses, and to become
acquainted with  elementary nursing procedures  before entering upon  the
actual care of the sick in the hospital.
Ethics—By Nurse Instructor.
The nurse's ethical relation to the hospital, physicians, patients, instructors and fellow nurses, hospital routine and administration, value and care
of hospital property. Professional ethics, discipline, courtesy, student government, the history of nursing and outline of required reading during the
course.
Elementary Nursing.
How to study, to take notes, ethics, loyalty to school and faculty, ventilation, afr composition, air contamination. Care of utensils, sinks, hoppers. Care of lavatories and refuse receptacles. Disinfection of discharges
and clothing. Bed making, occupied and unoccupied. Moving a bed patient.
Bed patient up in bed. Ether, fracture and air beds, changing linen, turning mattress of bed patient. Demonstration of cleaning room. Care of patient's room, dusting, general appearance of ward. Care of service room,
ice boxes. Method of keeping food hot. Setting up trays, folding linen,
care of linen closet, care of ice caps, hot water bags. Care of rectal tubes,
air rings,, catheters. Care of glass articles. Care of bed pans, urinals.
Arrangement of pillows and bed rest Admitting stretcher case, listing of
clothing, valuables. Cleansing bath, foot bath. Care of mouth, nails, hair,
back. Washing patient's hair. Giving and removing bed pans and urinals,
prepare patient for the night. Charting, printing, recording and fever, pulse,
temperature and respiration. Care of clinical and bath thermometers. Observation of symptoms, chills, pain, excreta, color, respiration. Asepsis,
anti-sepsis, solutions, disinfectants. Symbols and abbreviations. Pouring
and giving medicines, drugs, stimulants, opiates, cathartics.    Inflammable
31 preparations. Method of giving hypodermics, douches vaginal, douches
sural, douches nasal, enemeta cleansing, enemeta nutritive, stimulating, oil,
shock, astringent, enteroclysis. Colon irrigation. Lavage gavage. Nasal
feeding. Test meal. Catheterization. Care of specimens, single, 24th
hours. Bladder irrigation. Urine, retention, supression, residual. Counter
irritants, inflammation. Cupping, leeches, turpentine, stupes, fomentations.
Mustard paste, flaxseed poultice, steam inhalations. Hot and cold applications to eye. Typhoid sponge. Sponge bath, cold sponges. Hot packs,
hot air packs, sitz bath. Improvised croup tent, gyno positions. Method
of restraining. Preparation for physical examination, preparation for operation, shaving, anaesthetics. After care of ether cases. Surgical dressings.
Care of instruments and trays, making bandages, gauze, muslin, plaster
preparation for lumbar puncture, preparation phlebectomy for venous infusion, preparation transfusion. Preparation injection of antitoxines. Preparation of injection of sera.
Hygiene and Sanitation.
Lectures by Health Officer.
Outline of Topics.
1.   Introduction.
Definition of hygiene, sanitation, personal hygiene, public hygiene.
Relation of hygiene to nursing work.
Relation of hygiene to the nurse in her protection against disease;   in
relation to her efficiency;   in relation to her future career.
2.—Personal Hygiene.
Care of the skin, the teeth, the nails, the hands, the feet.
Baths, rest, exercise.
Ventilation of sleeping rooms, value of open-air sleeping, breathing,
posture, exercise, outdoor sports.
Clothing: special reference to corsets and shoes.
Rest, sleep, recreation. The relation of fatigue to mental and physical
efficiency.
Care of the eyes, ears, nose, throat. Hygiene of the excretory system.
Hygiene during adolescence; diseases and disorders peculiar to adolscent
period; physical and mental development; irregularities and symptoms in
connection with functions of reproductive organs.
Hospital regulations pertaining to illness, taking drugs, reporting illness, etc.
3. Ancient and Modern Theories of Disease.
Foundation of modern hygiene.    Discovery of disease germs.
Control of sources of infection;   contacts, carriers, incipient cases.
Conservation of health.   Prevention of disease;  the nurse's part.   The
practical application during training.
4. Hygiene of Food.
The general function of food.
Amount of food. Consideration of age, sex, occupation, exercise, climate, etc, as guide to amount required.
Dangers of excessive amounts, of insufficient food, unbalanced diets.
Food habits; regular eating, proper mastication, intervals between
meals. Dangers of irregular eating; constipation, indigestion, chronic appendicitis.    Effects on general system.
Dietary during training.
5. Ventilation and Heating.
The relation of heating to ventilation.
The purposes of ventilation.   Composition of air, amount of air required.
Efficiency of ventilation, taking into consideration temperature, moisture, movements of the air.
Tests of improper ventilation as increase in temperature, moisture
presence of unpleasant odors, closeness.
Methods of ventilation;  natural and mechanical.
Proper inlets and outlets.
Devices for obtaining good natural ventilation.
Systems for mechanical ventilation; plenum, vacuum, combination of
each.
32 Plumbing  pipes
Causes of stop-
Ventilating system in hospitals.
The nurse's duty in regard to good ventilation in wards and patients'
rooms.
6. Water.
The influence of water upon health.
Composition of water, sources of water supply.
Properties of pure water, dangerous water.
Purification of water. Methods of purifying water for domestic use.
Care of filters.
Uses of water in the body. Function of water as a food; amount required to be taken into the body in twenty-four hours; loss of water from
the body.    Dangers arising from neglect of drinking sufficient water.
7. Sewerage Disposal.
Important considerations in disposal of sewerage. The relation of
sewerage disposal to health. Methods of sewerage disposal; dry earth
system, water carriage system. Privy vaults, cesspools. Dangers of
pollution of water and soil.
Plumbing. Essentials of a good plumbing system,
and fixtures. Water closets. Care of plumbing fixtures,
page.   Expense of plumbing repairs.
Disposal of waste matter, as dust, paper, soiled dressings, garbage.
The use and care of garbage cans, dressing cans and other receptacles
for collecting waste material.    Crematories.
Bacteriology.
Lectures by   Pathologist.
Outline of Topics,
1. Introduction to the Study of Bacteriology.
Relation of Biology to Bacteriology.
Relation of lower organisms to disease.
Function of living matter in a living plant.
Cells, cell processes.
Protoplasm;   nature and reaction to stimuli.
The reproductive  process;   fertilization  and  development  of ovule.
2. History of Bacteriology.
Sketch of the work of Van Leeuwenhock, Lister, Koch, Pasteur and
others.
Historical theories of disease.    Importance to medicine and surgery.
3. General Morphology.
Various forms of bacteria. Methods of reproduction; spore formation;
classification.
Conditions affecting growth. Distribution of bacteria in nature, in the
human body.    Chemical changes caused by bacteria.
4. Microscopical Study of Bacteria.
Methods of cultivation. Methods of sterilization. _ Preparation and
use of culture media. Use of microscope. Staining principles and a few
simple routine bacteriological experiments.    Animal innoculation.
Method of examining dust, showing growth of cultures from dust.
The practical application to sweeping and dusting.
Cultures from washed and unwashed fingers.
Practical application to cleaning and disinfecting hands.
Cultures  from  teeth  with  practical  application.
5. Relation of Bacteria to  Disease.
Production of toxins, endotoxins, ptomains. Modes of bacterial action;
tissue changes, inflammation,  suppuration.
Transmission of disease by direct contact, by indirect contact.
Insect carriers; human carriers; shell fish, milk and other foods as
carriers.
6. Immunity.
Defences of the body against pathogenic bacteria.
Natural immunity.    Acquired immunity.
Montague,   Jenner).
Innoculation (Lady
Bacterial vaccines.
33 7. Pathogenic Bacteria.
Inflammation and suppuration.    Definition.
Pus-producing micro-organisms.
Name, form and manner qf growth.
Relation to technic of hospital work.
8. Non-Pathogenic Bacteria.
Fermentation and decomposition.
Some common varieties found in water, vegetables, milk, alimentary
canal, etc.
Yeasts and moulds.
9. Pathogenic Protozoa.
Origin and nature of the organism.
Plasmodium  malarine.    Amoeba  Coli.
10. Disinfectants and Antiseptics.
Definition, sterilization, asepsis,  germicide.
General principles of disinfection.
Qualifications of the disinfector. Terminal disinfection, (a) Chemical
disinfection.    Gaseous  disinfectants,  liquid  disinfectants,  acids,  soaps.
Standardization of disinfectants. Preparations Commonly used, strength
and relative value of each.
Method of disinfecting, taking into consideration the organism to be
destroyed, quantity of material, temperature of fluid, time of exposure,
(b)  Physical  agents of disinfection.
Sunlight, electricity, burning, dry heat, boiling, steam. Method of application, considering nature of organism and time exposure.
Practical application in the disinfection of the hands, dressings, utensils, excreta, etc.
Records.
Accuracy, neatness, importance of accurate recording, what should be
recorded,   wording,   spelling,   printing.     Proper   use   of   abbreviations   and
symbols.
Charting.
Hospital rules for charting, printing, spacing, etc., temperature, weight
and soecial charts.    Filling out blank forms, birth and death certificates,
operating room forms, requisition forms, etc.
Bandaging.
Varieties, roller, many tailed, triangular, purpose of method of applying   and   removing.     The   application   of   abdominal   and   breast   binders,
slings, etc.
Anatomy.
Cell life, tissue, structure of bone, form, number and name of bones.
Articulations.    Muscles, description and means of principle muscles.
Materia Medica.
Introductory, source of drugs, classification, form and action of principal  drugs, definitions.    Weights and measures.    Metric system.    Fractional   doses,   increasing  and  reducing  doses.    Preparation  of   solutions,
care of medicine closets, correct labeling.
Dietetics—Given by a trained dietitian.
Food, source, function, process of digestion, absorption, metabolism,
elimination. Classification of foods, food values, food as a source of
energy, various factors in the nourishment of the body, balanced dietaries,
preparation of food. Principles of cooking, effect of cooking on various
classes of food. Method of preparation and serving diets and dietaries.
General division of diets, diets in diseases, in special diseases.
Adulteration of Food.
Bacteriological decomposition, types of adulteration, dilution of value,
preservatives, etc. Care of food, care of ice box, pantry, kitchen utensils,
etc. Nurse instructor, demonstrations, preparation of tray, serving, feeding, special points in feeding very ill, helpless, unconscious, delirious or
insane patients. Charting and observation on results of routine and special diets.
34 Small Details Require Attention.
Feeding Helpless Patients.
Take time to do things right, have everything as neat and clean
and as appetizing as possible. Have clean hands. Remove all soiled
dressing excretions, etc., before you start to feed the patient. Give the
patient plenty of time to masticate his food. Cheerfulness on the part
of the nurse and appropriate conversation will aid the patient in forgetting himself, while partaking of food.
Serving Liquid Diet.
(a) To helpless patients, put your hand under the pillow, and raise
up the shoulders when the patient is drinking from a glass or cup. Feeding cup, glass tube and tray cover must be scrupulously clean. If the
patient drinks from a glass, do not have it too full. Do not have the
liquid too hot or too cold.   If broths are allowed, remove all grease.
(b) To unconscious patients, administer liquid slowly, use a teaspoon
or a medicine dropper, give at least half a teaspoonful at a time, because
swallowing is not inducted by a few drops. Unconscious patients often
must be fed by rectum.
Tray Serving and Food Serving.
Tray must be of the right size, neat and clean. If light diet is given
a small tray may be used. The tray cloth must be spotless. Food should
be palatable and attractive. Pupil nurses must not serve any article of
food to patients, except what has been ordered by the attending physician,
the head nurse or the dietitian. Rather give a small amount of food at
short intervals, than a larger amount at longer intervals. Serve hot that
which should be hot, and cold that which should be cold. A few flowers
will often be highly appreciated by the patient confined to the sick room
for a while. If possible divert the patient's mind from his own trouble
or anything unpleasant while he is partaking of food.
Examination of Urine, Feces, Gastric Contents, Sputum, Blood.
1. Review of Anatomy and Physiology of Urinary Organs.
Origin and secretion of urine. Pathology of the kidneys and diseases
with urinary symptoms. Definition of terms denoting conditions and diseases.
2. Chemical Analysis of Urine.
Chemical composition; gross appearance and characteristics of normal
urine. Quantity, reaction, specific gravity. Normal conditions influencing
character of urine. Influence of drugs. Consideration of the most common abnormal constituents of urine. Gross appearance of urine containing bile, blood, pus. Urinary sediments. Non-organized sediments oc-
curing in normal and abnormal urine. Organized sediments. Tubercle
and typhoid bacilli in urine. Method of handling and disinfecting infected
urine.
3. Examination of Urine.
Collection of specimen. Method of obtaining. Single specimen, 24-
hour specimen, voided and catheterized specimens. Preservation of
urine, sending to laboratory or physician's office. The cystoscopic
examination and catheterization of ureters. Preparation for and method
of assisting physician. Equipment for examining urine in laboratory and
in private home. Urine tests. Method of determining reaction and specific gravity.    Quantitative and qualitative tests for albumen,  sugar, bile.
4. The Feces.
Origin of the feces. Gross appearance of the normal stool; weight,
color, consistency, odor, reaction. Influence of food and drugs
mucus. How to describe a normal and an abnormal stool. Intestinal
on normal characteristics. Change due to the presence of blood, bile,
parasites. Consideration of various types found in feces. Gross appearance. Gall stones. Method of straining stool _ to obtain parasites and
gall stones. Collection of specimen for examination. Preservation of
specimen, sending to laboratory or physician's office.
35 5. Gastric Contents.
Gross appearance, and reaction of normal stomach contents. Vomitus.
Consideration of cause and gross appearance of some abnormal contents
as bile, bile-tinged, "coffee grounds," fecal, ropy, etc. Method of obtaining
specimen. Use of stomach tube. Sending specimen to laboratory. How
to describe gastric contents.
6. Sputum.
Origin of sputum. Consideration of characteristics as quantity, consistency, color, odor, reaction. Method of collecting specimen and sending to laboratory or physician's office. Consideration of abnormal characteristics in consistency, odor, color. Bacteria in sputum. Care and
disinfection of infected sputum.    How to describe sputum.
7. Blood.
Gross appearance of normal blood. Color, odor, taste, reaction, specific gravity. Amount of blood in normal adult. Red corpuscles; number and function. White corpuscles; number and function. Character of
arterial and venous blood; fresh and old blood, from pulmonary tract.
Object of the Course.
The object of this course is to give the nurse an understanding of
the nature of clinical laboratory work in connection with diagnosis and
treatment of disease, in order that she may intelligently assist the
physician in collection of specimens, and to be able to recognize abnormal
characteristics in urine, feces, sputum, gastric contents and blood. The
nurse must be able to make simple urine tests in the laboratory that she
may adapt to her work in the home. Demonstrations may be given in
the method of examining feces, sputum, stomach contents and blood for
further understanding of the nurse's part in the clinical laboratory examination, but the actual practice belongs in special post-graduate study.
Method of Teaching.
Instruction should be given by a clinician by lecture and demonstration, also experimentation in simple urine tests.   For experimentation the
class should be divided into small groups.
Text and Reference Books.
Urinary   Diseases       Blodgett
Clinical Laboratory Technic for Nurses   Gibson
Practical  Examination of the Urine    Tyson
EKamination of the Urine   Saxe
JUNIOR YEAR
Anatomy and Physiology.
Includes lectures by a physician, the circulatory, respiratory, digestive
and excretory systems.
Materia Medica.
Lectures by physicians, the special properties of drugs and their effects, poisons and their antidotes, drug habit, administration, taking orders, written and verbal, responsibility in executing.
Medical lectures, history and physical examination of patients, the
pulse, temperature and respiration, normal and pathological, observation
of patient, recording symptoms, special examination of blood, urine, feces,
etc., duty of the nurse in carrying out the treatment outlined in the following diseases:
(a) Diseases of the circulatory system, heart, blood vessels, pericarditis, myocarditis, endocarditis, arterioclerosis, apoplexy, aneurysm,
thombsosis, embolism, etc.
(b) Diseases of the respiratory system, nose and the bronchi lungs,
coryza hay fever, adenoids, enlarged tonsils, layrngitis, acute bronchitis,
pneumonia, pleurisy,  empyema, hemoptysis.
(c) Diseases of the digestive system, the mouth, the stomach, the
intestines, the accessory glands, stomatitis, structure of the espohagus,
gastritis, dilatation, acute and chronic, gastric ulcer, constipation, diarrhoea, volitis, appendicitis, peritonitis ascites, cholecystitis, cerrhosis,
pancreatitis.
36 (d) Diseases of the kidneys, the normal and pathological kidney,
weter, bladder, conduction and execution of the urine, bright's disease,
anaemia,  nephritis   (acute  and  chronic),  pyelitis,  renal,  calculus,  etc.
(e) Analysis of urine collection of specimens, gross appearance of
normal and pathological urine ,specific gravity, acidity, alkalimity, demonstration   of  quantative   and   qualitative  tests   for  albumen,   sugar,   bile.
(f) Constitutional disease, gout, diabetes, disease of the Thyroid
gland, goiter, cystic and exophthalmic, cutinism, myredems.
(g) Infectous diseases, infection, contagion, prophylaxis, inununity,
typhoid fever, cerebrospinal meningitis, cholera, malarial fever, yellow
fever, influenza.
Medical Emergencies.
Syncope, convulsions, heat stroke, paralysis, chill, collapse, method of
giving artificial respiration.
Massage.
Lectures and demonstrations by an expert masseuse.   History of m^
sage—objects,  indications,  contra-indications.    Methods—general  massage,
local massage.
Medical Nursing.
Classes and demonstrations by nurse instructor. Observation of patient, recording symptoms, preparation for physical examination. Effect
of local and general treatment. Method of administering nasal and rectal
feeding, infusion, stomach washing, test meals, assisting in transfusion,
lumbar puncture, phlebectomy. The general care of the medical patient
during acute and convalescent stages, use of appliances for comfort of
patients. Duties of nurse in emergencies. Duty of the nurse to the patient, to the family, to the public, and to herself in nursing infectious
diseases.
Surgery.
(a)
surgery.
.SECOND YEAR
Lectures by Physicians—Principles of aseptic and antiseptic
Surgical infection, process of wound, preparation for operation,
general and local, operating technique, duties of nurse in the operating
room, care of patient after operation, observation of pulse, temperature,
respiration, and color while recovering from the anaesthetic, diet after
operation,  in general and special cases.
(b) Surgical emergencies—Fractures, dislocations, sprains, contusious,
burns, scalds, etc., shock hemorrhage, thrombosis,, embolism, immediate
treatment and  duty of nurse while awaiting the  surgeon.
(c) Surgical Operations—Operations on the head or spine, on the
chest, stomach, liver, gall bladder, spleen, and intestines, operation on
the pelvis and pelvic organs, cysts, tumors, amputations, fractures. The
special nursing care to be emphasized  in each  case.
(d) Orthopedic Surgery—Study of defects and deformities, tubercular
diseases of the bones and joints, general care of the surgical child, care
of the apparatus and corrective appliances, casts, etc.
(e) Surgical Dressings and Bandaging—The technique of dressing
wounds,   bandaging  in   special   cases.    Application  of   splints,   casts,   etc.
(f) Anaesthetics and their Administration — History, _ various
anaesthesias, general and local, primary and secondary anaesthesia, preparation of patient, method of administration, care of patient after
anaesthesia,  complications.
Surgical nursing, demonstration and classes by Nurse Instructor and
Supervisor of operating room.
Details of preparation for operation. Care of patient during and after
operation.
Preparation of operating room, preparation of room in private house.
Care of instruments and appliances, preparation of water, solution, dressings, sutures, etc.
Examinations.
Position of patient for examination and dressing. The dorsal, knee,
chest, sims, lithotomy, trendelenburgs. Duties of nurse in assisting exi
aminations and dressings, in giving infusions, transfusions, rectal stimula-
37 tions, special douches, phlebectomy, infection of antitoxin vaccines, serums,
lumbar punctures, paracentesis, etc.
Obstetrics.
Lectures by an obstetrician. Anatomy and physiology of reproductive
organs, hygiene and physiology of pregnancy, complications of pregnancy,
physiology of labor, preparation of room, instruments, dressings, etc.
Preparation of patient for labor; duties of nurse during labor. General
care of mother during the puerperium, complications of labor and the
puerperium, obstetrical operations, post-partum hemorrhage, puerperal
fever, eclampsia, insanity.
Care of the New-born.
Complications  endangering the life of the child, the premature infant,
infant   feeding,   general  management  of  infant  as   to  bathing,   fresh   air,
exercise, sleep, etc.
Ethics of the Obstetrical Nurse.
Her relation and responsibility to patient and physician. Engagements,
awaiting call. Her responsibility to herself, rest, sleep, out of door recreation; her deportment, conversation, gossip. The protection of herself
in  infectious  cases;  gonorrhoea,  ophthalmia neonatorum.
Demonstrations by Supervisor or Nurse Instructor in Charge of Obstetrical Department—Preparation of delivery room, and of delivery' bed
in hospital and in home, preparation of instruments, water, solutions,
dressings, linen in hospital, in home economy. Sterilization in hospital,
in home. Preparation of patient for labor, care of patient, duties of nurse
during labor, care of the new-born; immediate care of the eyes and
umbilicus, oiling, bathing, warmth, etc. Complications—Preparation for
perineorrapy,  for major  operations.
The   care   of  the   mother   during  the   peurperium;   the  breasts,   the
genitals, massage of breasts, bandaging.
Complications.
Hemorrhage, eclampsia, mastitis, fissures of nipples, excessive secretion of milk, suppression of the milk, care and handling of the baby,
care of the mouth, eyes, umbilicus, bathing, dressing, nursing, training.
Complication of the New-born.
Cyanosis, asphyxia, artifical respiration, bleeding from umbilicus, infection, delayed urination, phimosis, preparation for circumcision, infection of the eyes, treatment, removing secretion, applying drops, compresses,
protection of non-infected eyes, infection of the mouth, thrush, care of
cleft palate, use of hot water bags and electric pad, care of the premature infant, management of incubator, improvising an incubator, ventilation, feeding,  dressing, weighing.
Tuberculosis.
Lecture's by Physician—The nurse in relation to tuberculosis, the
cause and control of tuberculosis of the bones and joints, tubercular
lymph nodes, tubercular meningitis, tubercular peritonitis, pulmonary
tuberculosis. The hygiene of tuberculosis in the hospital, in the hospital tent, in the sanatorium, in the home. State laws pertaining to
tuberculosis.
Hydro Therapy.
Lecture by Physiotherapist.
1. History and General Consideration.
Therapeutic effects of water. Terms used in describing. Terms used
denoting temperatures.    Classification of procedures.
2. Local Application of Heat.
Articles required. Preparation of patient. Procedure in applying
fomentations, stupes, compresses, chest packs, hot water bottles. The
arm bath, foot bath, sitz bath. Radiant heat, electricity. Effect of treatment.
3. Local Applications of Cold.
Procedure in applying compresses, chest pack, ice pack, ice coil, sitz
bath.   Effect of treatment.
38 4. General Application of Heat.
Articles required. Preparation of patient. Procedure in administering
hot pack; hot blanket pack (wet); hot blanket pack (dry). Effect of
treatment.
5. General Application of Cold.
Procedure in cold pack, cold sponge, wet sheet.    Effect of treatment.
6. Alternate Hot and Cold.
Neutral baths.    Revulsion baths.    Effect.
7. Rubs and Friction.
Purpose  of  friction,  general  order  of movements.    Alcohol   rub,  salt
nib, oil rub, dry friction.   Method of procedure and effect.
8. Special Therapeutic Baths.
Hydro   electric,   Nauheim,   Cabinet,   Turkish,   Russian,   Electric   light.
9. Sponges and Douches.
Shower bath. Cold or neutral spray. Hot, cold and neutral douche.
Method of procedure.    Effect of treatment.
THIRD YEAR—SENIOR TERM
Pediatrics—Lectures by a Specialist
The care of the child in relation to food, sleep, bathing, clothing,
fresh air, exercise, amusement, surroundings, etc. Observation of the
symptoms and needs of sick children, general management and care of
the sick child. Amusement during convalescence. Effect of local and
general treatment, effects of drugs on children.
Treatments.
Inhalation, stomach washing, rectal irrigation, nasal  feeding,  etc.
Nutrition.
Feeding in health and acute illness.   Diseases due to faulty nutrition,
maramus, scorbutus, rickets.
Diseases of the Digestive System.
Stomatitis,    acute    gastritis,    diarrhoea,    appendicitis,    constipation,
ascites, etc.
Diseases of the Respiratory System.
Acute and chronic nasal catarrh, pneumonia, empyema, bronchitis.
Diseases of the Circulatory System.
Pericarditis, endocarditis, etc.
Diseases of the Nervous System.
Convulsions,  chorea, epilepsy, tetany, spinal meningitis, paralysis,  etc.
Contagious Diseases.
Method of disinfection, isolation, quarantine, scarlet fever.    Symptoms
—Fever, rash, complications and precautions.
Diphtheria.
Symptoms—Fever, rash, general care and precautions.
Chicken Pox.
Measles, mumps, tonsillitis, whooping.
Ethics.
Lectures  by  physician.    Moral   prophylaxis,   ethics   of  private   duty,
ethics of institutional nursing.
Nervous and Mental Diseases.
Lectures by physician. Anatomy and physiology of the nervous system, neurasthenia, psychosthenis, hysteria, epilepsy, stupor, coma, insomnia, restlessness, violence and self-destruction. Depression, dementia,
mania, senile and post-operative.
Causes of Mental Diseases.
Drug habit,  symptomatology,  general   nursing,   care  and  management
of the nervous and insane.
Veneral Diseases.
Lectures by physician. Gonorrhoea, syphilis, dangers of transmission,
prophylaxis, caution to nurses.
39 The Skin.
Lectures by a specialist. Anatomy and care of the skin. Drug rashes,
urticaria, eczema, scabies, pediculosis, lupus, etc.
Orthopedics.
Lecture by Specialist.
1. Definition.
Review of anatomy and histology of bone and formation of joints.
Diseases of bones and joints; tuberculosis, lues, osteomyelitis, etc. Diseases due to faulty nutrition.   Postural diseases.
2. Deformities.
Congenital and traumatic. Club foot; claw foot; congenital dislocation, curvatures, etc. Deformities due to tuberculosis. Pott's disease.
Operations and manipulations for the correction of deformities. Flat
foot, and methods of strapping for relief. Method of extension for correction of deformity. General care of the child; hygienic conditions,
nutrition, etc. Corrective work. General exercise and special gymnastic
work.
3. Apparatus Used in Orthopedic Work.
Explanation of splints and braces. The preparation of plaster splints
and bandages. The application of plaster casts and jackets. The taking of
impressions in plaster. The duty of the nurse in preparing and assisting.
Demonstration in the application of apparatus.
4. Care of Patients in Plaster Casts and Braces.
Treatment of skin before application of cast or jacket. Care of skin
while cast is worn and after its removal. Methods of nursing orthopedic
cases. Comfortable position, exercise, bathing, massage. Methods of
protecting cast as regards cleanliness. Method of removing casts and
jackets.
5. Orthopedic Operations.
Consideration of the more common operations for defects and deformities. Bone and tendon transplantations. General and local preparations of patient.   Importance of the nursing care after operation.
The Eye.
Lecture by Specialist.
1. Anatomy and Physiology of the Eye.
General optical principles. Eye strain. Relationship of eye to other
organs of the body.
2. Diseases of the Eye.
(a) External.
(b) Internal.
(c) Traumatic.
(d) Contagious.
3. Examination of Eye—The Illumination.
Operations on the eye. Preparation of patient, local and general.
The anaesthetic. Preparation of operating room, the illumination, solutions, instruments, dressings, etc. Duties of nurse during the operation. Care of patient after operation, relative to surroundings, light,
quiet, feeding, etc. Names of the principal instruments used in eye operations.
4. Treatment of Eyes.
Application of drops, compresses, irrigations, ointments, heat and cold.
Solutions used in treatment of the eyes. The use of mydriatics, myotics
and cocain. Eversion of lids, removal of foreign bodies. Bandaging the
eye. Special appliances and dressings. Applications of and removal of
dressings. The nurse's duties in nursing contagious diseases of the eye.
Management in regard to isolation, contacts, care of discharges, bedding,
clothing, utensils, instruments, etc. The nurse's care of her own eyes.
Reporting of trachoma and opthalmia neonatorum. The use of prophylactic for ophthalmia neonatorum and care of infants' eyes.
40 The Ear.
Lecture by Specialist,
j;   Anatomy and Physiology of the Ear.
Relationship to adjacent organs. The phenomenon of hearing, of
equilibrium. Examination of the ear; the illumination. Preparation of
instruments, dressings, solutions, etc. Preparation of the patient. Duties
of the nurse as assistant.
2. Diseases of the Ear.
(a) External.
(b) Middle
(c) Internal.
Duties of the nurse in caring for contagious diseases of the ear
relative to discharges, bedding, towels, utensils, etc.
3. Operations on the Ear.
Paracentesis. The mastoid operation. Preparation for operation of
the patient for a general anaesthetic. Preparation of the part; shaving,
shampoo, disinfection, dressing. Preparation of the room; instruments,
solutions, dressings, etc. Duties of the nurse during operation. Complications following the mastoid, operation. Instruments used in ear
operations. Care of instruments. Dressing of the ear. Special appliances.   The bandaging of the ear.
4. Treatment of the Ear.
In trauma. In eczema. Syringing the ear; removal of cerumen and
foreign bodies. Nursing in acute middle ear affections. Remedies to be
applied in emergency conditions.
The Nose.
Lecture by Specialist.
1. Anatomy and physiology of the Nose.
Functions of the nose; the special sense of smell. The nasal sinuses.
Relationship of nose to adjacent organs. Examination of the nose.
Preparation of patient (adult and child)  for examination.
2. Diseases of the Nose.
(a) Acute.
(b) Chronic.
(c) Traumatic.
(d) Contagious.
3. Operation on the Nose.
Septum operation. Fracture of nose. Preparation for operation, instruments and disinfectants, solutions. Duties of nurse as assistant. Care
of patient after operation; complications following operations.
4. Treatment of the Nose.
Epistaxis—emergency treatment—when to summon the physician.
Removal of foreign bodies; irrigation, solutions, dressings, etc. Duties
of nurse in caring for contagious diseases of the nose. Care of discharges, linen, utensils, etc.
The Throat.
Lecture by Specialist.
1. Anatomy of Pharynx and Larynx.
Relationship to adjacent organs. Examination of the throat; position
of patient; the illumination.   Restraint of child.
2. Diseases of the Pharynx and Larynx.
(a   Congenital—Cleft-palate, bifid uvula.
(b) Acute infectious—Pharyngitis, tonsillitis,  diphtheria.
(c) Chronic   infectious—Tuberculosis,   carcinoma,   syphilis
Duties of the nurse in caring for infectious diseases of the throat;
care of instruments, utensils,  linen,  etc.    Protection of herself.
3. Operations on the Throat.
Tonsillectomy, adenectomy, trachelectomy, laryngectomy, cleft-palate.
Preparation for operation.    Preparation  of patient for a  general  anaes-
41 thetic. Preparation of the operating room; instruments required. Positions of patient for operation. Duties of the nurse as assistant Complications that may arise during the operation. The after treatment The
general care of adults and children relative to position in bed, rest, feeding and general comfort. Complications that may arise immediately following operation and during convalescence. Haemorrhage. The tonsil
hemostat Special care in the after treatment of operation for cleft-
palate and harelip. Management of children relative to feeding. Care of
the mouth.
4.   Treatment of the Throat
The use of gargles, inhalation, sprays, irrigation, applications. Nursing in acute conditions ;of tonsillitis, pharyngitis, acute laryngitis. The
croup tent, the intubation tube. Points to be emphasized in the management of children.   Method of obtaining a culture from the throat.
EXAMINATION    FOR    CERTIFICATE    OF    REGISTERED    NURSE
1. The Board of Examiners shall hold meetings at least twice a
year for the examination of applicants for membership in the Association. The registrar shall at least one month before the date fixed for
the examination give notice of the tme and place of holding of every such
examination, by publication of a notice thereof in at least two newspapers
published in the province, and in at least one Canadian journal devoted
to the interests of professional nursing, and by mailing a copy of the
notice to every applicant of whom the registrar has notice, and to every
approved training school in the province.
2. Every person desiring to become registered as a member of the
Association shall make application to the registrar at least one month
prior to the meeting of the Board of Examiners for examination and
registration, stating the qualifications of the applicant, the training school
attended and the length of the course of training, and shall furnish to
the registrar satisfactory evidence of residence, age, and identification,
and shall produce to the registrar the diploma or certificate of qualification awarded to the applicant by the training school so attended.
3. Every applicant who passes before the Board of Examiners a
satisfactory examination touching his or her fitness and capacity to
practice professional nursing, and who has- the qualifications required by
and otherwise complies with the provisions of Section 19 of this Act, and
who pays a fee of $10, shall be admitted to registration as a member of
the association and shall have his or her name entered upon the register
and. receive a certificate of registration signed by the president and the
registrar, and shall be entitled to practice professional nursing in the
province, and to append the letters "R.N," or any suitable words or
designation showing that he or she has been registered in accordance
with this Act.
At the opening of the examination, each candidate shall present with
card of admission, his or her diploma from the training school which he
or she has graduated, and shall receive a printed card of instruction as
to the procedure of examination.
The examination shall be written and may consist of practical demonstration. It shall be presided over by a member of the Board of
Examiners.
All written examinations shall be on paper furnished by the Board.
Each candidate shall receive an envelope containing a card upon
which will be a distinguishing number, which he or she will use instead
of her name for the purpose of examination. The candidate shall sign
his of her name on the marked card, seal the envelope, and return to the
examiner at the conclusion of the examination.
(Male nurses will be examined in genito-urinary work instead of
obstetrics).
Examination papers will be retained and kept on file.
Candidates shall be required to pass a grade of 75 per cent, in all
subjects. On the completion of the examination, the examiner shall forward to the registrar the marks obtained by each candidate.
42 Candidates shall be examined in the following subjects:
Anatomy and  Physiojogy. Medical Nursing.
Elementary Bacteriology. Surgical  Nursing.
Materia  Medica. Obstetrical   Nursing.
Dietetics.        \ Gynaecology Nursing.
Contagious Diseases.
Certificates—Candidates who have successfully passed the examination and who meet the requirement of the law, will be given a certificate
of registration.
STANDARD   TEXT   BOOKS   AND   REFERENCE   BOOKS   FOR
SCHOOLS  OF   NURSING
ANATOMY   AND   PHYSIOLOGY
Name Author
Text Book:
Anatomy and  Physiology   Dina   Kimber
Reference Books:
The Human Body   Martin
Normal Histology      Piersol
Anatomy and Physiology   Bundy
Bodily Changes in Pain, Hunger, Fear and Rage   Cannon
Anatomy,  Descriptive  and   Surgical   _  Gray
BACTERIOLOGY
Text Book:
Bacteriology and Pathology for Nurses   Roberts
Reference Books:
Principles of Bacteriology  Abbott
Bacteriology   for   Nurses     Mclsaacs
Bacteria and  Public Health    Newman
Bacteria. Yeasts and Molds _  Conn
Dust and Its Dangers   Prudden
Infection and Immunity    Sternburg
Story of the Bacteria   Prudden
HYGIENE
Text Book:
Hygiene for Nurses  -  Mclsaacs
Reference Books:
Exercise and Hygiene  -  Galbraith
Fresh Air and How to Use It Thomas Spees-Carrington
Four Epochs of Life   Galbraith
Principles of Sanitary Science and Public Health  Sedgwick
Industrial and Personal Hygiene   Pyle
Exercise in Education and Medicine   McKenzie
CHEMISTRY
Text Book:
Elementary Chemistry     Bradbury
Reference Books:
Elementary  Chemistry    Godfrey
An Introduction to the Study of Chemistry  Remsen
Essentials of Chemistry  - -  Linebarger
Descriptive Chemistry    Newell
MATERIA MEDICA
Text Book:
A Test Book of Materia for Nurses  Dock
Reference Books:
Drugs and  Solutions  -   Stimson
Materia Medica for Nurses   Stoney
Materia Medica for Nurses  -  Paul
43 Drugs and the Drug Habit  -  Saintsbury
Materia Medica  _    Groff
Quiz Compends   ,.--  Potter
See also under subjects like Medical Nursing, Surgical Nursing.
DIETETICS
Text Book:
Practical Dietetics
..A. F. Pattee
Reference Books;
Nutrition  of Man  _ _   Chittenden
Diet in Health and Disease  _ Friedenwald and Ruhrah
The Science of Nutrition  Lusk
Chemistry of Cooking and Cleaning  -  Richards-Elliott
Dietetics for Nurses  Friedenwald  and Ruhrah
Essentials of Dietetics  Pope and Carpenter
Food and Dietetics   _   Hutchinson
Food, Cookery for the Sick and Convalescent _  Farmer
Dietetics   Gilman Thompson
MEDICAL DISEASES
Text Book:
Essentials of Medicine    Emerson
Reference Books:
Practice of Nursing   Osier
Medicine for Nurses and Housemothers   Hoxie
Medical Hand Atlas   Saunders
Medical Essays .  O. W. Holmes
Aequanimitas      Osier
Practice of Medicine   Stevens
INFECTIOUS  DISEASES
Text Book:
Nursing in the Acute Infectious Fevers   Paul
Reference Books:
The Campaign Against Tuberculosis in the United States	
 Russel Stage Foundation
Fever Nursing   Wilson
Tuberculosis, a Curable and Preventable Disease S. A. Knoff
The Great White Plague   Otis
Fever Nursing  _  Wilcox
OBSTETRICS
Text Book:
Obstetrics for Nurses  _ _.  DeLee
Reference Books:
Principles and Practice of Obstetrics   DeLee
Nurses' Handbook of Obstetrics   Cooke
Obstetrics and Gynecological Nursing   Davis
Obstetrics   .„ Williams
CHILDREN
Text Book:
Diseases of Children for Nurses   McComb
Reference Books:
Pediatrics  _  Poteh Tuley
Quiz Compends—Diseases of Children  _  Hatfield
Theory and Practice of Infant Feeding Chapin and Pisek
Care of Baby  _..J.  Crozier Griffith
Diseases of Infancy and Childhood    Holt
Hygiene of the Nursery    Starr
Diseases of Children  _  Jacobi
Care and Feeding of Children   Holt
Orthopedic Surgery for Nurses   Bemf
44 URINALYSIS
Text Books
Practical Examination of the Urine   Tyson
Reference Book:
Examination of the Urine  _  Soxie
DISEASES OF THE EYE. EAR, NOSE, THROAT AND MOUTH
Text Book:
Nursing in Eye, Ear, Nose and Throat Diseases Davis and Douglas
Reference Books:
The Care of the Teeth  „  Hopkins
A Compend of the Diseases of the Eye  Gould-Pyfe
Diseases of the Eye and Ear  _  Ailing-Griffin
Ophthalmic Nursing  Stephenson
Sight and Hearing in Childhood  Carter and Cheatle
Diseases and Injuries of the Ear   Burnett
Nursing in Eye Diseases  _  Jeaffreson
Nursing in Diseases of Eye, Ear, Nose and Throat H. Manhattan
Epidemic Ophthalmia     Stephenson
Nursing in Diseases of the Throat, Nose and Ear  Yearsley
Oral Sepsis as a Cause of Disease   Hunter
A Compend of Dental Pathology and Medicine   Warren
Lectures on Dental and Oral Hygiene   Trigger
The Deaf Child  .  Love
Mouth Hygiene and Mouth Sepsis   Marshall
DISTRICT AND  SCHOOL NURSING AND  OTHER PHASES
OF SOCIAL WORK
Visiting Nurses in the United States   Waters
Democracy and Social Ethics   Addams
Spirit of Youth and City Streets   Addams
Misery and Its Causes  -  Devine
Efficiency and Relief     Devine
Hygiene and Morality     Dock
Medical Inspection of Public Schools  Gulick and Ayres
Pamphlets of American Society of Moral and Sanitary Prophylaxis.
An Englishman's Castle  -  Loane
Fatigue and Efficiency    Goldmark
Children of the Tenements     Eiis
The Spirit of Social  Work    Devine
Social Forces    - ~  Devine
The Delinquent Child and the Home  .'. Breckinridge and Abbott
Social Work in Hospitals   Cannon
PERIODICALS
Canadian Nurse. Dietetic and Hygiene Gazette.
British Journal of Nursing. Nursing Journal of Pacific Coast.
American Journal of Nursing. Kai Tiaki.
The Survey. Public Health Quarterly.
MISCELLANEOUS
Nursing for Male Nurses    Hattnard
Genito-Urinary and Venereal Diseases   Hirsh
Pocket Edition Medical Dictionary   Dorland
Medical   Dictionary   -    Gould
Private  Duty Nursing      DeWitt
Making Good in Private Duty  _  Lounsberry
Handbook for Nurses  -  Webster
Rules of Order  - .—-—-.-— Roberts
State Registration for Nurses  ■ Boyd
The American Illustrated Medical Dictionary  ... Dorland
HYDROTHERAPY
Text Book:
Practical  Hydrotherapy     Kellog
45 Reference Book:
Hydrotherapy
Baruch
SURGERY
Text Books:
Surgical and Gynecological Nursing Parker and Breckenridge
Accidents and Emergencies  1 - ~   Dulles
Reference Books:
Modern Surgery    DaCosta
Essentials of Modern Surgery  _  Martin
Surgical Technique for Nurses  -  Stoney
Principles and Practice of Bandaging  _ Davis
Red Cross Text Book on First Aid Major Chas. Lynch
Operating Room and the Patient -  Fowler
NURSING   OF  NERVOUS  DISEASES
Text Books:
Psychiatry        Paton
Nursing the Insane    Barras
Reference Books:
Practical Manual of Insanity   Bron Bannister
Influence of the Mind on the Body  ~  Dubois
Psychic Treatment of Nervous Disorders    Dubois
Self Control and How to Secure It      Dubois
Self Help for Nervous Women   Mitchell
Nursing the Insane  .'.  Clara Barruch
Nursing and Care of Nervous and Insane   C. K. Mills
A Mind that Found Itself  _  Clifford W. Beers
Invalid Occupations   .'.— Tracy
Psychology—Briefer Course   William Jones
Primer of Psychology and Mental Diseases  _.. Burr
PRINCIPLES AND PRACTICE OF NURSING
Text Book:
Practical Points in Nursing   Emily A. M. Stoney
Reference Books:
First Year Nursing  „ Goodnow
Modern Methods of Nursing      Sanders
Notes on Nursing   Florence Nightingale
Principles and Practice of Nursing „  Isabel H. Robb
Practical Nursing    Maxwell and Pope
A Text Book of Nursing  _   Weeks-Shaw
Primary Nursing Technique    _      Mclsaacs
HISTORY,   BIOGRAPHY   AND   MISCELLANEOUS   ESSAYS
Ethics of Nursing   Isabel H. Robb
History of Nursing      Nutting Dock
History of Nursing in the British Empire   Tooley
The Historical  Relations  of Medicine  and  Surgery    Allbutt
Notes on Hospitals      '.  Nightingale
Life of Florence Nightingale    Tooley or Eliza Pollar
The  Organization of Nursing   „  Nightingale
The   Art   of   Healing     „. _. „   Cabot
Epoch   Making   Contributions   to    Medicine,   Surgery   and   the   Allied
Sciences  ._    i . Camac
Counsels and Ideals from the Writings of William Osier Camac
DR. M. T. MacEACHERN—
I want to congratulate Miss Randal on the excellent paper which
she has given us, and Miss Mackenzie on her work. It is a great pleasure:
to know that we are going to have something standardized for training
schools in British Colombia. I folly agree with Miss Randal that oor
hospitals in the whole of Canada do not give the training school the
support they should.   I consider that our hospitals are efficient only as far
46 as oor nursing service is efficient. I think that all hospital administrators
and members of boards here will go home and decide that they have to
reconstruct and give their training school every possible support in the
future.
Miss Randal spoke about the University scheme, and I thought at
the time that possibly it might not be familiar1 to a number of you, and
I would like to explain a little about it. The University scheme is a
sort of pet of mine, and a few others, and we are so pleased to know
that the University of British Columbia has accomplished it. It is not a
scheme for the big hospitals altogether—the University affiliation in
British Columbia is open to every hospital in this Province if they can
measure up to what they should. Your nurses can go and take the degree if they can measure up to what they should. Furthermore, the University will turn out instructors, teachers and superintendents who
shall go to the smaller hospitals of British Columbia. It is to put nursing on a higher plane, and to stimulate smaller hospitals to more efficient
training schools. The' department will be manned by a teaching personnel, doctors and nurses. A nurse will be at the head of the department. They; will, for the time being, be very intimately connected with
our hospital, because we are paying the entire expense thereof, but if any
hospital in this Province can measure up to the standard, and their
nurses come, after having spent three years satisfactory training, together with the preliminary education, she will get her degree through
the University, which may be Bachelor of Nursing or Bachelor of Science
of Nursing. The University asks that there be two years preparatory
course—two years' Arts, and three years' training. You will find all
through this Province that we have wonderful educational advantages,
especially our high schools, and in this way our young women can, when
they finish their high school education, go right into the University and
complete their preparatory course. There is no reason why any small
hospital in this Privonce cannot train the nurse just as well as the large
hospital. Affiliation in the Vancouver General Hospital was inaugurated
on the recommendation of Miss Randal, and I think it is one of the
best things that we have ever done, and I am* sorry that more hospitals
are not availing themselves of the opportunity. I am not going to take
up your time, but I wanted to give you a brief idea of this University
scheme, to make you feel it is as much for you as for the Vancouver
General Hospital or the Provincial Royal Jubilee Hospital, etc.
MRS. M. E. JOHNSON—
There is one thing I think we absolutely need in British Columbia
before we can have standardized training schools or a standard curriculum,
and that is a training school inspector. Hon. Dr. MacLean told us this
morning that the government was contemplating supplying inspectors for
the hospitals, and we equally need inspectors for our training schools,
'which would preferably be, I think, a graduate nurse.
MISS H. RANDAL—
I would very much like to bring Dr. MacLean to my point of view—
to have a nurse inspecting the hospitals.
DR. M. T. MacEACHERN—
I think the standard curriculum as presented by Miss Mackenzie is
a splendid work, and I am sure we are all greatly indebted to her and
others for their trouble along these lines. I am sure it will be greatly
appreciated in all hospitals. I would therefore move that we recomend
the adoption of this standard curriculum of study in our training schools
in British Columbia. Seconded by Mrs. M. E. Johnson. This resolution
was referred to the resolution committee for further report.
DR. H. C. WRINCH, Hazelton—
In  regard  to  the  matter  of  establishing a  nursing  course,   does  it
include two years' preparatory course, two years in Arts and three years'
nursing—seven years in all?
DR. M. T. MacEACHERN, Vancouver-
No,  five years.    I was  speaking of two  years' Arts  as  two years'
preparatory  coorse.    The   entrance  to   the   University   is   matricolation ;
47 two years in Arts would be more along lines as are best adapted to give
the   nurse a broader foundation for her service.
DR. H. C. WRINCH, Hazelton—
There would then possibly be two classes of nurses, one would
satisfy the minimum requirements—high school and three years' course,
and the other who had taken matriculation, two years Arts and three
years' nursing course would get the degree. I was wondering whether it
was to be insisted upon that all should take the five years' course—but I
think this is a splendid arrangement.
MISS  H. RANDAL—
We have intended to carry out. and I think it will be done within the
next few months, decided propoganda among the high school students to
bring to their attention the fact that nursing is a profession and what a
wonderful thing it is for young women, and see if we cannot induce them
to remain through the high school in order that they may avail themselves of the University chance. Not sufficient publicity has been given
the profession, the fields have not been made sufficiently attractive, and
certainly they have not been given any means of, getting any further
education than the high school. There have been many reasons given, but
it has been simply a case where the young woman did not consider it
worth her while to go on, but if we show her it is worth her while to goon, we feel we will have a sufficient number in a short time. In a very
few years we will be able to raise the minimum to our present maximum.
DR. M. T. MacEACHERN, Vancouver—
What is Miss Randal's opinion of the nurse trained in the small hos-
pittal;  can she become as equally efficient as one trained in the  large
hospital ?
MISS H. RANDAL, Vancouver—
I shall be very glad to speak on that subject I am considered to be
an advocate of the small hospital nurse. I can truthfully say that I
consider the very best trained nurses that I ever put out in the world
were the nurses I had in the smallest hospitals, not because I had better facilities, but because ! could give them the personal touch and the
personal supervision and the personal care that I could not give in the
larger hospitals. However, there is no attempt in the small hospitals made
to procure the best kind of women for their hospitals—there is no attempt to ask the larger hospitals for women, there are very few in the
large hospitals who show executive ability. You are not willing to pay the
right price to the right woman to start your nurses along the right way.
When you realize that they have not had the advantage of facilities, you
must see that they get it through affiliation, you have your opportunity,
you have affiliation in the Vancouver General Hospital, m the Provincial
Jubilee Hospital. If you have the right woman and pay her the right
salary you will have no difficultyy.
MR. C. GRAHAM, Cumberland —
What does Miss Randal consider is the smallest sized hospital that
shoold have the privilege of affiliation?
MISS H. RANDAL, Vancouver—
That is really a difficult question; I don't know. Fortunately that
was the only point we had to give way—was to the passing of the nam-"
ber of beds. It seems to me that a great many of these young women
got all their hospital work in these small hospitals. Mental hospitals
and private hospitals have to be staffed by graduate nurses, all registered
nurses. May I ask for us the support of the hospital boards and see
that they demand that that recognition is given us, which we fought for—
the right to call oorselves registered nurses of B. C, to insist when taking nurses, that they are registered. I think there should be some arrangement made by which every small hospital may be given public aid so that
they might be supplied with these future nursing aids.
MR. C. GRAHAM, Cumberland—
The point that I want to bring out is: how does the size of the hospital affect the training of the nurse? What is the relative benefit of
experience in the hospital of 25 beds and that of 200 beds?
48 II  MISS H. RANDAL, Vancouver-
No difference, provided you give, your pupil affiliation in the third
year. If you give your nurse the proper training so far as your means
go in your small hospital, and insist on taking affiliation, I think you
have done your duty by the women you have taken in, and there is no
reason why they should not be as well trained.
DR., H. C. WRINCH, Hazelton—
How does it affect nursing in the smaller hospital; affiliating with
the larger ones; what about the patients? How are we going to do justice
to our patients when we let our nurses go in the third year, when they
are just becoming efficient? Could we consider the possibility of six
months' affiliation instead of one year? Consider the viewpoint of the
patients who are being treated in the smaller hospitals. We must consider both sides. Perhaps a six months' affiliation would answer the
purpose and give the smaller hospitals use of the nurse for the other half
year. Perhaps the fact that the small hospitals object is on account of this
point.
MISS H. RANDAL, Vancouver—
That brings forward the very point I was trying to establish. You
are training students, pupil nurses to take care of your sick. The third
year work is more essential for the theoretical than the practical. You
have no right to expect her to give up her third year for the sake of
caring for your patients—that is not the purpose for which she entered
your training school. You take in young women to train as nurses, but
primarily their training is of the utmost importance, they require the
three years' training. What can you give but a repetition of the same
thing over and over again. How many departments have you in your
small hospitals. You can give them medical, surgical and possibly obstetrical. You can give no dietetics, operating room, no chance of getting children's diseases, tuberculosis or anything that comes in the third
year training. In planning out this third year affiliation I took all this
into consideration and endeavored to give each nurse a full course. I
do not feel that it is an injustice to the small hospital, in fact, I think
you will get young ladies with higher education. I think affiliation, while
it may seem to be a hardship, is really an advantage.
MISS I. M. STEWART, New York—
They do not know diseases very well; they do not get a large enough
variety of cases to actually understand the different kinds of diseases
and be able to handle children, obstetrical cases and all the different
kinds of cases. The institution I represent has a standard admission;
it requires that all should have a training in no less than a 50-bed hospital; those trained in a 15-bed hospital are not accepted. Hospitals
who do not have affiilation should not take a nurse to train without the
nurse having a knowledge of the fact. It is a serious injustice to a
young nurse.
MRS. M. E. JOHNSON, Vancouver—
I think 15 beds is an exceedingly low minimum. We have put it at
15, and that is the lowest number that will be accepted, but then I am
sure in a prairie province some concession has to be made. Manitoba has
35, and they consider that exceedingly small.
If you want to standardize your hospital, one of the best ways is to
start and educate the government and municipal councils. There are
no two bodies in British Columbia that need more education along these
lines than the   Provincial   Government  and  Municipal  Councils.
Miss Randal's address this afternoon has shown us how utterly impossible it would be for a superintendent of nurses or superintendent of a
training school to be the ideal superintendent of a hospital, because there
are so many things that a superintendent of nurses or of a training
school has to look after and the executive work for which she has practically no training in the three years' course as a student nurse. The
war has brought out the necessity for so many special courses for graduate
nurses that it is almost necessary for nurses to take up school nursing,
visiting nursing, social  service, mental hygiene, public health and child
49 welfare work. All this work requires special courses after the pupil has
graduated from a general training, and it seems very necessary at the
present time that these courses be inaugurated in our larger hospitals or
in our universities, where pupils wishing to take up special work may have
advanced training for their work.
MR. R. S. DAY, Victoria—
The next paper on our programme is "Post-Graduate Work,"_ by Miss
K. Stott, R.N., assistant superintendent Royal Columbian Hospital New
Westminster. In the absence of Miss Stott, Mrs. Broom, of Vancouver,
has kindly consented to read this paper.
POST-GRADUATE NURSING
By the term post-graduate nursing we understand advanced nursing;
although various courses have been offered under this head. Some of our
larger hospitals in Canada are now offering post-graduate courses in
special lines, such as dietetics, surgery and obstetrics, which are very
beneficial and useful to a nurse, graduating from a smaller school and
whose experience in those lines has been limited, but covers practically
the same ground as the duties of a nurse-in-training. More especially
was this so two or three years ago of some of the hospitals in the
United States, when by paying a small remuneration of $15 or $20 per
month, the service of graduate nurses was secured while the course comprised the usual ward duties. In many cases the pupil was required to
wear the uniform of the school and was subject to much the same discipline as the training school nurse. Having taken a post-graduate course
in hospital management I shall endeavor to give you the plan followed
in the institution in which I studied:
Application was made to the instructress of nurses, accompanied by
credentials from the school from which the applicant graduated. On
entering the hospital the post-graduate paid a fee of $25, $10 of which
was intended to defray the expense of any breakage in the laboratory,
and during the six months' course no remuneration is allowed,
Advanced dietetics, assisting in commissary and general stores, outdoor clinic and night supervising were the principal branches taken up
by the post-graduate nurse. The first two months she attended the outdoor clinic conducted four days a week, from 9 a.m. to 12 noon,
which consisted mainly in assisting physicians in minor operations, mostly
tonsillectomies, treatments and gynaecological examinations. In the afternoon she reported to the superintendent of nurses' office, and relieved from
1:30 to 5 p.m. where the only matters to be attended to were those which
Occur in any hospital, receiving telephone calls from special nurses registering on or off call, calling nurses on cases, answering enquiries by
patients' friends and sometimes chaperoning a lecture or examination for
pupil nurses. The two mornings which were not taken up by the outdoor clinic were devoted to dietetics and chemistry. Sherman's text book
was thoroughly taken up, accompanied by instructive experiments and
lectures given by the instructress of nurses. The post-graduate nurses
had quarters in a building which had been used for private patients before the new hospital had been built, and in the same building there was a
fairly well equipped laboratory, where we were free to go at any time, and
a good deal of off-duty time was spent there to very good advantage. As
there were never more than three or four taking the course at one time'
we always worked out our problems and experiments together and received much more personal supervision from the instructress than one
does in a larger class.
The diet kitchen practical training usually came in the third and
fourth months, covering a period of six weeks, the hours on duty being
9 a.m. to 1 pjn., and 4 p.m. to 6 p.m.. and to the post-graduate was
generally allotted the preparation of special diets. Before going to the
diet kitchen each morning, she made rounds in the nurses' home, inspected
each room and sent in a requisition for anything requiring repairs. Once
a week she went to market with the dietitian to obtain prices of the new
fruits and vegetables available. To the average nurse who has never
had occasion to do anything of this nature before, this was quite a novel
50 and useful experience. Another duty in this department was the planning
of menus for the hospital, which were submitted to the lady superintendent
for approval. During the night duty term the post-graduate went on duty
at 9 p.m., assisted the night supervisor in making rounds and relieved at
midnight for four hours. At 4 a.m. the night supervisor returned and the
post-graduate went off duty. The time spent in the general stores was
probably the most instructive and useful, as it gave the nurse an opportunity of acquiring some knowledge of the fundamental principles of
business methods of hospital administration, and impressed on her the
importance of efficiency in that department and its relation to the hospital's service. This department was responsible for the purchase of
nearly all supplies, the care and distribution of same. Travellers of
various branches visited there and on hearing hospital equipment
and supplies with prices discussed, the pupil was able to glean much
valuable information regarding this important phase of hospital management, which never really presents itself to a nurse until she has charge
of a hospital, and then is often learned by sad experience. Quotations
were here received and careful watch kept upon the fluctuation of market
prices. Goods were received and checked with delivery slips. Invoices
checked and certified, and an adequate recording and filing system
operated. Daily order sheets from the wards were filled from the commissary stores and totalled at the end of each month and the price estimated.
Aside from these special branches the post-graduate was at liberty to
spend her unoccupied time in any part of the hospital where anything
of interest was taking place. Sometimes an operation of special interest
attracted her. An hour in the laboratory while the routine morning work
was being done, a doctor's lecture or a nurse's demonstration class, or
even an occasional visit to the laundry; there were always practical and
useful ideas to be gathered. At times there one was inclined to feel that
there was not a great deal to be gained in some branches of the work,
such as the outdoor clinic, but the knowledge gained in other departments
more than compensated for this, and *by placing it in the post-graduate
course the hospital relieved a pupil nurse for ward duties. In no way
did the post-graduate course conflict with the training of the pupil nurses,
and although the course at that time was more or less an experiment, it
proved a sufficient benefit to the hospital to warrant its continuation. The
post-graduate felt that the time was well spent and at the end of the six
months had acquired many valuable suggestions which prove useful in institutional work.
MR. R. S. DAY, Victoria—
The next paper on our programme is "Rural Public Health Nursing,"
by Miss J. Forshaw, R.N., Victoria Order of Nurses, Saanich, B. C.
RURAL   PUBLIC   HEALTH   NURSING
Lack of time forbids me to dwell upon the history of public health
nursing or conditions which led to the present stage of evolution in the
guarding of the health of the community. Public health nursing is but
one phase of community welfare, and under that one division comes a
great many problems, and the necessity of solving them is forcing our
evolution.
The last five years we have concentrated, and rightly so, our whole
efforts upon winning the war. Our doctors and nurses have given their
services overseas and in military service here. Those of us who had
not the privilege of serving had to stay at home to serve the great army
of civilians who were left to "carry on."
With the medical and nursing professions so diminished in number,
and the needs of the civilian population so great, intensified as they
were by the influenza epidemic, we have had very little time during
the last five years to carry on health education and public health nursing.
We have been forced to confine our energies to the care and treatment of
the actually ill.
Up until the time medical inspection was made compulsory in the
army and the results of such inspection made known, how many of us.
51 took any interest in preventative medicine. A few people who studied-
health and community welfare struggled to convince us of the advisability
of concentrating our efforts upon preventative medicine, thus reducing
the need of forced curative medicine. The war has had its horrors, but
it has in many ways convinced us that, far greater than our mines and our
forests and the wealth of our cities, are the clean healthy human beings
that make our cities and who develop our industries. A nation that overlooks the value of health in its zeal to economize, will soon have nothing
upon which to concentrate economy. It will be a nation with its "fences
down," its lands unsettled, its resources undeveloped. A nation is an
aggregation of individuals and the condition of the units which goes to
make up the community determines the efficiency of the whole. This is a
national question, a question affecting the future of our country, and if
we," as educators in health matters, cannot or will not assist the nation to
solve its problems of medical care and administration, the nation from
an economic viewpoint will have to, and also, to provide for the future
of our country, force us into public service. May we never live to see
the time when the medical and nursing professions will have become so
commercialized that the call for help will not be heard above the jingle
of dollars and cents. Let us pray from the depth of our souls that the
glitter of gold will not blind us to the physical and moral needs of our
fellow man.
We have won the war, and 'with it we have gained considerable
knowledge, knowledge by which the future generations of the country
will benefit. We will not be content with merely downing militarism. We
must use that organized effort which the crisis of a war forced us into,
in carrying on a war against disease with the same determination and
loyalty which secured us victory overseas. Infant mortality must be reduced, the mentally deficient cared for, tuberculosis controlled, venereal
disease stamped out. These are genuine alien enemies. The manhood
of our country rose to the call of service, and are we going to be peacetime slackers in this war against disease. This country is going to give
to the growing children the right to be proud of their flag, because it
is going to be the country which will give them the chance to grow into
healthy men and women, and we as members of the medical and nursing
professions, must be the ones to promote legislation and assist in the
execution of such legislation as will enable the child of today to be a better citizen of tomorrow; to provide against any possibility of disease, that
the generations yet unborn shall be a living testimonial to our foresight
To quote from the paper given by Dr. Young at the Hospital Convention last year, let me use Dr. Young's own words: "The war is not
over yet nor can we even begin to count the effect the loss of our men
is going to have upon our national life. When we begin to realize what
a halt this loss is going to cause in our productive life as a nation, and
when we begin to realize how even our national existence will be threatened, we are going to insist upon steps being taken to conserve our assets and particularly the assets of human life. Our mortality tables which
are at present simply records of our indifference and incompetency, will
be studied with a full knowledge of what they mean, and with an appreciation of that knowledge will give rise to an insistence by the people,
for different methods in the ordering of our lives. Not only will we insist that as far as is humanly possible, the span of life shall be
lengthened, but that during that span of life an individual shall stand for
one with fully developed spiritual, mental and physical powers that shall
be utilized to the best of their capacity and for the advancement of the
nation as a whole."
This paper is entitled "Rural Public Health Nursing," and I seem
to be very far from the subject, but Canada is divided into rural districts, with cities dotted in between, and I have tried to see other rural
districts through my own, but I find that there are very few, indeed, who
can boast of having a District Nurse. From the reports of 1918 issued
by the Provincial Department of Health of British Columbia, we find
310 rural districts without a district nurse, 12 municipalities without dis-
52 trict nurses, and the great majority of the school children without follow-
up work by the nurse.
There has been a very popular idea that rural and country school
children were quite healthy and did not need medical observation, but
statistics have exploded that idea. One of the most appalling revelations
of recent years is the fact that the rural school children of this country
are on the average less healthy and are handicapped by more physical
defects than the children of the cities, including all the children of the
slums, and this is true in general in all parts of Canada. The chief reason for the inferiority of country children seems to be that city children
receive more care than do those in rural districts. In the past most of
our best human material for leadership has come from the farm. In the
future the raw material to supply the needs of civilization, including the
best human supply, must continue to come from the soil. If rural Canada
is to continue to be a satisfactory nursery of human life for the nation,
it must provide conditions favorable for the cultivation of the best human
supply. Just how are we going to assist in securing that best human
supply, just how are we going to secure better health conditions? One
of the chief mediums through which we are going to realize improved
health conditions is through a good Public Health Nursing Service in
the broad sense of the word; and when I use the words "Public Health
Nursing Service" I do not mean an individual with starched dignity
who sails into a home where the already overworked mother is trying to
"carry on" to the best of her ability, and tell her that this should be
done and that should be done. The nurse who serves a rural community
must meet the people of that community on a common ground, and then
starched dignity must give place to the dignity of service.
In a rural community the nurse has many problems to solve—tier's,
indeed, is a much more difficult task than the Public Health Nurse in
the city, where specialization modifies the solution of the problem relative
to public welfare. She must be teacher, adviser, critic and friend, as
well as giving bedside care to those who are actually ill. The training
of the rural nurse should be carefully planned by those responsible for
her education.
I think we all realize and agree upon the fact that a district nurse
for each rural community, or as many as are necessary, according to
the size and need of the community, is as necessary as the school teacher.
How are we going to get nurses—and the right kind of nurses—to give
their services to the rural communities? What special qualifications
must she have and how can she acquire the necessary education which
must be specialized into knowledge of public health nursing and its
various branches; social service and a general knowledge of community
problems? These questions I am leaving open for discussion, but before closing, may I suggest that the success of the rural public health
nursing activities are largely dependent upon the nurse. She must
first be a good nurse, a woman with broad mental visions and large
sympathies. Combined with these qualities she must possess education,
executive ability and willingness to give the actual bedside care. A
public health nurse cannot go around preaching health education and
close her eyes to the wants of a bedridden patient. She should also
receive special public health training. It is cruel, and shows lack of
foresight, to send a nurse into a rural district who has not had special
training, and expect her to solve- community problems as they affect the
health and welfare of the district she serves.
The best course of lectures that any university can give with the
best possible organization to demonstrate the theories taught in the university, is none too good for the nurse who is about to take up rural
nursing.
I will close this paper with the earnest appeal to those who know
the needs of the public health nurse, both in rural districts and in cities,
and in 'knowing her many problems, will sympathize to the extent that
something definite will be done to give the nurse desiring to take up
public health nursing, a better specialized education so that she will be
better  provided   to   "carry  on"   in   community  welfare   work,   and   in   so
53 doing, we will not only be serving the nurse, but also the community
which she serves. Let this convention be a memorial in the history of
public health nursing in B. C. Not alone in the education of the nurse,
but making possible the provision of a supply of nurses fully trained and
equipped with a special knowledge of public health and district nursing
for the outlying rural districts of British Columbia. And in this connection I would like to mention the fact that the University of British
Columbia is establishing a Faculty of Nursing, leading to a degree, and
thus placing the hall mark of efficiency on its graduates. I am not informed as to the course, but I would strongly urge that courses be provided in order to enable registered nurses in practice to take postgraduate work. I believe that health work will be an important subject
in the curriculum, and if taken advantage of by those who wish to devote their time to community work, we would very soon be provided with
an energetic, competent and well trained body of women whose work
would go far to popularize the enactment of health regulations.
Before  leaving this  paper,  I wish to move  a  resolution:
WHEREAS the University of British Columbia has announced its
intention of establishing a Department of Nursing, the course of which
will lead to the granting of a degree and,
WHEREAS such a course is designed to prepare graduates for positions in specialized branches  of nursnig,
THEREFORE BE IT RESOLVED that this convention petition the
authorities of the British Columbia University, respectfully requesting
that provision be made to enable registered nurses to attend short courses
on the Principles of Public Health Nursing in all branches.
R. S. DAY, Victoria—
Before putting that resolution, I think we had better hear the lady
who is to open the discussion—Miss Cole, R.N., superintendent of Victorian Order of Nurses, Vancouver. Owing to Miss Cole's absence, Mrs.
Hannington, head of the Victorian Order of Nurses, Ottawa, will discuss
this matter.
MRS. HANNINGTON, Ottawa—
I did not come here today to take part in any way in the discussion;
I came to listen. I have been going rather strong on conventions recently, and after you have been at two or three you have very little left
to say. I was in ' New York not long ago and I found a convention
meeting there, so dashed into it. Among others I heard Sir Arthur New-
son, a great authority on Child Welfare Work in the Old Country, so
great a man that I believe Johns Hopkins Hospital were making offers
to him to come over to America. You can always know when we have
got a good article, because the people of the United States go after it
They had representatives from all countries. A fine big able looking
American doctor got up and one remark he made was to my mind the
most important. He said: "America, the United States, must learn to
deinstitutionalize their national standards," so I rose up, feeling that no
other convention could give me as much as that. Soon after I was in
the department of Indian Affairs at Ottawa. After talking to Mr. Scott
oyer what work the nurses had better do, he said rather regretfully:
,fYou know, that is where all our appropriation has gone to. I do not
know but what we have got to retrace our steps." I said: "I know
what we have got to do, we have also to learn to deinstitutionalize our
national standards."
It has been very interesting to hear of this work and the standardization of hospitals. I am very much in sympathy with that, but back of
that comes the idea brought out in Miss Flaw's paper, that besides our
. little towns and our large cities where we can standardize, there is that
Great West of Canada, filled up here and there with the men and women
that have the courage to go out and make their homes and bear their
children and settle this country of ours. I was asked last year: why do
these people go to these outlandish places and expect people to follow
them?   We build railways so that we may settle our country.    We have
54 got to get the nurse out into the rural district. That was the work of
the Victorian Order. We have not gone very far, but we still keep on.
Sir Arthur Newson says the care of women in childbirth is a matter
of national importance. I believe in Alberta they passed a resolution
asking the government of the Province of Alberta to select fully trained
nurses to give the farmer, men and women, a special maternity training and to send them out into the rural districts to take care of the
women, as the next best thing they could do to supply medical care. How
are we going to get the all round training and special training? We
teach her, give her a certain knowledge of school nursing. When she
gets to the far away places we see what little she can do. We have
always considered that first and foremost we were teachers. We can have
the finest institutions in the land and they would be good for the people,
but the greatest institutions that Canada has are her homes, and the people we want to reach are the mothers, to teach the mother 'while you are
talking with her to make a better home, to take beter care of her children,
and that is a standard we must never institutionalize in any way. That
has been the work we have tried to do. In so far as our work goes, we
have covered the whole ground, we have "blazed the trail." The day is
coming when all the nursing in our province will be all under the Provincial Deparments of Public Health. It shall be inspected by them, and
that is the work of the future. I do not think we are quite ready for it,
because we have neither nursing nor the proper training where all nurses
can go and get such training as will fit them for this work. I dread to
hear of the standards being put on too lofty a pinnacle. We have 3
country as large as the United States, with scarcely 8,000,000, when they
have somewhere near 70,000,000 or 80,000,000—and those great spaces in
between, those of us who are interested here I beg to think of that mother
who first of all we should reach in some way, and in providing this
training to make provision both for the theoretical and the practical
part of a public health nursing service, and that the men of this country
should find the way so that that service can be provided for everyone,
I do not believe we will have difficulty getting the women to go out if we
have enough of them, but they must have a thorough training to take
with them. There is nothing a public health nurse going in the rural
districts should not know. She must have such a love of God and man
that she is willing to put up with any accommodation, because she will
have to go in any hole or corner. We must have a great missionary spirit
if we are going out to provide such a vital service as is called for irt
Canada today, and I personally am delighted to think that in British
Columbia, after all the lovliest province in the Dominion, should be
making provision, but when you are, do not forget the little settlers,
because terrible things are happening, simply because we have not the
same vision as those who went to those far away places.
DR. H. E. YOUNG, Victoria—
The subjects that have been under discussion this afternoon are of
very great interest to me from the fact that I am connected with the
Provincial Board of Health, and I have to answer questions and endeavor in a practical manner to meet conditions. I have to oversee
those great outlying districts that Mrs. Hannington has so eloquently
described. I think to provide the health which we are very anxious to
obtain and which unfortunately we are not able to obtain in many cases,
and the absence and lack of this was driven home to us very forcibly during the last epidemic of influenza. The papers that have been discussed
this afternoon have been interesting to me in that they illustrate the
steps that are necessary to be taken to make the profession of value to
outlying districts. We had a very able discussion from Miss Randal
on the standardization or the education of the nurse. The second paper
dealt with the subject of specialization and the third paper, which appealed
more particularly to me, was somewhat in the way of suggestions as to
the practical application of the arguments advanced in the other two
papers. Some months ago Mrs. Hannington visited Victoria and called
on me, asking if she could expect the co-operation of the Provincial
Board  of  Health.     I   thought  Mrs.   Hannington's   visit   was   "   -•"
55
a   sort   of "manna in the wilderness." I had been groping for some straw to
lean upon and I found very substantial encouragement. I assured her
that the Provincial Board of Health was only too anxious to assist in
the work of the Victorian Order of Nurses and would select particularly
the work of these nurses as a demonstration of what the Provincial
Board of Health hoped to do in British Columbia. For some years I
have been connected with the government and during the time that I was
Provincial Secretary I had to provide medical men and nurses for outlying districts. I was very hard put to it and when the Nurses' Bill
came up in 1915 I took an attitude as regards that bill which I believe
put me in the bad books of the nurses. I have tried to impress upon the
sponsor of that bill the fact that there were vital questions concerning
public health affected thereby. I want to co-operate with that bill in
every possible way. I was opposed to certain clauses which would not detract from the merits of that bill or detract from R.N., but would provide
for the licensing of a woman who came here with proper credentials to
take charge of midwifery cases in outlying districts. They would not
accept this.    They overlooked a very important fact.
The government of any country is the will of the people. Now if the
people in our outlying districts are going to insist on this the government
is going to give it to them. The will of the people will verify the truth
and the expression "a scrap of paper." Mrs. Hannington has told us of
the experience of the Alberta people. In Ottawa a short time ago I
met a lady who was connected with the government there who told me
the attitude the women of Alberta were taking in this respect. They
were going to insist on their government enacting just such legislation,
and you are going to have the same experience in British Columbia
unless you wake up to the fact that the rural districts are making an
insistent demand  for nurses.
Some months ago Miss Forshaw called and suggested the establishment of a health centre in Saanich district, adjoining Victoria. I did
not tell Miss Forshaw how overjoyed I was, but I formed the opinion
that I had met a very active young woman and gave her every encouragement possible. She has gone along and I believe now that the idea is
taking practical shape and that we- are going to have a public demonstration of what will ultimately be an every-day occurrence in British
Columbia, and that is the service carried to the home. We may standardize professions to perfection, we may carry on specialization until, as it
happens today—an instance I know of—a man went with a sore elbow to
a doctor. This doctor said: "No, go to Dr. So-and-so, I only treat the
knee joint." We have got to learn the broad general truth, and through
application, to meet the needs of the public.
You will find that the great step in standardization has been taken
by the University of British Columbia in raising the length of time for
teaching and insisting on an academic two years' course before practical
work, thus placing the hall mark on the graduation degree. You are
bringing about a standard that will settle the question for the small
and large hospital, that will become the standard that will be recognized
as the best one. The medical schools of 25 or 30 years ago were scattered
all over the country, particularly in the United States. Two or three
doctors would get a charter and run schools. The other schools, the higher
schools, were turning out men who were spending a good many years of
their lives and a great deal of money to equip themselves in the practice
of their profession. Then standardization was begun. People are today
educated to the point of asking what school did you graduate from and
what is the grade of that school—as A, B, C, D. D is not recognized;
C is not a good school.   A and B are good schools.
The standardization of your profession will come about, but what I
want more particularly to impress is this: that in the practical application by the government of the work which they have undertaken in the
health department we have got to get the means of getting at the people,
we have got to educate the people to what the word "hygiene" means, to
what the word "contagion" means. We have already established our
machinery by the assistance of the hospitals.    We have done remarkable
56 work, and last year when I asked all of my school inspectors to give
their opinion as to what the effect of that work had been, they in-
sisted it had been good. There are a lot of parents who get the idea that
this is all done simply to make work for the doctor. They do not realize
that the defects of today as shown in the armies of Britain, France and
the United States, and have to acknowledge that one-third of their men
were rejected at the recruiting station and 25 per cent, of the men were
not fit to go into the fighting line. We are going to produce a race of
children that have the right to grow up into physically good men and
women. When we know that these things are preventable, when we know
that thousands of children are dying every year that should not be dying,
from measles and other preventable diseases, and we can only stop this
by having rural nurses going to the homes to explain to the mothers about
these conditions and educate them along sanitary and public health lines.
State medicine is being discussed. It is going to come by hospitalization, by the extension of the activities of our hospital, by the establishment in our hospitals of paid experts, by doing away with a lot of our
■ smaller hospitals, making one big hospital, calling it the hospital centre—
with experts in all lines, and with all the branches of nursing being taught,
not only bedside nursing, but tuberculosis work, all the defects we find
in school children, etc. We have got to educate the people to the fact
that they own that hospital, that when they go to that hospital it is not
to a charitable institution, but go with the same spirit as if they were
sending their children to school. They will take their child to the hospital where they know they have the best facilities. Rural nursing has
got to come in Canada. We have illustrations of it in large cities—and
it is not discouraging, it is hopeful in a way, but it is discouraging to a
man in my position when he picks up reports of proceedings of conven-
tons and he reads a paper from some gentlemen or lady who is a member of a staff in a city like New York, Toronto, or Montreal, where they
have a fully paid staff, where they have a city divided like a checker
board—they can tell you how many they have saved, how many they are
going to save. In British Columbia we have 400,000 square miles of territory with a population of 400,000. We can go forth with an idea of doing our duty, with an idea of living up to what we know is the ideals of
Canadianism. We want the assistance from rural nurses to that class of
people.    We will get it by the self denial  spirit.
DR. H. C. WRINCH, Hazelton—
I would like to compliment the writer on the excellence of the paper.
This is a very important and serious question. We cannot solve this
problem by sitting back in our chairs. I can show you a centre 60
miles in diameter without a doctor or a nurse—Burns Lake. The nearest
hospital is 80 miles. There should be two or three nurses at least, for
that centre.    It is one of the. finest agricultural districts in the Province.
MRS. HANNINGTON, Ottawa—
When you were speaking of the hospitals you proposed establishing
in British Columbia, there was one point which was not dealt with, and
that is: where you put up the small hospital it is of the greatest possible advantage to attach to that a public health nurse; you make not
only a hospital but you make a health centre. Now that is being done
in perhaps half a dozen hospitals I know of. You have a small hospital,
say 30 beds, you have a small training school—three graduates and eight
pupils—you have attached a public health nurse. She has_ a great distance to go. It is her duty to go to the houses to see if the oatient
should go to the hospital. Will you send out a nurse who will take
care of ordinary cases of sickness, who will take care of people in their
own homes, who will take care of normal cases of confinement. What
will be the salary? Get a map of your municipality, mark on that the
number of people in that community which the nurse has to serve, where
the villages are, the number people in each village, the nearest doctor
and nearest hospital. I find that there are three villages of various sizes,
with a doctor resident in the largest. You cannot do better than send a
nurse in there and the doctor will be willing to help her.    The nurse and
57 doctor work it together, she goes to the farthest village, they work over
that community—where the doctor cannot go the nurse does her best,
but in case of necessity there is always a way today with the telephone
and motor car. In that way it is remarkable the work that can be done
by one doctor and one nurse. It does away with the need of finding
quarters for a nurse. In that way you can very nearly cover British
Columbia. I think the way is opening very fast, but only with the cooperation of the department of public health, the doctor and the nurse
following out the wish of the people, can that service be given.
MISS HASKINS, Vancouver—
I have much pleasure in seconding Miss Forshaw's resolution re the
establishing of Public Health Courses for nurses in the University of
British Columbia.
MR. R. S. DAY, Victoria—
I would suggest that the resolution left by Miss Forshaw be referred
to the Resolution Committee to report on.
This ends our Nursing Session. A Round Table Conference wai
announced on the programme, so I'll ask Mr. Charles Graham of Cumberland, to conduct this.
(As the afternoon was a very heavy one and the delegates were
anxious to see the exhibits, the Round Table Conference was adjourned
till 9 a.m. next morning).
The meeting then adjourned, to meet at 8 p.m. for the evening session.
TUESDAY,  JULY  8th,   1919.
The meeting was ,called to order at 8 p.m. Dr. M. T. MacEachern,
President, in the Chair.
PUBLIC HEALTH SESSION—8 p.m.
PRESIDENT—
We are fortunate in having with us tonight a distinguished visitor
from the city of New York in the person of Miss Isabel M. Stewart,
Professor of Nursing, Columbia University. Miss Stewart is a Canadian,
and one of the leaders in the nursing profession. She has kindly consented to address us on "Public Health Nursing Education as Offered Today, and the Need for Same."
MISS ISABEL M. STEWART—
As Dr. MacEachern has just said, I am a Canadian, and I am always glad to come over and visit my own country and have a chance to
confer with the nurses and hospital people on this side of the line, because our problems are after all just about the same. I have been very
much interested in the conventions in Vancouver last week, and in what I
heard of this convention, and it just merely emphasizes what I have said,
that our problems are much the same.
One of the problems that has been taking a great deal of our attention over on the other side of the line is this whole question of Public
Health Nursing. I think it is Dr. Winslow, of Yale University, who is
Professor of Public Health there, who says there has been three eras in
Public Health. The first, Sanitary, the period when people were very
much interested in putting in good water supplies, sewerage systems and
in cleaning up generally. That was very effective as far as it went, but
there was always something lacking. We still had epidemics of diseases.
The next might be called the Laboratory era, when the doctors were chasing the germ down, taking cultures and trying to discover where the
germ was and what its habits were, and that was very effective, but we
still had epidemics and a great deal of disease. Now we come to the
third stage, that is where we concentrated on the human being, on the
individual. We have to go where the individual is, we are trying to find,
trying to educate the people in masses, but as a matter of fact that does
■not go very far, and so we have to go back into the homes and into
the schools and try to teach them something of the principles of Public
Health.   Now in this last stage of Public Health work you have to have
58 the personal message and the agent that has probably proved most effective in that particular line has been the trained nurse, what we are
learning to call the Public Health Nurse.
The visiting nurse as we think of her today goes back about sixty
years, to the time very shortly after Florence Nightingale began her
work, when John Rathbone, of Liverpool, organized the first Visiting
Nurse service. Although hospitals have grown and although they have
penetrated in to all parts of the country, we still have about 90 per cent,
of our sick cared for in their homes—just about 10 per cent, cared for in
hospitals. That leaves a very large proportion in the homes. Of these
a very small proportion are cared for by trained nurses. The people of
the home care for a great many, and a great many are sadly neglected.
It is that group the Public Health nurse is interested in. We have a
little idea of just how effective that work is by a study which was made
by the Metropolitan Life Insurance Company some years ago. A lady
one day tried to convince one of her friends in the Metropolitan Life
Insurance Company if they would have the families of the insured working men visited by Visiting Nurses while they were ill, there would be a
lowering of the mortality. So about ten years, ago that system of visiting
nursing for insured working men was instituted and finally extended over
a large part of the country. They took the statistics of five years before
the Visiting Nurses began their work and five years after, and they took
a million policy holders in both classes, and they found that the mortality
rate succeeding the induction of visiting nursing gave them' a lowered
mortality of 12%' per cent. They eliminated all other factors that might
have influenced that mortality rate, and they concluded that that reduction was due entirely to the work of the visiting nurses. There is
no question, I think they were convinced that it was a very good proposition, and a great many others have been convinced that the work of
the visiting nurse will materially reduce mortality.
The work of the visiting nurse has extended, as we heard this afternoon, into a great many other fields. We have first, the field for the
-Public Health nurse besides the visiting nurse, then the field of tuberculosis work; I have no statistics to show just how effective the visiting
nurse work is there, but I do know where there is a very intelligent
effort being made to combat tuberculosis they have large fields for visiting nurses. We have in New York a group of 150 nurses who visit
.tuberculosis cases, go to the homes where cases are reported, and the
patients are taught how to live; the nurse sees that they have a proper
room with fresh air, an adequate milk supply, she sees that they get
the milk that they need, and the family is taught to care for the patient,
and so on, and that is a regular, part of the city's work. That is also
being done in a good many parts of the country.
Then we come to the Infant Welfare Field, and we soon found the
mortality rates begin to drop, and though the nurse was only one factor,
she was a very material factor; yet medical experts feel that the moneys
spent has created a most important factor, because not only did she
follow up the babies but she was able to advise the mother and teach
the mother, and to keep the sick baby in touch with the doctor, and in
that way a great many babies had been saved. In New York City the
infant death rate was 185 per thousand births. That is a fairly high
death rate. It has now gone down to around about 90 per thousand
births, and that has been accomplished in about fifteen years. There is
no question at all that it has been largely the work of the large staff
of visiting nurses. They keep going into the schools until near the end
of June, then they start their public welfare work. Of course, that is
not just a very low death rate. We still have a long way to go before
we get down to New Zealand's death rate, which is 50 per thousand.
The doctor in charge tells about the beginning of that work in New Zealand. He believes that the marvellous result is very largely due to the
welfare nurse. Instead of concentrating on the public, however, they are
going back into the pre-natal period as the most effective time of preventing death. They divide the city into blocks, they got the mothers
in one block before the babies were born, they got them in touch with the
59 clinic, the nurses followed them up and they had every opportunity to
find out complications and to teach the mother before the child was
born. As a result of that pre-natal work they followed the cases up for
two years and they found that they had cut the maternal mortality in
two, that is, there was just half as many mothers die as in the other districts. In the first year they cut the death rate by one-third, and the
second year, by one-half. It is evidently more profitable to start in early
to check up this mortality, and I believe that now emphasis is being
put on that pre-natal period. Of course you all know how serious this
question is. The Children's Bureau recently made a survey and they find
that maternal mortality is the highest next to mortality due to tuberculosis, among women of the child-bearing age. That seems terribly
high, and it is astonishing that we have not cut it down. The Children's
Bureau believes that this is simply an indication for better districts and
better nursing. The Public Health nurse in the rural districts think
maternal mortality can be cut down very much lower. We do not begin
to cover the schools as yet, but we are told that we are going to need
thousands of school nurses within the next few years. I am very much
interested also in the fact that you are thinking here about the whole
question of social insurance. We have had bills up in several states, and
it is very evident that before very long we will be having some form of
social insurance for people receiving $1,200 a year or under in the United
States at any rate, included in the medical service which is to be given
as well as the nursing service, so that we are going to need a large
number of Public Health nurses if the social bill on medical insurance
goes through.
We are having a great number of requests for nurses to go into factories and department stores. They are there to do first aid and small
dressings, but that is only a very minor part of their function; they are
really there to look after the employees, to see that they have proper food
and proper hygienic surroundings. That industrial work is going ahead
very rapidly. The field of mental hygiene is also going ahead very
rapidly. It is generally believed that we can save a great many of the
mentally broken down if we can get them in the early stages, and a
good many patients are not really ill enough to send to insane asylums,
so the nurses are employed to follow up these cases, to advise them and
help them and prevent, if possible, their getting into the institutions for
the insane, and if they are discharged from those institutions, the nurse
still follows them up and keeps track of them, so there is a great deal
of social service as well as public health to be done with that group.
During the infantile paralysis epidemic we had a lot of infants who were
suffering from paralysis. There is, as you medical men will know, a form
of exercise that can be given, and if that is followed up as long as a
year, the patient probably recovers. The state government in New York
employed a band of nurses—they had all those cases of infantile paralysis
marked, and sometimes a nurse would go just once a week and see that
the exercises were properly carried out, and in that way a good many
that would have been cripples now have the use of their limbs. All of this
work is being developed very rapidly in the United States, and I notice
that in this country, too, there is a great deal being done along these
lines.
A most recent field for nurses is the field of venereal disease We
have, this summer, in the institution I belong to, a set course with
nearly twenty _ taking that course, and they are going back to prepare
as social service in venereal clinics, and the United States is hoping in
that way to help in the suppression of venereal disease. It is absolutely
necessary before we send out nurses for that kind of work that they
should have some sort of training, some special training that will enable them to take hold of work of that kind and really do justice to it
A good many nurses haye succeeded, they have won out, but some on
the other hand, have failed. It is because they lacked training or an
aptitude for the work. We have gone through the trying-out period
now, and we realize that the Public Health nurse must be trained for
that work.
60 We find first of all that it is necessary to help a good many of the
nurses who would like to take that training, because nurses do not usually
have large bank accounts to draw upon, and some are not able to
finance the course. In the United States universities are giving scholarships and individuals are giving scholarships. It is not reaily a pioneer
project, because a Department of Nursing Health has been in the Columbia University for twenty years. I have been there about ten years,
and have seen the thing grow up from a very small beginning and now
the department is quite large. We have 100 students during the summer.-
The department was organized originally to train superintendents and
teachers of training schools, and for some years that was all it did. Then
it took up the administrative side of hospital work and laid emphasis
on the educational side. However, this new Public Health work developed and finally we received an endowment from a very wealthy
lady, with the idea that we should develop this new Public Health Nurse,
and the department has now become one of the most important departments of the college. We give a course in both practical and theoretical
work. Our training is much like that given in a number of other colleges—Cincinnati, etc. The theoretical work is better given in a university, because as a rule you have facilities there. In the scheme of
social welfare and social work we also recognize the home economic side,
and the organization of the household on an economic basis. Those are
the fundamental things. A good many of our students are undergraduates, doing the work in the last part of their third year, and we
have quite a large number of students who are taking that kind of
they come to us after eight hours theoretical work A number of people
are telling us that the hospital training does not prepare for Public
Health work, that we should have a different kind of training, that we
do not need visiting nurses for Public Health service. I believe that
we will always need the good sound foundation that is given in the
hospital, but that training must be somewhat different. I think we are
quite sure that the Public Health nurse needs more work in children's
diseases than she gets in the ordinary hospital, she needs obstetrical
work and work in contagious diseases. In the eye, ear, nose and throat
section we feel that a dispensary service is more essential. We feel that
the surgical side has been over-emphasized, but these other branches are
very important, and if, in addition to the work in diseases, we can get in
good theoretical and practical work in the prevention of disease, in hygiene
and in sanitation, we feel that that will make a better beginning for
the student who is going afterwards to enter the Public Health Nursing
field.
I think you might be interested in knowing that the Rockefellow
Institute gives the best training in Public Health Nursing. They are
spending a large amount of money on it. Miss Goldmark is to take
charge of this investigation and within the next year we hope that this
commission will report; I believe it will be a great help to all training
schools to have this thorough investigation made, even though it is not
entirely with the idea of helping hospitals, but rather with the idea of
seeing how more public health nurses can be trained and how best we
can see how best these young women can be trained in this large field
that is opening up. »•
PRESIDENT—
I am sure, Miss Stewart, the B. C. Hospital Association deeply appreciate your remarks, which are most fitting on this occasion. I trust
you will accept our thanks, indeed, for this opportunity we have had of
hearing you.   We will now have an address, entitled:
PUBLIC  HEALTH  SERVICE
By Dr.   R.  H.  Mullin,  B.A.,   M.B.,  Director  of  Laboratories  Vancouver
General   Hospital,   Professor   of   Bacteriology   University   of
British   Columbia.
A Public Health Service may be defined as a governmental agency
whose function is to as far as possible prevent disease, as long as pos-
61 sible postpone death and as much as possible promote the physical comfort
and well being of the people represented by that particular government.
Health Services will vary in the details of their organization with
different governments; while the fundamental objects of each service will
be the same, variations in individual mechanism will be required to conform with differences in function of the types of government concerned.
In Canada, the types of government may be listed as Federal, Provincial,
County, Township and Municipal. The problems presented by each of
these will differ slightly on account of the variations in size of the communities governed, in differences in local conditions and the density
and distribution of population. Moreover, the amount of money available for all governmental purposes will be different with each form of
government. One fixed type of health service may not necessarily fit
all of these different forms of government unless a considerable variation
be made in the organization of each individual service.
There has been a considerable change in the scope of Public Health
Service. At times this change has been gradual, while at others it has
been rapid to the point of being revolutionary. Originally Public Health
Service started as merely a mechanism for the collection of statistics regarding the number of births, deaths and marriages. Frequently even
these were so incorrectly kept as to be of little scientific value. Ideas
concerning their value have changed; now a considerable amount of attention and expense is given to obtaining such information in an accurate
and condensed form. The study of various communicable diseases followed the compilation of vital statistics. Here the changes in ideas and
methods of control have been very rapid since the newer information
supplied by more accurate data form the bacteriological sciences has
altered the accepted ideas concerning the methods of spread and danger
of contagion from these diseases. Hand in hand with the efforts towards
the prevention of these diseases, the control of the routes of their spread,
as water, milk and other foods, was developed. This naturally led to a
review of the means of the disposal of waste, since it was found that
these are especially responsible for the spread of most infecting diseases.
Later and perhaps simultaneously the importance of Industrial Hygiene,
School Hygiene, Mental Hygiene and last of all, Infant and Maternal
mortality have been appreciated so that these have come to occupy a
very prominent and well deserved place in all up to date Health Services.
The evolution of the Public Health Service may well be divided into
three stages; the first dealing with vital statistics, being the recording
stage; the second dealing with other factors mentioned might well be
classed as the prevention stage. The third stage is one upon which apparently the services are about to enter, if the prophecy of some of the
foremost thinkers of today turns out to be true. This third brought about
by an alteration in the attitude which is being taken in the public
conscience regarding the relative importance of a human being. Formerly
sickness was considered mostly from a sentimental side, and death as
more or less a visitation of Providence. The treatment of the sick has
been up to the present a matter of individual expense borne by the
individual who is afflicted, if he is willing to pay, by the physician if
the patient is able but unwilling to pay, or by the community in the case
of the indigent poor. In such a_ conception the relation and value of
the individual to the community is completely forgotten. It is the appreciation of the economic value of the individual to the community that
is responsible for changes in ideas concerning the proper mechanism for
the prevention and cure of all sickness. The human being is beginning to
be looked upon not as an individual altogether independent from other
individuals and from the community, but as an economic unit of the community who has a very definite^ productive value to the community. He
is therefore a community asset in the same way as natural resources are
a community asset, but necessarily of a slightly different type. If this
is a correct view then it at once becomes a matter of community interest
to protect and improve human health with the idea of preserving and
conserving one of the national natural resources upon which the success
of the community depends.   So keen a thinker as Mr. Lloyd George, bor-
62 rowing some familiar military phraseology, says that there cannot be an
A-l nation with a C-3 population.
In the protection of health, hospitalization is recognized as being
the most economical method of treatment. There is the same loss in
efficiency for a practicing physician to visit ten or twelve different patients in as many different and distant localities as there is for ten or
twelve different dairymen to deliver milk to the same locality. Hospitalization will remove this loss in efficiency if it does nothing else.
It does more; hospitals lend themselves to the development of the most
economical treatment since they are organized with the idea of reducing
the cost per patient by treating large numbers of people. Moreover in
hospitals equipment and service of various kinds can be provided which
is impossible to supply in private houses or by individual practicing
physicians in an economic way. These factors bring hospitals into intimate relationship with the development of health service which may be
expected if the beginning ideas already referred to are carried to their
completion. It would be well, therefore, for hospital authorities to appreciate and understand the health problem in the community and the
organization of health services in order that the proper relationship between hospital and health service as a whole may obtain in the rapidly
changing development which is apparently close at hand.
The problem of discussing Health Services in general is very large
on account of the variations already spoken of in governments. Since this
audience represents provincial hospitals, it may be well to restrict the
discussion to provincial health services, not losing sight, however, of the
fact that there must be always correlation between all health services.
The success of the Provincial Health Service depends upon four fundamental factors: (1) organization; (2) budget; (3) personnel; (4) cooperation.
Organization.
In the organization of a Health Service efficiency must be the keynote. In the past it has frequently occurred that such services have been
developed to meet sudden emergencies, or as the result of some particular
voluntary organization which has made such progress in its work that
it has seemed beneficial to take it over into a public service. The result has been a department of heterogenous character without any proper
relation between its various branches, or the appropriation for a particular branch and the importance of that branch. If success is to be
obtained there must be a well considered elastic plan which will permit
of growth without disturbing the whole service at any time when a new
department is installed. The essentials to such are: freedom from
politics, necessary legal machinery and provision for growth and
elasticity.
It is easy to talk about keeping a Health Service free from politics,
but in theory it seems a more or less difficult procedure. The Health Service must be a function of the Provincial Government and as such must
be closely related to the government. Moreover the funds necessary for
the support of the service must be obtained by governmental provision,
so that it is never possible, nor desirable, to absolutely divorce public
health service from some form of governmental control. These difficulties
are not as great in practice as they might appear to be in theory. As a
general rule in health services, as they have been, there is little in the
way of political plums or positions of the nature of sinecures, so that the
tendency to use such' positions as rewards for political merit is not as
great as in some other departments of the government. The best mechanism to prevent any tendency towards political interference is to have
appointments to the service made, not by the minister himself, but on
recommendation of a board appointed with long terms, acting in an advisory relationship to the health service.
The legal machinery necessary should consist in the first place of an
enabling act passed by the legislature, and in the second place of regulations passed by the advisory board. Legislative acts can be changed
only at infrequent intervals which usually occur when there is no immediate emergency to meet.    Regulations passed by a board, however, if
'63 they have the force of law, are of equal administrative value, and can
be made or altered at any time to fit the needs of any particular
must be in charge of a capable administrator, usually known as a commissioner of health, chief officer of health, executive officer, or some
such name. He must be the connecting link between the technical side
of the work and the administrative side. He is the one that applies
the scientific information that has been derived to the welfare of the
people. He should be invested with complete police power for the enforcement of public health laws and regulations. Frequently people may
object to doing something which may be for the protection of the community while it acts to a certain extent in confining their own personal
activities. In such cases it is necessary to recognize that the community interest is paramount and the administrative officer must have
the authority to compel people to protect community interests. This administrator is the one who should correlate the different branches of
the work within the service and at the same time he forms the link
which binds the technical side to the government itself. He may or
may not be a highly technical worker, but he should be well j versed in
all health matters. He must have tact and organizing ability to a
superlative degree. Needless to say, such positions should not be given
for any consideration other than ability to serve in that particular capacity.
Provision for Growth.
Stability and elasticity are essentials in the organization of a health
service. It is impossible to fortell at any time the routes along which
the development of public health will occur; it is equally impossible to lay
down a plan of organization which will take care of all forms of future deveopment. It is essential, however, that when development does
occur, it can be included in the service without a complete disruption
and re-organization of the whole service. It should be possible to devise a department to which new branches could be added, existing
branches combined, altered or dropped without interfering too much with
the whole department. Correlation of all branches in the service is
necessary for the elimination of duplication in personnel and equipment
Budget.
It must be admitted in the beginning that the matter of budget is
the great stumbling block that always occurs in the organization of any
health service. This is especially true in the beginning of such a service
where no local demonstration of its good effects can be had. It must be
remembered always that there are many fingers, in more or less intimate
contact with the provincial purse, all of which are anxious to deplete that
purse to the individual needs. It is reasonable to suppose that any
minister of the crown will have a certain amount of difficulty in persuading his own cabinet of the necessity of some new branch of his own
department receiving a large appropriation not hitherto granted. It is
just as reasonable to expect that the cabinet* itself will have a certain
difficulty in persuading the house under similar conditions. These difficulties may be obviated by altering the basis upon which appropriations
are made. Instead of the appropriations of each department depending'
upon what they have received before or the personal influence of the
minister in charge or upon some other extraneous factor, they might be
made upon a percentage basis. Then most of the difficulties of governmental appropriations would be solved. It would become a matter of
simply determining the relative importance of any particular service and
assigning it a corresponding percentage of the revenue. It has been
estimated by careful observers in the most progressive states that from
1% to 2 per cent, of the annual expenditure should be given to public
health service. This should not include poor relief, care of the insane,
hospital grants or such like. If such a basis were adopted in British
Columbia it would provide between $135,000 and $180,000 for this work—
a sum very much in excess of the present expenditure of the department. Would such a large increase in expenditure for a health service
be justifiable?    It has  been stated by those high  in office  in  the  Pro-
64  — 4 vincial Government, that any government should be willing to spend public
moneys on productive public work   Can it be demonstrated that a health
service is productive public work?    It has been well  stated that public
health is a purchasable commodity.    If this be true then  the amount of
public health which is obtained must bear a definite ratio to the amount
of  money  that  is  expended  in  obtaining  it,  and  any  community,  therefore, may reasonably expect to obtain as much as it is prepared to pay
for.   Would the amount already mentioned be justifiable as a reasonable
expenditure in British Columbia?    This is more or less difficult question
to answer if local data alone is to be relied upon.    Moreover, it is always difficult to estimate when a life has been saved.    If an individual
remains alive, it is exceedingly difficult to show that he might have died
or would have died under other altered circumstances, unless the alteration is so great as to make it at once apparent.   However, an approximate
answer to the question may be given by drawing deductions from what
has occurred in other communities.   In the state of California they have
estimated the  results  of their  efforts  for the  prevention  of typhoid by
means of data derived from a study of death  rates  in that disease.    By
applying to the present population the typhoid death rate as it occurred
before  the  control  measures  which  were  instituted   in  that  community,
and comparing the figures so obtained with the number of deaths actually
occurring  now, they have shown that  the  value of  lives  saved  by the
efforts at control  in typhoid  fever alone  during the last year,  exceeded
by a considerable amount the total appropriation of the health service for
that state for all purposes.    In estimating the amount of money earned
by saving a life, it is necessary to arrive at some basis for the valuation
of human life.    In most works  dealing with this  aspect of health problems, it is generally accepted that the value of an average life may reasonably be placed at the figure which is paid by a  common carrier  for
causing the death of an individual.    This is $5,000 for an adult, and for
an infant under one year $500, with variations between the two amounts
for different  ages.    These  amounts  may be  applied  to  British  Columbia
statistics with very interesting results.    The following figures have been '
obtained from a  report of the Provincial  Board of Health  for the  year
1917.   In that year there were 762 deaths of children under one year of
age, including still-born.    If the  same proportion exists  in British  Columbia  as  has  been   shown  to   exist   in   other   communities,  then  200  of
these children  under  one year who  died  during  1917 might  have  been
saved,  i.e.,  the  amount lost through  their  death  was  $100,000.    During
the same period there were  59 deaths  from accidents of pregnancy.    If
the same percentage  occurred  in  British  Columbia  as  in   Sweden,  then
of these ten could have been prevented, or a value of $50,000.    There
were 24 deaths from typhoid fever,  all  of which  could have been  prevented, i.e., a loss of $120,000. . There were three deaths from smallpox—
all   of   which   could   have   been   prevented—entailing   a   loss   of   $15,000.
There were 19 deaths from diphtheria—all of which might have been prevented—giving a  loss  of  approximately $20,000,  depending  upon  the  age
of the various   decedents.     In   these   five   conditions   alone,    therefore,
there was a loss to the community of $305,000.
Some doubting Thomas may believe that these are only fictitious
losses, because there has not been an actual loss of dollars and cents,
but only life. It can be shown, however, by reference to other diseases
that there is an annual cash expenditure devolving of necessity upon
the Provincial Government through failure to provide sufficient preventative measures early in certain diseases. There can thus be drawn from
British Columbia's experience alone an idea of the amount of the penalty
in such cases. Take for instance the disease syphilis. This is known
to be one of the causes of insanity. At the Provincial Mental Hospital during the last year there was an average of 130 patients throughout the year whose insanity was due to syphilis in part or in whole.
The annual cost of maintenance for each patient in that institution is
about $250 per year, so that last year it cost the Provincial Government
in the neighborhood of $32,500 to support 130 individuals at the mental
hospital, all of which  could  have  been prevented by  adequate means   of
65
5 treatment at the time those unfortunate individuals received their infection. This does not take into effect the loss which has occurred to
the community from having these 130 individuals converted from assets
into liabilities. The institutional life of the syphilitic insane is somewhere
between ten and twenty years, perhaps fifteen is a fairly correct average.
Each one of these individuals, therefore, adopting this basis, will have
cost the community $4,000 actual cash expenditure. From some of the
work that has been accomplished in communities which have lately
undertaken an active crusade against this venereal disease, it has been
estimated that where the treatment is undertaken by the community, the
cost per case is not in excess of $25, so that if these figures be correct,
this community could afford to treat 160 patients for syphilis free _ of
charge for the same amount of money that they spend in maintaining
one individual as a syphilitic insane; they would be ahead the amount
that a syphilitic insane individual would have produced had he remained normal, to say nothing of the amount of sickness that would
have been prevented in the other 159. The diseases already mentioned
do not constitute a complete list of the possibility of saving effected from
an adequate health service, but there is sufficient to indicate that such
service can reasonably be looked upon as a productive and remunerative
public work returning an excess of profits over expenditures to an extent usually described as profiteering.
Personnel and Technical Staff.
It must be recognized that this is an age of specialization in every
walk of life. This applies particularly to the medical profession. It is
well known that now there are numerous specialists in medicine, each one
of whom is supposed to know all about the particular branch in which
he has specialized. In large cities especially, the general practitioner is
gradually and slowly becoming a thing of the past. This specialization
has also differentiated clearly what is known as the private practice of
medicine and the practice of public health. The object of the two professions are entirely distinct; in the one there is the treatment and
cure of a sick individual by a practicing physician for a fee; in the
other, the prevention of disease in a community by a community official. The two sciences are not entirely similar and it does not follow that a successful practicing physician will make a successful public
health official. More and more the idea of trying to combine private
practice with public service is dropping into disuse. Such a mechanism
usually means that the public service part of the work is more or less
neglected for the remunerative private work. It is recognized, too, that
there is more than sufficient work in most public health services to
keep any individual connected therewith fully engaged for longer than
the standard eight-hour, day, so that if anyone is attempting public
service in this line there would be little time left for him to engage in
private work.
The public health service itself is becoming just as highly specialized
as any of the other professions; there have developed colleges comparable to other professional colleges designed for teaching the science
of public health alone. This naturally leads to the training of experts
in the profession. It has been found "that there is an increasing demand
for such experts since it is easily demonstrated that they can give an
increased amount of service to the community. There has been also a
change in ideas of remuneration for public health workers. If the
science is a highly specialized one requiring even collegiate training
additional to that obtained in medical schools, it should follow that
the_ remuneration should be commensurate with the amount of training
which has been required and the amount of experience that has been
attained. Such a worker should be placed on a financial basis that will
enable him to take a place corresponding with his worth in the allied professional circles in which he moves. This idea has not been completely recognized by many communities, so that the ranks of public health
services are being continually depleted by workers receiving and accepting better  offers   from  private  commercial   concerns.    Any  commer-
66 cial concern in employing an individual does so with the idea of making
a profit out of the services he renders. Surely it would be better for
the community to obtain these profits by giving a remuneration at least
comparable with that which commercial concerns are prepared to pay.
A pculiar type of man is required in public health service. It seems
unnecessary to say that he should be sufficiently and highly trained in advance and should not expect to attain proficiency at his work at the
expense of the community he serves, but should come to the community
already prepared to fulfil all the obligations which he is paid to perform.
He should be prepared to devote his whole time to the service and not be
expected to compensate for an inadequate salary by private venture. He
should be young, energetic and progressive in order that the productive
period of his life can be given to the public service. If possible he should
be unselfish and dominated by a desire to work for the public good.
Loyalty to the organization which he serves is a requisite that seems
scarcely necessary to mention. Such men do exist. They are becoming
trained in greater and greater numbers so that the supply can be reasonably expected to keep approximately equal to the demand if the service
is made of such a kind that the grief frequently connected with public
service is minimized to the greatest extent.
Co-operation.
This is one of the most fundamental features for the success of any
public health service. Public health is not a matter that is limited to any
community or to a particular class in the community, but is applied
equally to all and knows no geographical boundaries so that it cannot be
limited by the ordinary means of differentiating communities by set
boundary lines. This co-operation must be both within and without the
service. The service should be so organized that all branches within
that service are absolutely and completely correlated and brought in
unison with the minimum amount of friction. This will prevent economic
loss by overlapping between the different departments and from the loss
of time and energy due to friction from within. Co-operation from the
outside must be obtained from all sources, particularly from similar governmental agencies such as the Health Service of the Federal Government, other provinces and international agencies. There have been developed numerous bodies having in whole or in part health functions
which do not come under governmental control. If complete success in
health work is to be attained, those related agencies must be brought
into a sympathetic co-operation with the Governmental Health Service.
Much of the advance that has been made in the science of public health
has been due to the stimulus which has been exerted by the so-called
"Voluntary Associations." These are associations which have j been developed in some particular phase such as tuberculosis, housing, child
welfare, social hygiene and so on. While much credit must be given
to these voluntary associations for the education propaganda which they
have carried on, it must be appreciated that their work ceases with the
educational function. They can never take any part in control since no
government will pass to such an association the police power which is
essential for the control. The same remarks apply with an equal force
to endowed institutions. Usually such institutions are more than ready
and anxious to co-operate in every way with recognized governmental
agencies, so that the only difficulty presented is that of enlisting their
support. Other government services, too, may be interested in a more_ or
less direct way in problems associated with the Public Health Service.
It is essential that complete co-operation between such government services should be attained. This is particularly true with educational institutions, since it is recognized that most of the advances in health lines
come through education of the people. There has always been a dispute
between educational departments and health services as to the proper
place in an administrative organization for such a branch as the medical
supervision of school children. That this branch is of exceeding importance is being demonstrated more and more clearly by the recent
work in mental hygiene which shows beyond peradventure of a doubt that
67 frequently the educational system is misapplied in that it fails to take
into account the mental ability of some of the children who are going to
school. It should not make a very great deal of difference whether the
department of school hygiene is under the educational department or the
health service if the proper amount of co-operation between the two
occurs, although it does seem since this is a health problem to perhaps
a greater extent than it is an educational problem, that the health service might better be the one in which it is definitely placed.
The health service is also definitely related to the so-called higher
education. Where the Provincial Government is maintaining a provincial
university with a medical school attached, necessarily the teaching of
medicine and public health will come -under the jurisdiction of the university. Frequently in scientific work economic factors as applied to
the community are more or less lost sight of in the endeavor to develop something to the highest extent in one or other of the particular
branches which may exist. This is well exemplified by what has occurred in some places in the development of laboratory services. In at
least one city in Canada in which there is a university with a medical
school, a number of hospitals, and which city happens to be the seat of
the Provincial Government, there have been found well developed and
well equipped laboratories in each of the hospitals, in the City Health
Department, in the Medical School of the University, in the Provincial
Health Service and an additional research laboratory supported more or
less by endowment—all doing work which overlaps to a considerable extent. This means duplication in equipment and to a smaller extent in
personnel. It leads to a loss of efficiency in that frequently those engaged in teaching and in service are two entirely different sets of people. The latter leads to a considerable loss since teachers lose the value
of the experience of service and those engaged in the service of the department lose the stimulus which always comes from endeavoring to
instruct others. It would seem if a reasonable amount of co-operation
could be obtained that all such laboratories might be combined into one
with very beneficial results. This leads to rather an important principle. Where the government maintains a more or less extensive university which is supposed to carry on its teaching staff the most highly
trained and proficient man obtainable, why should that government itself
not make use of the expert information which is obtainable from the
university faculty for the various provincial services? In other words
why should the Provincial Government duplicate services, one in the
university and one in the various departments, both of which are doing
in part more or less parallel work. Might not the government so constitute its departments that similar or related departments in the uni-
versiy would act as the technical advisors to the government. This
could be applied, not alone in the health service, but in all the services
connected with the government and would prevent duplication in many
instances, would encourage co-operation and make the service and teaching departments one and the same. In addition it would remove further
and further from the influence of politics the scientific and technical
work which the government should carry on.
Co-operation with the people as a whole is, of course, a "sine qua
non" for the success of any health service. It is unquestionably true that
progress can be made in health work only a little bit faster than the
people will permit. That is, the people in general must be familiarized
with the problems of health and with the efforts which the health service is making for their protection in order that they can demand from
their representatives in the legislature sufficient funds from the provincial treasury to give the necessary amount of protection which the
importance of their health demands. It is for this reason that departments of publicity or education as they are called are being developed in  the various  health services.
Taking all these things into consideration it is possible to tentatively
suggest an organization for an adequate health service for British Columbia. It may consist of an advisory board, a commissioner and a
technical   staff arranged   in   bureaus.       The   advisory  board   should  be
68 comparatively small and composed of men.who are willing to serve from
a sense of loyalty to the community. In order to link the service to the
government it may be well to have a minister of the cabinet, ex officio,
a member _ of the advisory ; board. This would have the advantage of
' bringing him more closely into contact with the work of the service so
that he would become more and more familiar with the pressing needs
of the service. The president of the university might also be an ex-
officio member, especially if the_ principle of having the university act
as an expert advisor to the province be adopted. The five others should
have had some experience in sanitary science, the science of medicine,
sanitary engineering, social science and nursing. They should be appointed for a term of five years, one vacancy being made and filled each
year. This would give stability and prevent sudden change. The yearly
vacancies could be filled without disrupting the whole service. The
duties of the board should be to devise legislation and regulations for
the protection of the public health, to make appointments when vacancies
occur in the commissionership or among the technical staff, so removing
these posts further and further from political interference. This board
should recommend to the government for necessary appropriations and
should supervise and distribute the appropriations so obtained among
the various technical divisions, according to the importance of their
need. It should be the especial effort of this board to effect co-operation with other agencies to the fullest possible extent.
The commissioner should be a full time, well trained man of the
particular temperament that enables him to meet people well in all walks
of life. He should be provided with an adequate salary and have a
Sufficient tenure of office to make the post attractive to the most desirable man. He should act as secretary and administrative officer of the
service and enforce all the health acts of the Province or Dominion, and
the regulations of the service. He should represent the service at every
national and international health meeting and serve also on the advisory board of the Federal Health Department. He should publish an
annual report of the work of the service so as to justify its existence and
the expenditures which are made upon it.
Technical Staff.
This should be divided into bureaus according to the need of the
work; each bureau should be in charge of a director who should be a
fully trained expert devoting all of his time to public service. Each of
these bureaus should be subdivided into divisions as necessary according
to the need of the work. As the work of any division increased in importance and quantity, it could be advanced from a division to a bureau
without interfering in any way with the rest of the service. ] All of the
technical workers should be full time, trained experts of various grades
of efficiency and experience. Where the work of any bureau parallels or
is closely associated with a university department it would be advisable
to have the university department serve as that bureau under the Health
Service. New bureaus should be added from time to time as advances
in public health work create new necessities. The following bureaus and
divisions are tentatively suggested as of immediate importance:
1. Vital Statistics.
2. Publicity  and  Education.
3. Communicable  Diseases:
(a) Tuberculosis.
(b) Venereal   Diseases.
(c) Epidemiology.
(d) Laboratories.
4. Sanitation:
(aj Industrial Hygiene.
(b) Sanitary Inspection.
(c) Sanitary Engineering.
(d) Housing and Town Planning.
69 5. Food  and  Drugs.
(a)   Drugs.
(c) Food.
(d) Water and Milk.
6. Mothers  and Children:
(a) School Hygiene.
(b) Child Hygiene.
(c) Infant and Maternal Welfare.
7. Mental  Hygiene:
Not only should the service be organized from within, but some
organization of the Province as a whole should be attempted. This is best
accomplished by dividing the Province into so-called Health Disticts.
The Health District should not necessarily correspond exactly with municipal or township lines, but should depend upon other factors. For
instance, in and around Vancouver there are a number of separate and distinct municipalities which each maintain a more or less well developed
Health Department. From the health standpoint all of those municipalities
in reality constitute one health district, since the.problems are practically
identical, and there is a large migration of individuals from one municipality into another daily, constituting in realty these different municipalities into one health district. The dstribution of these health districts should depend to a certain extent upon the density of population.
They should be in charge of a trained expert who will advise with but
not supplant the local authorities.
Such an organization as suggested follows in general principle that
found advantages in other provinces and states: Variations have been
made which appear to be suitable to this particular province. It provides a practical and expert health service for every portion of the province and promotes opportunities for co-operation and elimination to a considerable extent of overlapping in effort which always means an economic
loss.
PRESIDENT—
I will now call on Dr. F. T. Underhill, Medical Health Officer for the
City of Vancouver, for his paper on "Infectious Hospitals for British
Columbia."
"INFECTIOUS   HOSPITALS   FOR   BRITISH   COLUMBIA"
By Dr. F. T. Underhill, Medical Health Officer, City of Vancouver, B. C.
I should, I suppose, feel honored by being asked to give a paper on
such an important subject as "Infectious Hospitals for British Columbia."
I would far sooner, however, have preferred that the honor and the
labor of preparing a paper had been conferred 'upon someone better
fitted to do justice to this very important question, and someone in a
better position to give expression to the needs of the Province as a
whole. I can only speak for Vancouver and the surrounding portions-
of the Mainland and their needs. Other problems confront Victoria,
New Westminster and the Upper Country which'can only be answered
by those with a knowledge of their requirements and' conditions. There
are, however, a few fundamental principles which can be accepted by all.
Infectious diseases need to be treated, not as belonging to any particular city or municipality with its circumscribed area, but as a community disease to which all are, or may become, involved. Take bubonic
plague or influenza, for instance; if it should occur in Vancouver or
New Westminster it would not necessarily confine its ravages to that
particular city, but might spread far and near—as the late epidemic of
influenza did, throughout the Province. We must, therefore, prepare
ourselves by combining together to provide the greatest good for the
greatest number, and let no question of local boundaries or past troubles
interfere. The limit of area should be estimated upon a transportation
basis, that is to say, the centre should be the point from which radiates
the   roads,   railroad  and   steamship   lines   that   cover  the   district  to  be
70 administered for this purpose. In such an area the local authorities of
the individual districts, urban or rural, would combine to erect a modern
up-to-date infectious hospital capable of taking care of all cases that
arise in the area served. The estimate of the standing and permanent
accommodation provided and always kept in a state of readiness for any
emergency that might arise, would be calculated upon the basis of population, official returns of infectious diseases and percentages obtained
from previous epidemics. Such data properly analyzed would enable us
to determine the service needed some years ahead.
There is need for closer co-operation in hospital matters between
the hospital and the public, as represented in its properly constituted bodies
—the city or municipality and the government. It must be recognized
that a hospital is a public utility and one of the most important of all
our institutions—that it is a necessity which should receive prior consideration above all other considerations. It must also be recognized that
adequate and immediate attention for sick people means the shortening
of the period of sickness and the saving of valuable lives, and that the
saving thus effected both in the duration of sickness and the lives of
the patients, is a very decided economic factor in the problem.
It is also conceded in these enlightened times that a hospital must
be built on modern, scientific lines, and that "any old building" is not
suitable and cannot be made suitable for hospital purposes, and that
certain costly appliances are very essential in the up-to-date treatment
of many diseases. These things cost money, much money, but the results fully justify the expenditure, and it should be possible to so arrange matters that the maximum of service might be obtained from the
expenditure—that is to say, by concentrating or pooling our resources,
better buildings and better equipment would be available. The cost of
erecting half a dozen small hospitals in as many adjacent municipalities
and equipping them with anything like a working plant, would obviously
be much greater than if one good-sized hospital were erected and equipped
in a central position at which all the patients could be treated.
The only limit should be transportation, that is to say, where we
have good roads, train and steamboat service, the various cities and
municipalities should combine and erect a modern infectious hospital capable of taking care of all cases of infectious diseases within certain
areas or districts, as may be determined. It is possible that this cooperation and combining of forces could be done at any time, but I
believe we need first to start off by asking the government to enlarge
the scope of the Provincial Board of Health, and among its activities
create a Bureau of Infectious Diseases, with its necessary requirements,
for without this central authority it would be almost impossible to
amicably arrange the manifold interests involved. Such, for instance,
as the proportional cost to be borne by each municipality in the erection
of the buildings and its maintenance; the decision as to who is responsible for the keep of an individual who has been working, we might
say, in a logging or mining camp and comes to the city for treatment,
or a person who is brought in on a train from some distant portion of
the Province, or possibly from some other Province or the States. Many
cases of infectious diseases are arriving in the city from time to time
and require to be taken care of. These not only constitute a menace
to our population, but fill up the wards of our isolation hospital—frequently at a time when we have special need for them ourselves. In
fact we have frequently been reduced to keeping cases at home which
it would have been wiser to have moved to the hospital, because of the
constant stream of patients off trains and boats for whom accommodation
had to be found.
The suggestion has already been mooted in Vancouver, having been
placed before the authorities in the form of a report, pointing out the
need for and the advantage of a comprehensive hospital scheme for
Greater Vancouver to comprise all the surrounding municipalities and
cities. This was laid before the councils of the various districts proposed to be included in the scheme and was well received by them, but
71 so far no definite steps have been taken to bring about its accomplishment.
Further, I feel very strongly that the time has come when the entire
cost of the care and treatment of infectious cases should be borne by the
city or state, for after all, one of the principal reasons in the public
mind why infectious cases are sent to a hospital is to prevent the spread
of the disease, and for this reason quarantining or isolation is often
necessary in the public's interests, but undoubtedly works a great hardship upon individual families and is, I believe, often unnecessarily long;
but it will take up an hour or two to discuss even this aspect of this
large question of infectious diseases.
Seaport towns have necessarily to assume greater responsibilities
than inland cities, and this must always be recognized by those in
authority. Again, there is the large question of immigration to be considered, especially with regard to tuberculosis, and the fixing of responsibility of the authorities where the immigrant may settle. All
these difficulties can, in my opinion, only be dealt with and adjusted
by a central authority such as a Provincial Board of Health. I have
traced a number of cases of tuberculosis who undoubtedly had the
disease in an active state when they entered Canada. Such cases as
these frequently become a very heavy burden upon the municipality, and
for this reason, as I stated before, I believe the cost should be borne
by the state.
Before discussing the question of hospital accommodation, let us first
see what are the existing conditions in the province today; what provision, if any, is made for the care and treatment of infectious diseases?
Leaving on one side the question of tuberculosis, we find that there is
no city in the province with a real modern and up-to-date hospital for
infectious diseases. Some of the cities, like Victoria and Vancouver,
have wooden frame buildings which are used for this purpose, others
either hire a house or make use of an old shack if an emergency arises,
but one and all feel the pressing need there is for proper buildings where
the public can obtain the best of treatment.
Take Vancouver—our infectious buildings consist of two frame structures erected some years ago as temporary quarters until such times as
the city could estimate what would be their natural requirements with an
increasing population. These buildings have long outlived their usefulness, and it is impossible to take care of the ordinary infectious diseases
which occur in a community of this size. The lower portions of these
two buildings are used, one for diphtheria and the other for measles; the
upper portions are divided into several sections to take care of measles,
whooping cough, mumps, etc. (There is no provision of any kind for
venereal diseases, erysipelas, etc.). These small wards are at times overcrowded, and it is practically impossible to find a bed to take care of
cases that come in on trains or boats or may be found in a hotel or
rooming house. This condition exists throughout the province, with one
exception which I shall mention with regard to Vancouver, and that is,
we have a modern hospital for the care and treatment of smallpox, provided with the necessary suspect wards. One could well enlarge upon
this subject and point out the many difficulties that have arisen from
time to time and the means that we have to devise to cope with them,
but it would occupy too much time in a meeting of this nature. I think
I have said sufficient to point out the necessity for providing hospital
accommodation for infectious cases.
In the erection of such a hospital provision must be made for the
care and treatment of the many and varied diseases with which we have
to deal: Scarlet fever, diphtheria, measles, whooping cough, chickenpox,
mumps, erysipelas, venereal diseases,' etc. The number of beds would be
determined by the population and the district to be served. An essential
is the providing of an observation ward or cubicles each separate from
the other, where all doubtful cases can first be placed until a correct
diagnosis can be made. We are all aware how difficult this sometimes is,
and we have found a very great benefit arising,from the observation ward
that has been provided by the Vancouver General Hospital for the past
72 two years. A maintenance building and adequate sleeping quarters for
nurses, with due provision for their training in infectious diseases, must
be provided. Laboratories in connection with infectious buildings are most
necessary, a very important portion of their work being the examination
of specimens for diagnosis and control. A steam sterilizer is also a
necessary adjunct, for it is the only scientific and efficient method of disinfecting clothing, bedding, etc., and an infectious disease ambulance
service with its trained assistants is an essential. Due provision must
also be made for visitors to see their friends and relatives without coming in actual contact with them. I lay some stress upon this, for many
times very sad and heart rending conditions arise when a parent is prevented either from speaking to or seeing their child that is known to be
likely to die. This can be overcome in the construction of a building by
providing a room or rooms with glass partitions and telephonic communication.
Very briefly, these are some of the requirements of a modern infectious
disease hospital, and you can well see that they will add materially to
the initial cost of such a building, but like all other branches of public
health work, the public and those in immediate control must be educated
as to what is required in a well organized and equipped hospital. I
make no mention of hospitals for the care of epidemics, such as influenza.
Temporary arrangements will always have to be made to meet such conditions as they arise and must be  dealt with by local authorities.
Although I have had no opportunity of reading Dr. Mullin's paper on
"Public Health Service," which preceded mine, I feel confident that he
will have enlarged upon many of the points I have already briefly sketched.
I have tried to point out the need for hospital accommodation for the
better treatment of cases, at the same time ever bearing in mind that
public health is for prevention, and our energies must be strained towards
the prevention of these diseases by every modern method in our power—
vaccination, inoculation, serum therapy, etc., which are making such
rapid strides. The time may come when these buildings which we hope
to erect will no longer be necessary for the treatment of the sick, but
will be used as institutions where the preventive treatment will be given.
The medical service in the late war has. shown what can be done along
these lines.
PRESIDENT—
Dr. H. E. Young, Victoria, who is the Secretary of the Provincial
Board of Health and President of the Canadian National Association of
Public Health, will open the discussion on Dr. Mullin's paper.
DR. H. E. YOUNG, Victoria—
I had the privilege of attending the first convention of
the B. C. Hospital Association last year, and I thought that it was one
of the best I had ever attended. I have reason today to change my mind;
not as to the merits of last year's meeting, but to wonder at the advances
that may be made and to still wonder at the latent ability of our friend,
Dr. MacEachern. He has put his best efforts into the formation of this
association; and if progress is going to continue from year to year, then
I have a very hopeful outlook for the future health of the people of
British Columbia.
The officials of the Government of British Columbia are only too
.anxious to have the assistance of such men as Dr. MacEachern, who,
from pure love of the subject and unselfish devotion to the interests of
the public, are willing to devote their time, knowledge and energy to
assisting the government in the framing of laws that will be remedial
in their provisions and beneficial by their enactment. It is not a difficult
matter to have laws placed in the statute books of the province—laws
which may be styled a "Monument of Foresight," but often are only a
monument, marking the resting place of the dead hopes of those who
conceive them, unless their provisions can be enforced.
Unless the purport of such laws are explained to and understood by
the people, it is useless to hope for resulting benefits; and the duty of
those   who  have   the   responsibility  of  enforcing  the  provisions  of  any
73 law, is to secure the co-operation of the public, and this can only be
done by education—educating the people by precept and example, by
proper presentation of the subject, and through the influence of just such
people as Dr. MacEachern and yourselves who are in constant touch with
the people in all parts of the province. I wish, indeed, that we had the
whole population of British Columbia as an audience, that they might
imbibe the spirit of the convention, the earnestness of its members, and
follow the unfolding of the ideas on health matters that are being presented to us today.
The explanation of the subject matter in the papers read is the result of experience. The conclusions arrived at are based upon the results  of actual practice  and  are not simply presentations  of  theories.
We have listened to papers read this afternoon by those who have
had experience and are leaders in the particular branches of the work
which they have discussed, and we are particularly fortunate in hearing
from others whom it certainly has been a treat to listen to.
Our valued Canadian friend, Miss Stewart, who has just returned
for a visit, comes to us as the occupant of a high position in her profession in one of the largest institutions of learning in the United States.
After listening to Miss Stewart, we can appreciate the fact that the peo-
sition which she fills so worthily today, has been earned by her ability;
and one can appreciate this fact after listening to the masterful description of the work along health lines which has come within the scope of
her duties. Miss Stewart's description of the results that have been obtained by putting into practice those principles in health matters which
we hope to make applicable and obligatory in British Columbia, will put
heart into those of us who are engaged in the work in this province.
There are times when contemplation of the problems in British Columbia,
is apt to make one down-hearted, and to feel like saying: 'What is the
use of it all? Our answer is the splendid report given by Miss Stewart
of the results accomplished in a large cosmopolitan city where the obstacles of ignorance, illiteracy, obstinacy and racial difficulties are as
mountains compared to the conditions which we have to face. Miss
Stewart's words have been a fountain of encouragement and makes one
feel like taking a fresh hold and attacking our own problems vigorously^
because: "What man has done man can do." I feel sure that you have
interpreted Miss Stewart's message as I have; and to you people, who,
from unselfish motives, have come from all parts of the province to discuss our present problems, I would ask that you will carry the message
you have heard to your homes, and impress upon the people of your
district the seriousness of the conditions as described by Miss Stewart,
and more particularly the necessity of correcting these conditions by concentration of effort by those who know, and co-operation by those who
are anxious to learn.
Dr. Mullin is a man who has been with us now for some time in3
connection with the  B.  C.  University.    Dr.  Mullin  came  to  us  with  a
deservedly high reputation.    The doctor - has filled a  very important position in one of the seats of learning in the United States; and just in
passing, I might say, in regard to our two speakers tonight, it is wonderful how the homing spirit  shows  in  all  Canadians—he  comes back with
a message taught by experience, and has  set forth  in his  paper  tonight;
the outline of a constructive policy which, if we can adopt in its entirety,-
would lay a basis  for the  solution  of many of our problems;  and  it is
not too much to hope that, in the near  future,  practical  effect may be
given to Dr. Mullin's suggestions.    Dr. Mullin's description of the evolu
tion of health work, by
of progress as follows :
dividing into three stages, places the milestones
Recording,
Prevention,
Correction.
and
I notice that Miss Stewart followed in her remarks the same lines iff]
reference to the gradual growth of public health work.
74 Dr. Mullin has dealt fully with the first two—Recording and Prevention; the Recording of Vital Statistics which led to the study of the
various communicable diseases and the compilation of the facts in connection with these. The knowledge gained, together with the data obtained from the advances in bacteriological work, led to the adoption of
the second stage—that of Prevention. We are progressing from these two
now, to the most essential step in public health work, and that is Correction. We are beginning to learn what the real value of the human
being is to the state. We boast in British Columbia of our great natural
assets. We have made provision in our laws for the protection and development of these assets; and have noticed during the past few years the
rapid expansion of the different departments of the government which are
entrusted with this responsibility. During the great economic expansion
which has taken place in British Columbia, we have not included the
human asset_ We have gone along serene in the belief that the supply
of men was inexhaustible; and we did not know how we stood until we
were suddenly called upon during the war to realize upon this asset and
we found that we had been leaning on a broken reed. When the returns
were received of the results of the examination of the flower of our manhood, by the military authorities, we were appalled to learn that, at
least, one-third were physically unfit to become soldiers. It was a very
serious lesson to us; and our duty is to embark upon a vigorous campaign of Correction.
We find in the examination of our school children, the existence of
defects that, if permitted to continue, will when the next war comes,
simply show that we will be as ill-prepared then as we are now to provide men. If the defects existing in the children of British Columbia
today, are corrected, then we can make good our boast that physically
and mentally the people of British Columbia are people to be proud of.
We have the material to work upon. We have probably, among the
provinces of the Dominion, the purest Anglo-Saxon population of any.
We have not been afflicted with a foreign element that, in the other
provinces, has become such a problem and so difficult to assimilate. We
have not the elements that Miss Stewart is more acquainted with in the
large cosmopolitan cities, which form islands of nationalities clinging to
their national customs and habits—customs and habits that are far below
the standard set for ourselves.
I remember once, in speaking in regard to the University of British
Columbia, of comparing the population we have to the water of the River
St. Lawrence. I remember as a boy sitting on the banks of the river
and swimming in the stream. I can remember the beautiful clear limpid
stream, and the reason of its purity was that, before entering the river,
this water flowed through the chain of Great Lakes which acted as settling basins. The debris sank and the flotsam and jetsam stranded on
the bars, and by the time the water reached the river all the detritus had
disappeared. The population of British Columbia is similar in its purity
of race, because the tide of immigration which reaches our continent on
the Atlantic shore, flows over the great provinces to the east of this,
which act as the Great Lakes have done—as settling basins. All the
derelicts have dropped by the wayside, and we have in our population a
splendid example of the survival of the fittest. We have that pioneer
stock that Mrs. Hannington referred to this afternoon—that always went
farther because the difficulties were greater.
With this splendid material to work upon, does not our responsibility-
seem the greater? Should it not spur us to greater efforts to preserve
and pass on to the following generations the indomitable spirit and the
physical capacity that our people have shown in overcoming the difficulties
in getting to British Columbia? This stock possessed many good qualities, but it developed the strain of individualism that was apt to overlook the community as a whole. They are beginning to learn now. that
the individual is not altogether independent from other individuals and
from the community. As our knowledge of public health progresses, we
subordinate the idea of individualism to the community interests. We
know that the conduct of the individual can be regulated, and must be
75 regulated to follow out our scheme of society. We do that in order to
provide a community sentiment; and if we have followed out this line of
conduct in regard to the general affairs of our province, there j is no
excuse for us having overlooked the fact that disease in the individual
is detrimental to the community. We have got to learn in this connection that the individual wish or the individual habit, must subordinate
itself to the general good, and we can only bring this condition about
and explain our propaganda by co-operation from the people.
Co-operation is the subject which I just wish to say a word about,
because as head of the Provincial Board of Health, it is one thing that
I am most anxious to secure. It is the one thing that will bring about
realization of the scheme that the government have in view and of the
hopes I personally have of furthering the interests of the Board. Dr.
Mullin said that progress can be made in health work only a little bit
faster than people will permit. People require leadership, but that leadership must be something, the object of which they understand. They must
have the object of any movement explained to them and if you can put
it up to them so they can see it is for their own advantage and the
advantage of the country, you will find that you will get support that
will enable you to go ahead. Now co-operation means co-operation with
Central Government, Federal Government and other Provincial Governments, with our Municipal Governments, and then in regard to ourselves,
securing the co-operation of the volunteer organizations which Dr. Underhill spoke of. The ones I hope to obtain the most help fro mare the
organizations that are being formed voluntarily, not with the idea of any
particular object as regards health work, but with the idea of upbuilding
the public life in the province. We have some splendid organizations,
particularly among the women of British Columbia—the Womens Institute, Red Cross Society, I.O.D.E., and many others. Their ability and
willingness to do needs no praise. The demonstration that they have
given during the war has shown that when they make up their minds to
accomplish something they will bring it about. Why should these splendid
organizations that are in working order be allowed to disband? Preservation of the nation, whether from war or disease, is the same thing. If
the women will say, "Here, we have helped to win the great war, now
we are ready to carry on the war against the enemy within our gates, then
with their help we are going to bring about the result very quickly.
The women of British Columbia do not realize as yet, what their responsibilities are, nor how efficient they are in the discharge of these responsibilities. They have demonstrated by their quiet persistent work their
ability to accomplish what they set out to do. They have shown this by
the fact that their names are today inscribed on the Voters List of the
Province. The result of their persistence was well described by a remark
made by a gentleman in his speech at a convention which I recently attended in Ottawa, which was called to deal with the venereal question.
In speaking to a gathering of medical men, he said:
"You   medical   men   probably   are   preening  yourselves   somewhat
on the thought that it has been the result of your efforts that the
establishment of the Ministry of Health has been brought about, but
I wish to tell you that, while great credit is due to you for your assistance,  that the  great  influence  which  forced  this  action  upon  the
Dominion   Government   came   from  the  women  of the  Dominion   of
Canada, and it is the women of Canada who are going to force upon
the   Government   of   the   Dominion   the   actual   carrying   out   of   the
measures that are to be adopted for the control of venereal disease."
Now if the women will just awaken themselves to the fact that they
have demonstrated the power of their organizations, why can't they continue the good work and bring about the elimination of all  preventable
diseases?   There is no excuse for the existence of epidemics of measles,
whooping coughs, typhoid fever or smallpox.   Why is it that, among the
millions  of  men in  the  British  Army,  these i diseases   were   practically
negligible?    Why is  it that,  in all the deaths in the army, only 5 per
cent, of the casualties in the Canadian Army was due to disease?    It is
because  the principle  of Prevention  and  Correction   in  regard  to  these
76 diseases were enforced under military rule and these diseases were dont
away with in the army when they were living under conditions—physical
and mental—that we would not tolerate for a moment. Why is it that we
have to record from year to year so many deaths from these diseases in
our homes? It is simply because of the negligence within the camp.
It is only lack of understanding, lack of knowledge—not lack of willingness to do or follow the lead of those who know; and it only needs that
the people should be instructed; that they should be taught to learn that
the power of Correction and Prevention lies in their own hands. There
were no great truths discovered as regards health measures during the
war; it was simply the practical enforcement of the teachings of the
health authorities. Now why can't we do it among ourselves? Why
can't we manage, so that every child in the community will have an equal
chance to grow up as physically strong as his playmate, no matter what
the circumstances of his people may be? Why should we live as selfish
individuals? Why do we neglect our duty to the community? We may
do our very best for our children, but our neighbor next door who neglects the ordinary precautions of health, may, through his neglect, start
an epidemic that will make a lamentable increase in the death rate among
the children. It is up to you to preach the gospel of health; to insist
upon the individual so comporting himself that he and his family as
not a menace to the community.
This is our present duty, and I feel sure that the inspiration you have
received at this convention is bound to have a lasting effect which will
be felt in your different communities. I would particularly ask that you
women, who. are members of the Women's Institute of British Columbia,
make it your first duty to insist upon the common ordinary rules of health
and hygiene being carried out in your schools and homes.
DR. R. H. MULLIN, Vancouver-
It has been suggested in order to get some action a resolution might
produce the desired results, I therefore propose and move that,
WHEREAS Public Health Problems have become so important to
the community,
BE IT RESOLVED that the Government of the Province of British
Columbia be memorialized to take prompt and energetic steps to give the
citizens of this province an adequate and up-to-date Provincial Health
Service.
Seconded by Dr. F. T. Underhill.
DR. A. G. PRICE, Victoria—
In speaking about this subject of Infectious Disease Hospitals, I am
very glad to be able to follow my friend, Dr. Underhill, of the big city
over the sound, or over the water there, Vancouver, who has had a
great deal of experience in the treatment of all the isolation of infectious
diseases, and I fully endorse his suggestions that every city shouid be
provided with a real large up-to-date infectious disease hospital. It is
a very large subject, Infectious Disease Hospitals. You remember an
infectious hospital—the first and foremost purpose of an isolation hospital
is to isolate, it is a public health matter, and second to it but only a very
mere second, is the treatment of the patient. Some people might consider the patient came first, but as a public health officer I consider that
isolation comes first. There is the separation of the diseases. There are
a great many infectious diseases and we cannot treat scarlet fever, smallpox, diphtheria, mumps and chickenpox all in the one_ ward. We must
have separate places; whether they are in one large building or not, that
is a matter of opinion, but we can in separate wards in one large building,
take proper precautions to prevent the spreading of one disease from one
ward to the other. This is the seperation of disease. Then there is the
separation of sex; you cannot have both sexes in the same ward. You
can put the children in the women's wards. Then again, you cannot
nurse a Hindu and Chinaman with a white man. You cannot nurse Chinamen and Japanese together, and we have to separate races, and that is a
very great difficulty we had in managing our hospital treatment during
the" epidemic of  influenza.    We had the Japanese,  Chinese,  Hindus  and
77 white men; then we had the Japanese women, Chinese women, we had the
Hindu women and we had the colored lady. We had to keep them all
separate. Now you did not know there was so many sections, but you
have to keep them separate, so remember in making plans you have to
have an immense building. Then there is the separation of classes.
There are dukes and beggars. I would rather isolate the beggars any
day than the dukes. I mean by the dukes, men who wanted a special
nurse, perhaps three nurses, when the whole of the city was crying out
for nurses. I say men, remember. The men were the trouble. We have
to have private separate wards in an institution. Now you can imagine
what an immense big institution this would be. Then we have another
obligation, the separation of nurses. We cannot put the smallpox nurse
to sleep in the same room as we put the scarlet fever nurse or any other
nurse, so we have to separate them, so you have also the nurses quarters
to consider. I am just leading up to the point that you must not be
alarmed if the health officer of your city asks for a half million dollars to
establish a proper Isolation Hospital. Do it in thoroughly good style or
not at all.
Our present Isolation Hospital in the city of Victoria consists of
three brick buildings, and we can accommodate quite a lot of patients
there. We can accommodate, I think, 46 patients altogether, but I
would like any of you to come up and see our hospital and see all the
things that are wanted. We have been able to work along without them,
but we want considerable additions, in fact, we want a new building.
There is nothing there now to frighten you, there is only one patient, a
little girl with scarlet fever. I would like you to come out and see the
hospital.
In addition to the nursing in the hospital, there are other necessary
adjustments besides nursing, there is the cooking. It is a most difficult
thing to arrange for the proper feeding of the patients and dieting for
different stages of convalescence. They want expert cooks. Our greatest
difficulty was our cooking during the epidemic of influenza. Several of
the ladies of Victoria volunteered and came forth. I do not know what
we would have done without them; they were expert cooks and invalid
cooking was very well carried out to the great delight of the patients,
for many of the patients after leaving the hospital said to me: "Well, we
had something good there every  day."
Now there are other matters which are different. We want a band
of caretakers, the hospital must be kept clean. These are infectious
wards, and the cleaners cannot go from one infectious ward to another.
We must have janitors who will not communicate one disease to another
ward. Again, we must keep very careful tab on all the diseases that
come in. We must watch them very carefully. We must keep registration of them in our books, attend to the taking in and see that they go
out properly disinfected.
Now, the expense of running the hospital. The expense of our hospital of the city the seven months during the influenza ■ epidemic, cost
us close on the $12,000 compared with $4,000 of the equivalent seven
months of the previous year. That shows that the epidemic in the
Isolation Hospital alone cost the city the sum of $8,000. We also had aff
Emergency Hospital which cost the city something between $3,000 and
$4,000, so that shows you the epidemic in this city cost us between $11,000
and $12,000. Now how was that amount expended? A great deal of it
was expended on nurses' fees. We could have done with fewer nurses
if we had had an up-to-date impact hospital. Now, if we could get our
patients more clumped together in wards, perhaps we could do with a
smaller nursing staff. Unfortunately when the influenza came we were
very much in need of nurses. About two hundred ladies came forward
and offered their services. Now only for these ladies coming forward,
offering their services, helping us out, we would not have got through
with the epidemic as we did, for nursing of the influenza was really half
the battle, and they came forward and nursed in homes and in hospitals, many of them got the disease themselves and became patients
in the hospitals.   I am sorry to say a great many ladies in Victoria    did
78 not come forward, and the two hundred did come forward, all honor
to them, but a great many who might very well have come forward
and helped did not, and those girls who were nursing were nursing not
only eight hours but twenty-four hours some of them. The matron of
our Isolation Hospital for seven months stood up, I don't know how she
stood up, the worry and the strain working night and day for seven
months was more than any woman could stand, all honor to her and all
honor to the ladies who came forward and nursed through that epidemic.
I want to say a word about the treatment of some of these diseases
in isolation hospitals—scarlet fever, smallpox and diphtheria—it should
be compulsory to treat those diseases in the hospital. There are other
diseases which need not go to a hospital unless we had an immense hospital in which to receive them. The influenza epidemic did, of course,
bring hundreds of patients to our hospitals, yet the fair majority remained
in homes, and we know that patients who came to the hospital were taken
out of their beds when temperatures were up to 104 and 105 degrees.
I do not advocate the treatment of diseases like influenza in hospitals.
I hope if the epidemic appears again, which it may, in the city next
year, that we will have a better staff of nurses, a more numerous staff
of nurses to go round from house to house and attend to the patients. Of course, we will take as many in the hospitals as we possibly
can. If it was necessary I would have suggested that all the public
schools and public buildings be turned into hospitals, but we did not
think it necessary, and I found it much more advantageous to carry on
the nursing in the homes as much as possible, where we had such a
fine band of nurses to go.
DR. J. W. McINTOSH, M.L.A. Vancouver—
I heartily endorse the plan outlined for an up-to-date Board of Health,
having been associated with Dr. Mullin on the Reconstruction Committee which called for such an outline for the Province of British
Columbia.
The main idea in Public Health being prevention of disease, there
is no logical -reason why this should stop short of the State putting the
. means of attaining and retaining health and fitness, within the reach of
each individual. To the average citizens, sickness, with its present cost
for all the means of diagnosis and treatment (especially surgical), laid
an impossible burden.
Capacity production in peace and readiness for defense in war require all-round fitness. Compulsory State Education secures mental development. Logic widens the scope to compulsory State Insurance against
sickness, for those earning an income not over the amount necessary for
a reasonable standard of living, along lines similar to the present Workmen's Compensation and Insurance Against Accident. As there are nearly
100,000 secured under the latter, it would seem a conservative estimate
to place the number at 200,000 who would come under the former, inasmuch
as dependents would be included. This would be 50 per cent, of the
population of British Columbia, on an estimate of 400,000. It will
therefore readily be recognized how such an extension of the state's interest in Public Health, together with that necessary to carry out the recent
Act for the control of venereal disease, will require the organization of
just such a Board of Health as has been outlined in Dr.  Mullin's paper.
It is also obvious that such an extension of State Health Control
will vitally affect the hospitals of the province, bringing this discussion
home to this organization. To adequately discuss this aspect would require a whole session, but one is led to see that such extension may lead
to the state taking hold of the administration of the hospitals. If that is
done it will mean the employment of a staff of full time medical men and
nurses directly by the government. To do this properly will necessitate
the creation of a Commission, such as the Workmen's Compensation
Board, in order to remove it as far as possible from politics._ On such
a Commission one or more medical experts would be required. This
would be the beginning of a State Medical Service without interferring
unduly with private practice.
79 Not only would medical men employed full time be required on hospital staffs under the State, but for the purpose also of taking the responsibility of signing sickness claims, to the benefit of the state and
the advantage of the attending doctor. The further _ duties of _ educating
the public and working in collaboration with Municipal, Provincial and
Dominion Health Boards, would naturally fall to such full time professional men also.
Since the public and returned men have seen in the present war
what can be done in the way of prevention of disease by proper organization, there remains only the duty to impress upon our legislators the
necessity for immediate action, and such a duty very well falls within
the purview of this association and should be pressed home.
PRESIDENT—
I will call on Dr. A. Whiting, Vancouver, to bring before the meeting the substance of a petition which has been sent to our association.
DR. A. WHITING, Vancouver-
Several of the social workers of the province who are interested in
cases of drug addiction and venereal disorders, in the petition before you,
ask you to consider the advisability of approaching the Provincial Government regarding the formation of a public hospital for the treatment
of these cases. In their petition, which has been numerously signed by
those who are laborers for the betterment of the masses, and who are
associated with the various organizations handling such problems, they
give evidence of having viewed the matter from all angles, and their
experience in dealing with social evils is probably a sufficient guarantee
of the wisdom of the various suggestions which they make, although the
title, "Lock Hospital," is a very unpleasantly sounding name, and descriptive of only one phase of the work of the suggested institution.
Isolation Hospital is very little better. Probably some such title as
"The Good Samaritan Hospital," or simply "The Retreat" (a title used
in one instance in England), would be more appropriate. But whatever
title is given, most cases need to be isolated from the so-called friends
of the patients who are often their worst enemies.
The   suggested   methods   of   treatment   beyond   isolation   consist   of:
1.   Appropriate   medical   treatment,   which   (all   are   agreed)   is
necessary.
2   Educational treatment.
Many of the fallen girls enter upon a life of immorality and shame,
being quite ignorant of the dreadful ravages of venereal diseases, and
if they could be earnestly educated in these matters, and also in the
responsibilities of motherhood, it would do much to help them back to the
pathway of virtue.
Coupled with educational treatment there is the moral side of the
question. In our hospital work as at present administered we do not
endeavor to render that moral advice which is necessary, and yet education, without the refining elements which make up the nobler side of
life, may be instrumental for evil rather than good, because knowledge
is power, and needs to be wisely directed.
The petitioners also mention spiritual treatment. I believe we do
not use Christian influence as we should, among the sick, especially in
dealing with unfortunates. Both Protestants and Catholic organizations
have done more to reform and uplift the sunken tenth than have similar
moral,   but  non-spiritual   organizations.
Lastly, there are the occupational and recreative methods suggested.
I have seen men and women shut up in isolation for months with nothing
to do. No play, no recreation, no employment, no spiritual exercise at all.
Is it a wonder that they became restive and unmanageable, and departed
shameless and hardened.
Prior to the inception of this petition the Child Welfare Association,
I believe, adopted a similar resolution, and this should be before you
tonight, but in some way it appears to have miscarried, but I heartily
endorse the matters which it and the petitioners are interested in. I
therefore move,
80   THAT this convention go on record as being in favor of the project
mentioned  by the petitioners,  and  resolve to approach the  Provincial
Government with the purpose of having their desires fulfilled.
Seconded by Dr. J. W. Mcintosh.
PRESIDENT—
This again comes as a motion and resolution from the convention
as a whole, and will be submitted to the Resolution Committee and reported on Thursday afternoon at the general session. The petition reads
as follows:
"We, the undersigned, respectfully request the convention of the
B. C. Hospital Association to urge the Provincial Government to establish a Provincial Lock Hospital for the treatment of sexual troubles and
drug habits.
"We, as workers for the social welfare of the people, believe such
an institution to be an urgent necessity, and further recommend for the
effectual service of the same, the following as essentials of its constitution, viz.:
The institution shall  be  equipped  for the medical,  occupational,
educational, moral, spiritual, recreative and disciplinary treatment of
its patients.
Provision   shall   be   made   for  an   outdoor   clinic   in   connection
therewith, with similar facilities.
The  institution  to be  affiliated with the various  industrial  and
welfare homes and juvenile, police or other courts  of the province,
and powers to be given to the courts to commit to the hospital such
cases as may be advisable.
The institution to be open to receive suitable voluntary cases applying to it for treatment."
This petition was signed by a large number of influential officials and
citizens of Vancouver.
Meeting adjourned to meet at 9 o'clock next morning.
WEDNESDAY,  JULY  9,  1919.
Round Table  Conference   Conducted by  Mr.   Charles  Graham,  President
Cumberland Hospital Board, Commencing at 9 a.m.
QUESTION NO. 1—
Is  it possible that nurses  before  graduation  or  as  a post-graduate
course could have instruction  in  X-Ray work?
MR. C.  GRAHAM, Cumberland—
This question has been referred to Dr. H. H. Mcintosh,  radiologist,
Vanconver  General  Hospital  and he  replied by letter as  follows :
Charles Graham, Esq.,
President   Cumberland   General   Hospital,
Cumberland, B. C.
Dear Sir:—
Dr. MacEachern has handed me your letter containing the question
of Mr. Grimmett: "Is it possible that nurses before graduation or by a
post-graduate course, can have instructions in the use of the X-Ray
machine, especially such instruction as would be found particularly
beneficial in outlying hospitals?"
The answer to this question must necessarily be somewhat qualified.
The field of X-Ray work is a large one and requires a considerable
time to be spent in mastering even the rudiments. In having a nurse
trained for this work much must depend on what kind of work it is intended she will do. Even to be fitted for taking skiagrams of extremities and bone work only, there is much to be learned. I judge that
it is more especially for determining the nature of fractures, whether
or_ not displacement has been corrected and the progress of repair that
skiagrams are to be made. Examination of the chest, abdomen and head,
and the carrying out of treatment require knowledge beyond that to be
expected of a nurse, and should only be done by her under the supervision of a medical practitioner who thoroughly understands X-Ray
therapeutics and methods of diagnosis.
81 The types of apparatus used in different places throughout the country vary very much in detail, and to be able to operate every one of
these various types would require considerable technical knowledge.
Were a standard form of apparatus in general use it would be relatively
simple to  train  nurses  in the work.
This training cannot, in my opinion, be given as part of the nurse's
course in hospital training. One who chooses to do this work should
take it up as a special study after graduation. It requires knowledge
that can only be obtained by experience in the actual work of running
the machine, so that a short course of study only fits one to start the
actual work of learning to operate the X-Ray apparatus. The same
would apply to the dark room technique. Experience is the only teacher,
and there is much to learn in running the  dark room properly.
The most satisfactory way at present would be to teach the nurse the
technique of operating the machine she is to use and thoroughly training
her in its use. This would, of course, mean that the practitioner must
himself be familiar with the operation of his own apparatus. The
alternative would be, having selected a nurse for the work, to have her
take a course at one of the schools where they teach X-Ray operating,'
then to visit the manufacturers of the apparatus to be used and be
thoroughly coached in that particular type of machine. Time would then,
if the nurse be adapted to the work, enable her to make the more simple
examinations.
When all is said and done, that only provides for the least of the
difficulties—the most important remains—the interpretation of the skiagrams, which of course can only be done by one well versed in the meanings of the shadows seen on the skiagram. I emphasize the latter, as
much harm is done and many bad results are due to improper interpretation of X-Ray plates.
The answer is thus negative to a course of general training at present and affirmative in that the nurse may be trained specially for operating a special X-Ray unit, the interpretation being, of course, left to a
qualified medical practitioner.
Yours truly,
R H. McINTOSH,
Radiologist Vancouver General Hospital.
Dr.   T.   R.   Ponton,   Vancouver,   was   asked   for   his   opinion,   and   he
corroborated Dr. Mcintosh's statement
i DR. MORRIS—
Does that lead to the necessity of X-Ray machines being standardized
in  our  hospitals?    I   imagine  when  a  hospital  buys   an   X-Ray  machine
they will  buy  from the ] first  traveller who   comes   along.    There  should
be some means of arriving at a standard.
DR. T. R. PONTON, Vancouver-
There is no standard machine at the present time except that used in
the United  States Army.    I  do not know the machine,  but I understand -
it  is  a  very satisfactory  one  for ordinary  work.    As   far  as  a  hospital
buying  a  machine   from   the  first   traveller  that   comes   along,   I   do  not
think   that   is   good   policy.     An   X-Ray   machine   costs   anywhere   from
$1,000 up.    Anything less  is  money thrown  away.    If you  cannot  afford
a first-class machine, get part of your machine, go as far as your money
will buy, but when you buy buy the best and take the advice of an expert.
DR. M. T. MacEACHERN, Vancouver-
Is running an X-Ray machine like running an automobile?   If you buy
a Cadillac and change it  for a McLaughlin, you seem to get on to the
running of that car from the first.
DR. T. R. PONTON, Vancouver-
Yes, you pick it up more quickly.   At the same time there is a big
difference in types, the  controls are very different
MR. C. GRAHAM, Cumberland—
I should think the control proposition is more of a mechanical
proposition.
82 DR. T. R. PONTON, Vancouver-
It is not difficult to operate the mechanical end so long as everything
goes right.
MR. C    GRAHAM, Cumberland—
If anything goes wrong with the machine could a radiologist find
what the matter was?
DR. T. R. PONTON, Vancouver	
An instance of that; week before last our big machine in the Vancouver General Hospital refused to work one morning. Dr. Mcintosh
being an expert, _ it took him about five minutes to trace the trouble.
A person who did not know the theory as well as the practice, would
probably have done one of two things. If he was wise- he would have
called in an expert • If not, he would have tried himself .and probably
been burned with electricity.
DR. M. T. MacEACHERN, Vancouver—
To sum up, therefore, our conclusions are as follows: That it is not
recommended to make this work compulsory in training, but could be
recommended for post-graduate work; that it is possible and easy to
train a nurse technically, but with this she is not able to interpret the
findings, as this can only be done by a medical man; and finally, that the
best arrangement is a medical man with a trained technician to do the
work for him if he is too busy to do all the technique himself.
QUESTION NO. 2—
Can a suitable woman be obtained as  a housekeeper and dietitian?
MISS M. P. MACMILLAN, Nanaimo—
I think a graduate nurse with a knowledge of dietetics would be a
suitable housekeeper and dietitian.
QUESTION  NO. 3—
Is there any charge for babies in hospital when breast fed? Is there
any charge for babies in hospital when not breast fed? On what grounds
should a hospital permit a  baby not to be breast fed?
DR. M. T. MacEACHERN, Vancouver—
I desire to speak particularly on the last part of the question. It
should not be optional as to whether a baby should nurse or not. That
is a very serious question. If your hospitals allow babies to be taken
off the breast indiscriminately then you are going to get into trouble
some day. Some hospitals today are doing a fine business in placing
babies as quickly as possible after birth. These babies are taken off the
breast and sent to institutions often immediately. Investigations show as
high as 90 per cent, mortality among such cases. Many of these cases
are illegitimates. One of the best institutions that I know of allowed
this practice for many years till shown up by the vital statistics in an
investigation. All babies should be breast fed as long as possible, unless contra-indicated by physical conditions in the baby or mother;
and there are few of such conditions found. We have a rule in the
Vancouver General Hospital today that every baby must nurse at least
twelve to fourteen days if the mother is in with it, unless certain physical
conditions contra-indicate such. The hospital authorities must satisfy
themselves as to whether the baby should nurse or not. Sometime ago
we opened an Infants' Hospital in Vancouver, a very splendid place to
send all illegitimate or deserted babies—and we found that _ a good many
cases came into the hospital with a request that their babies be sent to
this hospital, but this can only be allowed after conforming with, the
rules as laid down and after consideration of each case on its merits
In regard to the charges-—I think you will find that most hospitals
cover this in a fiat charge per day for the mother, and this charge is
higher than for other types of cases. Suppose you add on 50 cents or
$1 per day to the room charge, this to cover baby, case room, anaesthetics,
etc. The flat charge is more satisfactory to the patient and fair to all,
as they all get similar service.
83 MR. C. GRAHAM, Cumberland—
In Cumberland Hospital all these cases are charged 50 cents a day
extra, and there  is  50 cents per day more on maternity cases than on
others.
MRS. M. E. JOHNSON, Vancouver—
I charge $5 more per week for maternity cases.
MISS M. P. MACMILLAN, Nanaimo—
Is it usual to charge for the delivery room?
DR. M. T.  MacEACHERN, Vancouver—
Generally there is no charge     Our only charge is for gas anaesthesia,
at about $5 to $10 per hour, depending on how much used.
QUESTION  NO. 4—
How can we induce more young women to take up nursing, and how
can the small hospitals particularly, attract young women for their work?
MRS. M. E. JOHNSON, Vancouver—
This question was thoroughly discussed last week, and the nurses'
convention went on record as wishing to encourage V.A.D.S who had
hospital experience in military service to enter the training schools, and
they would be willing to give a certain amount of time and that each
case would be considered on its own merit Another way of encouraging
pupils to enter training schools was to make our training schools just
as attractive as possible; to make a very great effort to have the hours
of duty shortened. The convention went on record as favoring the eight-
hour day for nurses, and urged all superintendents to go back and make
a special effort to introduce that system, and in that way they felt there
would be more young girls wishing to take up the training. Another
way to encourage girls to come in was to have it advertised more in the
schools, among the parents and children. Encourage them to go on
further in their high school course, matriculate if possible, with the idea
of taking nurse's training. These were the three things that we emphasized
at the nurses' convention.
DR. M. T. MacEACHERN, Vancouver—
The Resolutions Committee approved of a standard curriculum for
the province and a nurse inspector for training schools. That will improve your training schools, and if the Department of Nursing in the
University see fit I think that during the coming year, a year from now,
we will endeavor to open up a six months' training or post-graduate work
for your hospital superintendents of B. C, that want to come for it—
a short summer course so that they may keep in touch with nursing
problems of the times, which they cannot do here and which they cannot go east to get because the distance is too great. That should be a
stimulus to them and should in turn stimulate more nurses to come in.
It rests with yourself to improve the training schools. If you get an
inspector of Training schools you will have a great advantage because
she will go to the different training schools and spend a week working
things up, and I think that will be a recommendation of this convention.
DR. J.  K. UNSWORTH,  Nanaimo— u
I was interested in Miss Gunn yesterday speaking of the project of
these nurses' aids or attendants. I would like to know how far along
the matter is in our own province in the effort to give such girls assistance
in the development of the nurse's aid idea beyond that of licensing the
present midwife. As I understand it there has been nothing done along
that line.
MISS J. F. MACKENZIE,  Victoria—
So far, of course, the whole thing is all hanging in the balance on
account of the national nursing service and it will be another year before that can be whipped into line because it has all got to be referred
back to the Red Cross Association, but I think if things move as they
have done at this convention, we will not have to wait very long. ■
MRS J. D. D. BROOM, Vancouver-
Is the question of training the nurses' attendant to be left over for a
year?
84 DR. M. T. MacEACHERN, Vancouver—
I suppose it will as far as the National Association is concerned.
As far as we are concerned, I do not know whether we should or not
MISS J. F. MACKENZIE, Victoria—
I think we will allow it to be worked out under the National, as it
will all have to be controlled under the National. Then it will be worked
out in the different localities and provinces. The particular person you
speak about can now get work in British Columbia in the Soldiers'
Civil Re-establishment Hospitals and spend her time in that actual work,
and perhaps when the National movement is settled, will get recognition
for it
DR. M. T. MacEACHERN, Vancouver—
We have forty-eight such girls in our institution who have been there
two or three years, who may receive such recognition.
MRS. J. D. D. BROOM, Vancouver-
It would seem to me that that particular attendant would have that
particular training in  her home.    I do not think the trained attendant
would fill the bill in the home.
QUESTION   NO.   5—
Is the nurse a legal anaesthetist?
DR. M. T. MacEACHERN, Vancouver—
An investigation was made two or three years ago all over the
United States, and the report of the Interstate Anaesthetists' Society of
America did not approve of the practice. It has been carried on, though, in
Canada and the United States, especially during the war. Now the
legal advisors to our hospital consider that it is illegal, because it is the
administration of a drug, and until such time as the B. C. Medical Act
is altered, it will be illegal, and the hospital would bear the responsibility.
Now the question comes: do you want nurse anaesthetists for British
Columbia? Do you want to legalize them? We can train them. If you
want to legalize them you will have to ask for the Act to be amended.
If you want to know whether it :s advisable or not you should consult
the B. C. Medical Council, I would think. Personally, as a hospital administrator, it would be far more satisfactory, I think, for us to have
nurse anaesthetists, but the public are only too glad to hinge a lawsuit on
the hospital for the most trifling tiling now a-days. You would have
to be protected in that respect. I would like to hear some opinions as to
whether they want this, so it ••.ould be referred to the B. C. Medical
Council. That is our status at present and we have done nothing about
it in Vancouver.
MR. C. GRAHAM, Cumberland—
. The way that question is put would requve some specific action.
MISS J. F. MACKENZIE, Victoria—
I am only a nurse myself, but I do not approve of Nurse Anaestheists.
I think they all ought to be taught something about giving an anaesthetic
and the care of the patient while it is being administered and know
something about it so if they are caught out in the country they can do
it with a certain amount of safety. I would not recommend any of my
nurse to be licensed for anaesthetists.
DR. H. C. WRINCH, Hazelton—
I saw a nurse giving anaesthetics at Rochester; she gave eight or
ten a day, and I did not see a single difficulty, and at that time they
were giving thirty or forty a day, and I did not see one case go wrong.
As far as ability to give anaesthetics is concerned, there is no reason
why a woman should not give as good anaesthetics as a man, and when
they are giving their whole time to it I do not see why they could not
give a better anaesthetic than a man who is not giving his whole time.
MRS. M. E. JOHNSON, Vancouver—
As far as the giving of an anaesthetic is concerned there is no
reason why a nurse could not give it just as well as a doctor, but the
thing is: it is illegal in British Columbia, so there would be no object in
giving a nurse training in anaesthesia without it being legalized.
85 DR. H. C. WRINCH, Hazelton—
It affects the small hospitals very materially, where doctors have
often to work single handed. It could be attached as a post-graduate
course, 1 should think, without licensing the nurse or authorizing her to
give anaesthetics excepting in emergency cases.
MRS. HANNINGTON, Ottawa-
It is absolutely necessary that a nurse should be able to give an
anaesthetic and give it well if the need arises. I do not believe it is
well to license them in your hospitals, but if a nurse cannot give an
anaesthetic today it is no use to send her out in the faraway districts,
for if the necessity arises, what is the use of having a trained woman
unless she can give an anaesthetic. I know of a small hospital where
there were just two nurses, no doctors; I have known those nurses to give
anaesthetics and do quite a surgical operation. It was either that or
the patient should die. A man was brought in with his throat cut from
ear to ear; the nurses operated on him, they did the best they could, and
the man recovered. It is the same thing with maternity training; it is
very weak. There is not always a doctor, therefore .the nurse should
know a great many things that she does not know.
MRS. M. E. JOHNSON, Vancouver—
I think every anaesthetist should have more training.    I  have seen
medical men  give anaesthetics that made me  tremble.
QUESTION  NO. 6—
Should  Maternity   cases   have   a   separate  building?
DR. M. T. MacEACHERN. Vancouver—
I do not think we should pass that last question up by the Association
without further consideration—about the nurse anaesthetist—because that
is coming up so often, we hear so much about it lately.
In regard to Maternity cases having a separate building, that is most
desirable.   We regard Infectious Diseases, Infants' Diseases and Maternity:!
cases as separate phases in our hospital nursing, requiring special nursing.
From the nursing  standpoint  it  is  desirable that the  Maternity pavilion
should be separate from the rest.    Secondly, from the patient's standpoint,
as far as publicity is concerned, patients do not like coming in through the
usual entrances to the main hospital; they do not wish to be seen, naturally. I
The further away you carry the Maternity case from general infection the
better.   In any general hospital we cannot get away from pus cases, though
we segregate them.   Then, again, there is the noise which is often created
around a Maternity ward, which is displeasing and annoying to other patients.   I think the ideal way is a separate building.
DR. W. E. WILKS, Nanaimo—
These patients do not like to be seen coming into the hospital, and they
do not like the idea of a Maternity case being regarded as a hospital case.
I feel perfectly certain if there was a separate building entirely that this
would be largely overcome.
MOTHER PROVINCIAL, Victoria—
I confirm what Dr. W. E. Wilks has said.   I quite agree with that idea ,
of separate hospitals for Maternity cases.
QUESTION NO. 7—
The special nurse and the diet kitchen?
This question has been submitted to Miss M. MacLeod, Superintendent
of Nurses, Vancouver General Hospital, and she has asked Dr. MacEachern
tr> answer it.
DR. M. T. MacEACHERN, Vancouver-
Miss MacLeod does not approve of the special nurse being allowed in
the Diet Kitchen.   I suppose it is impractical to keep her out, but her reason for this is that the special nurse usually has more the interest of her
patient, of course, at heart, and takes for that patient her proportion or
more," and disturbs the running of the kitchen, inasmuch as often the regular work of it is disturbed through the desires of the special nurse.   Usually*
the nurse in charge of the ward is responsible for that ward and prepares-
the diet and takes it to the patient.   The special nurse has only one person
86 to satisfy,.and that is the private case; but at the same time it may be at
the expense of some of the others. Remember that the nurse has perhaps
twenty or thirty cases to consider, and it is almost impossible to do so
unless you treat them all alike. I do not think it is approved in large hospitals. Miss Mackenzie and Mrs. Johnson can speak from experience on
this point. I am only trying to convey to you Miss MacLeod's sentiments.'v
MRS. M. E. JOHNSON, Vancouver-
Nothing disturbs my housekeeper and dietitian more than the special
nurse coming into the diet kitchen. The way we do, my housekeeper looks
after the serving of the trays entirely, excepting, of course, when a patient
is on a fluid diet, but otherwise the special nurse has nothing to do with
the diet kitchen.
MISS J. F. MACKENZIE, Victoria—
We have the same rules and regulations.   Wp do not approve of the
special nurse coming into the diet kitchen.   If she wants something special
after all the other nurses  are through she is perfectly welcome in the
kitchen, but otherwise not
MISS M. P. MACMILLAN, Nanaimo—
I agree with Mrs. Johnson and Miss  Mackenzie.
QUESTION   NO.  R—
What is the'best attitude to take about allowing patients out in hospital grounds, and what clothing should they wear?
DR. T. R. PONTON, Vancouver—
I think, provided the doctor attending the patient sanctions his patient
being outdoors, by all means they should be out. The question of what
they should wear is very difficult. The patients I have been accustomed
to seeing the last three years, out on the grounds, were technically called
"Blue Birds"—the military hospital uniform. That brings up a matter that
could be well considered by every hospital, the disposing of patients' clothes.
A good plan is to have a little closet built off each ward. If a patient in
our ward wants to go out for a day, or permanently, it takes so much of
the nurse's time getting that patient's clothes. It is a better system for
other reasons, too. As it is at present the matron is technically responsible
for the clothes in the store. Personally I should not care to be responsible
for the clothes store in any hospital; too many people have access to it.
MRS. M. E. JOHNSON, Vancouver—
In the hospital I graduated from, each ward had its clothes closet—
there was a long closet divided into sections, one for each bed, and those
sections were numbered the same number as the beds, and the nurse in
charge of that ward had charge of those clothes, and it was a very simple
matter, if they were allowed out, to get the clothes that were needed.
DR. T. R. PONTON, Vancouver—
If possible they should wear their own clothes, but if their own clothes
are in the hospital store they should be provided with dressing gowns that
. they will not catch cold in.   They should be allowed outdoors subject to
their physician's orders.
DR. H. C. WRINCH, Hazelton—
In public wards many patients come in with exceedingly, dirty clothes,
and there may be animals on them.    What precautions  are taken?    Are
their clothes taken out and baked?
MRS. M. E. JOHNSON, Vancouver—
In the hospital where we had the clothes closet the clothes were inspected on being taken off the patient, and if necessary they were sent to
the fumigation or sterilizing room and were then returned and listed so as
to keep track of them.
QUESTION NO. 9—
Should the Superintendent of a Hospital be a medical man?
DR. T. R.  PONTON, Vancouver—
I think the answer to that question is obvious. If you were going to
build a house you would not engage a plumber to superintend the building:
you would engage a contractor. I think it is absolutely wrong to run a
hospital with anyone but a medical man at the head of it.   He should have
87 a Superintendent of Nurses in charge of the nurses, and a business man
who is advisory on the business side. In the small hospital the lady superintendent would naturally do most of the managing of the hospital, but
hers should not be the responsibility, because as I say, it is a medical institution and questions arise where, no matter how efficient she may be,
not being a graduate in medicine, she has not the authority to deal with;
them. I happen to have seen several large institutions that have tried to
run with a person who is not a graduate in medicine, and it was not a
success. I remember St. Boniface Hospital in Winnipeg, a most efficient
institution in a great many ways, but an institution that at that time—in
'98—from the medical standpoint was very badly run. The Mother Superior
was one of the most excellent women and one of the most excellent business women I have even seen. From the medical standpoint it had a great
deal to be desired, and St. Boniface Hospital got such a black eye at that
time that it took a great many years to overcome it. On the suggestion
of the medical men who were working in that hospital, the Mother Superior
put in a young medical man, but a good one, in charge of the medical side
of the hospital, who was responsible for the medical side. She was big
enough to be advised by him. St. Boniface at the present time is a splendidly run institution. The last T. knew of it it had two medical internes—
five years ago, who were responsible for the medical side of the hospital,
which practically was the responsibility of the hospital. In the smaller
hospitals in British Columbia the question, of course, arises of paying a
man for the responsibility. You cannot get a big man for a small institution—you do not want him. A young man for a small hospital, who is big
enough to be advised by older men who will be associated with him, is the
type of man that is wanted. He should, I think, be in the same position as.
an officer commanding a military hospital is technically; he should be responsible to the Board of Directors for everything that goes on in that hospital. As a matter of fact, he technically has under him a Superintendent
of Nurses, who is responsible for the nursing side of the hospital; he has
under him a secretary, who would correspond to the army quartermaster
sergeant, on the financial side. He does not want to be personally responsible for the work of each special department, but leave the work of these
departments to the people in charge.
CASE  RECORDS  SESSION.
Meeting called to order by the President at 10.00 a.m.
PRESIDENT—
I will now call on Dr. T. R Ponton, Director of Medical Records,
Vancouver General Hospital, for his paper, "Case Records in Hospitals."
DR. T. R. PONTON, Vancouver—
Before starting to read my paper on "Case Records in British Columbia
Hospitals," I wa$t to say a few words explanatory. When I took hold of
the work of Records in The Vancouver General Hospital last fall, I took
it over with the idea of organizing a record system for that hospital alone.
Very soon after that, Dr. MacEachern pointed out to me that the hospital j
records in B. C. hospitals needed standardization, and suggested that I work
with a view to giving the British Columbia hospitals something to work on,
worked up by "a man who had been giving all his time to it in a large hospital. With that idea in view, assisted by Dr. MacEachern and all of the
men who worked on the Staff of The Vancouver General Hospital, we have
worked up the present system of Records, primarily for use in large hospitals like The Vancouver General, but which can be adopted to any size
hospital. A number of men in private practice in Vancouver have adopted
our system of Records in their own Case Records. This work has been
colossal. At one time I felt that it was almost impossible to get the thing
going. I think even Dr. MacEachern's wonderful optimism was rather
dazed at one time; things looked black. Just at that time Dr. Bowman
came along with his Hospital Standardization Committee. They went into?'
the system, approved of the ideas which we had worked up so thoroughly,
and gave us so much encouragement that we went on. The result I will. ■
show you. These forms, and the whole system, I may say, has the approval
of Dr. Bowman. PART L—INTRODUCTION.
The Hospital Ideal.
Is.
How to Attain this Ideal.    What a Medical Record
What an Ideal Medical Record Is.
This is the day of ideals in spite of social unrest The modern hospital must have its ideal, and this may be very briefly stated as "One hundred per cent efficiency." By this I mean that every patient who enters
such an hospital must be guaranteed that no aid known to modern medical
science will be lacking that is necessary to make a sure and accurate
diagnosis or which will make his cure as safe, quick and pleasant as it is
possible to make it. We have to deal with human nature in the person of
both the doctor and the patient, and not infrequently, the friends. In addition most hospitals are more or less handicapped for money and will not
permit of all our ideals being realized. Nevertheless whilst we cannot attain our ideal, yet we can strive for  it.
Today we hear a great deal about Hospital Standardization, which,
after all, means just what we have been discussing, and one of the fundamental principles of such a condition is that of having Medical Records.
In this paper I therefore desire to outline for you as best I can, our difficulty, and let me even call it our struggle, to accomplish this end in The
Vancouver General Hospital. I shall endeavor to show you how this was
accomplished, how the many difficulties were overcome, and, finally, the
results, and how the system is maintained.
It fell to my good fortune, on my return from overseas, to be appointed Director of Medical Records of The Vancouver General Hospital
by the General Superintendent of this institution, which position I immediately assumed. I therefore am addressing you today chiefly from my
personal experience, having given the matter of Medical Records my entire thought for many months. I trust, therefore, that I may be able to
give you sufficient enlightenment on this important subject that you may
each and all return to your hospitals and establish therein Case Records
of all your patients. Though my remarks are applicable to the large institution in which I hold this important position, yet I know they will be
more  readily adaptable in the  smaller  hospitals.
The keeping of Medical Records and their proper classification had at
first for its object the collection of certain information as to Heredity,
Previous Illness, Symptoms, Treatment and Result, chiefly for the purpose
of medical research, and as such, was practised more particularly in teaching or university hospitals. Even in the days of the old family practitioner, he kept records of all these things and co-related the opinion of
various specialists that he consulted. With the development of the specialties and the treatment of special diseases by different men, it soon became
apparent that there must be some method of co-relating and co-ordinating
information gained and the opinion expressed by various specialists, for
the ultimate good of the patient. Hence, unconsciously, I think, was developed the modern hospital Record System. Medical Records, however,
to my mind, have still a more important relation to the patient and to the
physician. Medical men are as human as any other class and as liable to
err. If the medical man puts in writing a record of his work and his
opinions on the case and knows that this record is available and will be
seen by other medical men who may subsequently attend that patient, then
he is going to i-'ke greater care to avoid mistakes. Again, if this patient
should change his or her residence or doctor, or if the doctor should die,
and there is to be some future operation or treatment, how exceedingly
valuable a good record for reference would be. Hence we see where we
get better work from the doctor and better care of the patient.
The ideal Medical Record must contain a complete story of the patient's medical life—his or her heredity must also be shown, the illness
during the past must be indicated sufficiently definite to show any effect
they may have on the present or future illness. The patient must tell what
he felt like and what his early symptoms were before coming under the
doctor's observation. If the patient cannot tell this, somebody who knows
should, if possible. There should be an accurate description of what the
patient thinks is wrong with himself and what he feels or has noticed, as
well as what the examiner finds—or in short, there must be an accurate record of all "SUBJECTIVE" and "OBJECTIVE" symptoms, on admission. The "ob'ective" symptoms or signs may be found by the doctor who
has at his disposal many means of physical examination, or may be revealed by the various diagnostic departments of the hospital, as X-Ray,
Laboratories and other special departments. Then comes his treatment
with observations of progress made or symptoms, and here the nurse's
notes and temperature charts are of vital importance. Finally the patient is
discharged, and it is important to note his or her exact condition on leaving
the hospital. Is the patient "cured," "improved," "unimproved," and, if
any, what is the degree of disability or invalidity? To what extent does
this patient now approach normal physical health? All the data should be
most carefully compiled and then the Record closed.
PART II.—THE  SECURING  AND  KEEPING  OF  RECORDS.
Difficulties Met With in The Vancouver General Hospital.   How They Were
Overcome.   Confidential Nature of Records.   Results.
The securing and keeping of Medical Records is indeed no easy task
In a large hospital it is almost colossal. There are several factors interested in each Record, namely, the patient, the doctor, the interne and the
nurse, and all four must co-operate harmoniously to secure a good and
complete Medical Record. The patient must be handled so that the necessary information may be readily elicited. A Case Report or History with- .
out the patient's co-operation is very incomplete. The elicitation of private and semi-private histories is more difficult and the attending doctor
on such cases should be persuaded to write these. The public ward case
can readily be handled by the interne, who must be taught what he is to
do and that it must be done. The nurse must be instructed in the obser^
vation and recording of symptoms so that she may be "an extra eye for the
physician"—an eye that is at all times observing the patient—while the
physician can naturally only see the patient for a comparatively short time
daily. She must conscientiously and intelligently carry out all orders for
treatment and record exactly what she has done, as well as her observations of the patient. I must lay strong emphasis on the last point, and
wish it could be made a more substantial portion of the curriculum in our
Training Schools, as I have seen volumes of nurses' notes which may be
considered useless.
We are prone to interpret another person's opinion in relation to our
own, hence all reports and orders should be unambiguous and in writing,
and this particularly so in consultant's reports. Available special means
of treatment with exact doses of same, must be recorded. Orders must be
explicit and definite. Hygiene, Dietetics, etc., are now very important
factors in modern medicine. It is no longer considered sufficient for a
physician to merely order "Milk diet" for a Typhoid case. He must know
the exact quantity and state it. In diseases of Metabolism, such as Diabetes, the dietetic treatment becomes more complicated, and it is only',:
by recording exact quantities of food and the exact results as shown by
Laboratories, that scientific treatment may be carried out.
Records having been obtained, must be kept in such a condition and
by such a system that they are immediately available for reference in case
the patient enters the hospital again or for medical research purposes. This
means a proper place to keep them, as well as a convenient filing system,
as shall be explained later.
In the establishment and development of our present lystem in The
Vancouver General Hospital we had difficulties, and I desire to show you
how these can be overcome if there is "team work" in the Staff. In The
Vancouver General Hospital various attempts had been made to keep some
kind of record of the patient. Various attempts had been made at getting
records of all the patients, but to a certain extent they were a failure. The
final outcome was the establishing of the Department of Records and the
appointment of a Director of Medical Records. I was instructed by the
Superintendent, Dr. MacEachern, to take charge in November, 1918, following the epidemic of Influenza. The condition could only be described
as a state of chaos, and I certainly did not realize the task ahead of me
or where it was going to lead to.   We had a Chart Room downstairs where
90 many thousand charts were arranged more or less in order. Upstairs there
was a small room with a girl in charge who did not have much experience
in medical work. Hundreds of charts and cards were piled all over the
room. In examining these I found that the internes and doctors were not
attempting to write histories, and the nurses' notes as to treatment and
observation of symptoms were incomplete and of little value. I found even
the alphabetical index of patients had become disorganized during the influenza epidemic. In short, there was no real system of securing or keeping the Medical or Case Records. The forms used were in most cases
good, but*some were redundant and imperfect. The staff of housemen and
nurses were overworked and had been for months. The war had disorganized the staff for four years. The result of all was that they had possibly adopted an attitude that Records were unnecessary. This state of
mind was very difficult to change, and it took several months of very discouraging work. As a climax, on January 1st came the death of a most
valuable Assistant Superintendent, Dr. Mahony. This left the Superintendent with the whole load on his shoulders. I took the Annual Report off
his hands and shelved the Record work for the time being. The report
meant classifying nearly fifteen thousand patients as to Disease, Operation, Cause of Death, etc., as well as the Outpatient Department and other
medical phases of the hospital work. It was February 11th before we were
able to again resume our Record problems.
The old adage came true once more—"Behind every cloud is sunshine."
At fiirst there seemed nothing but clouds, but by real co-operation between
the Superintendent and Staff we are beginning to find the sunshine.
We started at the beginning and worked out our plan. We found out
what we wanted and decided on a system to be evolved. The result of this
is our present set of charts or Record forms and our system of filing, cross-
indexing and classifying, which will be described later. The question of
Medical Records of private and semi-private cases was a somewhat difficult
one. The doctors in charge of these cases had to be persuaded to give
Records of their cases.   To accomplish this we gave them three options:
Firstly—They could write short histories on the summary forms or long
histories  on the  complete  forms.
Secondly—They could dictate their report to one of the Record Office
stenographers, who would write the history and attach it to the patient's
chart.
Thirdly—They could leave a written order on the ward, and one of the
housemen or seniors would write this report.
Under such conditions it is very difficult for the attending doctor to
pass it up. In the public wards the housemen had to be made to understand that what they considered uninteresting drudgery had to be done and
that such Records would be somewhat of a measure of the class of work
they were doing on their wards. Likewise, it was pointed out to the nurses
that the keeping of good case notes was second only to giving their patients good care. They had to be trained in what constituted good Records,
what to observe, and what to ignore.
The results are quite satisfactory. We are now getting good reports
on many cases, though others are not yet satisfactory, but we are getting
some kind of report on all cases. A sufficient staff is at work and the
system working well. In the Chart Room downstairs the old histories are
being sorted and made available for reference. It will take nearly a year
to get this work as complete as we wish to have it. Upstairs three medical
clerks, who are stenographers, are working full time. All current charts
are available at five minutes' notice—they are cross-indexed as to name
and disease. We have undertaken several new features which will be mentioned later on. Housemen are writing good histories on all public ward
patients, and the men attending private ward patients are giving us Records
which are improving all the time.
In all reports there is one thing which must be assured, and that is that
such reports are confidential. In all cases these Records must be considered as sacred as the confidence between patient and physician. They are
in the ward, kept under the supervision of the head nurse in her office.
They are handled in the Record Office by a staff who fully understand the
confidential nature of their position and who are selected with a view to
91 maintaining this confidence. They are available only for the physician attending the patient on a written order from the patient or an order from
a court of law.
PART HI.—SYSTEM USED BY THE VANCOUVER GENERAL
HOSPITAL.
General Outline.   Forms and Charts Used.   Filing and Indexing.   Classification of Diseases.   Operations and Deaths.   Outdoor Records.
Follow-up System.    Cost of System.
In describing our system in The Vancouver General Hospital let us
follow the patient through the hospital and take up the details of each
important step.
The patient is first admitted and a card and ward slip made out in the
Admitting Office. This card is numbered serially, and is the patient's official identification. The ward slip indicates merely the Hospital Number,
Name, Ward, Doctor, and Date. This goes directly to the ward with the
patient, thus giving the patient his or her number immediately on admission, as well as the nurse, sufficient data to receive this case. In the Admitting Office is the Register and Diagnosis Book, wherein the Admitting
Officer enters Hospital Number, Name, Address, Ward, Date of Admission
and Doctor in charge. After this the admission card is sent to the Business Office, where the necessary entries are made from it, and when this
is completed it goes to the ward, where it remains during the. patient's stay
in the hospital.
The patient, having been duly admitted, we will next consider the Medical Records, the history of the case, the clinical chart and all data connected with it. In the Supervisor's Office in each ward is a full supply of
Medical Record stationery, so that the houseman or doctor can write the
history at any time. The clinical charts, consisting of Temperature, Medication and Nurse's Notes, are attended to entirely by the nurses on the
ward. All Laboratory and other special reports are sent to the ward and
attached to the patient's chart. A summary Laboratory report form disposes of the various small individual forms and thus guards against loss
of same. These are copied on to the summary, and this copy initialled
by the nurse who does  it.
When a patient is discharged the supervising or head nurse is held
responsible for seeing that all the documents are properly completed and
returned to the Record Office. The attending physician enters on the admission card "Diagnosis," "Date of Discharge." and "Result," and then
signs the card. The nurse takes this to the Admitting Office, where the
Admitting Officer enters "Date of Discharge," "Diagnosis," and "Result of
Treatment" in the Diagnosis Book already referred to. She then signs
the Superintendent's name to the card to signify that the necessary Medical
Records have been completed. After this the nurse takes the patient or his
or her representative, with the card, to the Cashier's Office, where the necessary financial arrangements are made and the patient is then at liberty to
leave the hospital. The card is left in the Secretary's Office for further
business purposes, and when they are finished with it it is sent to the
Record Office for permanent filing.
As stated before, the Supervisor or head nurse must see that the chart
is properly completed, numbered and sent to the Record Office. Here
everything is handled by serial number. The charts are immediately on
receipt filed serially in the working file of the office until they are completed and ready for permanent filing. Later the patient's card is sent to
the Records Office after being finished with in the Business Office. The
corresponding charts are picked out of the working file and are placed on
my desk so that I can examine them to see if the histories are complete
and satisfactory, diagnosis properly stated on the card and Record, and
check up all details of purely medical nature. At the same time I make
a note of any special information I want placed on the summary sheet,
and of such cases as I want followed up.
The medical clerks now take the charts for completion. All pages
which are untidy or illegible are copied, unless it is of real value to preserve the original.   The Summary Sheet is made out or completed, and
92 this shows what documents are contained in the file—the diagnosis, a short
summary of the history and treatment with the result. The sheets are
arranged in a definite order, the Summary Sheet being first and the yellow
Laboratory Report last This is the only colored sheet used, and being
placed last forms a noticeable division between the various numbers when
finally bound. Each page of the chart filed is stamped with the patient's
Hospital Number, and the whole file^ placed in an envelope having the
number in the upper left-hand corner. This envelope is then filed in the
current filing cabinet.
When a sufficient number of charts have accumulated they are bound
in volumes of fifty. These volumes are numbered. A book of the serial
numbers is kept showing in what volume the chart is to be found. The
purpose of this is apparent if you consider that the serial numbers are the
numbers on admission and patients vary in the length of time they stay in
the hospital, as for instance: a patient admitted in 1914 receives a number, say, in the thirty thousand group, but he may be discharged in 1919.
Probably all other thirty thousands are discharged and the charts bound,
excepting this one. It must then be bound with a later series, possibly the
seventy-five'thousands. It is not in volume six hundred, as one might expect, but may be in volume fifteen hundred, and by looking in the serial
book you can see at once in what volume it is.
' The admission cards are all carefully checked over and further necessary data added. They are carefully compared with the report so as to
see if the medical data thereon is correct. They are then cross-indexed
for "Name of Patient," "Disease," and "Complication." After this they
are filed in their serial arrangement for a ready reference and for brief
information about the patient. At the end of the year the cross-index is
bound.
Having carefully considered a general outline of the system, let us
next consider for a few moments the forms used. These are as brief as
we can make them consistent with efficiency, though at the first glance they
aopear to be voluminous. All forms are numbered for commercial convenience in ordering. (Reproductions of forms will be found at the end
of this book).
The forms used may be classified as follows:—
(a) Summary,  Sociological, Financial  and Medical data.
(b) History of Case—General, Special.
(c) Special Examination  forms.
(d) Clinical Charts.
We will deal with each of these forms,
(a) Summary, Sociological, Financial and Medical Data—
This comprises the following forms:—
Form No. 46—Admission card.
Form No. 40—Admission slip.
Form No.   7—Patients'  Register and Diagnosis  Book.
Admission Card—This is best of a standard size—4x6. The first
page is filled in by the Admitting Officer, and contains sociological data.
The first half of the second page is filled in by the doctor in charge of the
case on discharge, and it gives the Diagnosis, Complication and Result of
Treatment.    The remainder contains business  data.
Admission Slip, Form 56—As stated before, this slip has merely the
Name, Doctor, Ward, Date and Hospital Number—this going direct to the
nurse in the ward with the patient, and serving a working knowledge for
her necessary to receive the patient and get the chart opened. From it she
gets the patient's Hospital Number, which we insist on having on all Requisitions, etc.
Patients' Register and Diagnosis Book, Form 7—This is a permanent
serial record of all patients admitted to our various hospitals, and from it,
in case of loss of other business or medical records, the essential lntor-
mation about the patient can be obtained. On admission the Admitting
Clerk enters the data as previously mentioned, and the remainder on discharge, thus making the record complete, and showing the Hospital serial
Number, Name, Address, Sex, Ward, Doctor, Date of Admission and Discharge, Diagnosis and Result, using two lines for each patient.
93 (b) History of Case—
This  is  divided into General  and Special forms.
These forms are now as complete as can be made in a large general
hospital. Their number is due to the fact that we have to deal with every
class of disease excepting "Small Pox" and "Plague." All these forms are
made slightly larger than letter size. This makes it necessary to use larger
filing cabinets, and in this respect is inconvenient, but it makes a standard
size volume for binding, which  compensates.
(1) General Form—
By this I mean forms which are used for mostly all cases. There are
a large number of these and may well be called "history forms."
(a) Summary Form, No. 26—This form is designed to give an indication of what documents are contained in the patient's file. It is not written
out in the ward on Public Ward cases, as we prefer to summarize these
in the office. It is used, however, in the private and semi-private cases,
and filled in by the doctor in charge. On this account we leave considerable space for actual history, including heredity, patient's condition on admission, what he or she felt or thought was the matter, and what was
found on examination, as well as treatment in the hospital, and finally,
condition on discharge.
(b) Detailed History of Case, Form No. 27. Condition on Admission,
Form No. 28. History Continuation, Form No. 29—These three forms
filled in by the housemen on all Public Ward cases, and by the doctor
are designed to record the more detailed history of the case. These are
attending in a great number of private cases.
The first sheet, or Form No. 27, takes the history of the patient up to
the time of admission, whereas the second sheet, or Form No. 28, gives
the condition on admission, referring to the various systems. If notes of
any system are brief, or if it is normal, the space allotted for the system
is used. The" one mainly concerned in the present illness is referred "below." This may be done of any system where more voluminous notes are
needed. Under "Progress Notes and Results," which constitutes a daily
diary, we describe in detail the condition of the patient and treatment, including mention of any operation performed. The third sheet, or Form
No. 29, is a Continuation of History. Finally on discharge we ask for a
statement of his or her condition with special mention of any remaining
disability.
(c) Diagrams—Desirous of keeping the history as brief as is consistent with a good description of the case, we have adopted very useful
diagramatic sheets—as seen in Forms No. 30 and 31, which go with each
case, so tha tfrequently the location of the trouble may be indicated instead of giving a long description which might be ambiguous. These
forms might well be described as "universal," inasmuch as they will suit
almost any case, regardless of whether Medical, Surgical, Obstretical,
Gynaecological, or other.
(2) Special History Forms—
These are for the Eye, Ear, Nose and Throat and Maternity cases.
Eye, Ear, Nose and Throat Forms—
These are designed by the men in charge of the department or
staff. They are all of a semi-stereotyped and diagramatic nature. For
the Eye there are two forms, No. 32 and 32A; for the Ear there are
also two forms, No. 32B and 32C, and for the Nose' and Throat, one
form, No. 32D. Of course, the general forms already described are also
used for these cases for the preliminary history, and the special forms
for a more accurate and scientific description of the lesion concerned.
Obstetrical Forms—
These forms are made for the mother and the child, and consist of
four parts:
First—The  preliminary   history.
Second—The labor record.
Third—The post partum history.
Fourth—The baby history.
94 Preliminary History, Form No. 15—
This contains the past history of the patient, previous findings, labors
and puerperium, if any, as well as such history as might have a direct
bearing on her present condition, and also contains the result of a complete examination of the patient, internally and externally, with measurement of the pelvis. This is a most complete form and one which is more
or less universally acknowledged as being the best..
History of Labor, Form No. 16—
This form contains a complete history of the labor with a description
throughout and how it was managed and what the result was. The
data for this sheet is collected at the bedside on a small form which
makes provision for the data required and is filled in at the time of labor.
History of the Puerperium, Form No. 17—
Tells the history of the patient after confinement, with complications,
if any, and a record of the examination on the day of discharge.
History of Baby, Form No. 18—
Gives a description of the baby at birth with measurements and a
further description of the main things that happen during the first
fourteen days in the hospital, or stay in the hospital, and condition on
discharge, with special reference to weight.
These forms are filled in by the doctor or houseman in charge.    The
other forms  pertaining to  the baby,  which  consist  of the baby's  weight
and special chart, are looked after by the nurse.   They are special clinical
charts.
Baby's Weight Chart, Form No. 19—
This form shows daily weight of the baby in a diagramatic way, indicating the loss or gain from day to day.
Baby's Special Chart, Form No. 20—
This gives a complete description of the observation by the nurse
with special reference to the feeding, medication, bowel movements and
other  information  bearing on  the  progress   of  the   case.
To save complications in recording diets we have adopted a standard
milk diet for ordinary bottle babies. Unless the doctor in charge orders
a special diet the nurse enters the formula number. As with the mother,
we have a working sheet to avoid soiling the permanent sheet and to
avoid missing details. The night nurse enters on it the names of the
babies and weight yesterday. The nurse in the morning records temperature, weight, bowel movements, etc., and this information is transferred
to the individual baby's chart.
Specialist's Report, Form No. 5—
As we wish the specialists  to  report their findings  and  opinions  in
writing, we have provided Form No. 5 for their use.    The doctor asking
consultation   states  the  nature  of the   report  he   wishes   and   the   region.
The specialists then report their findings in writing.
X-Ray Report, Form No. 62—
This   report  needs  no   mention   beyond   stating  that   a   copy   is   filed
with the patient's chart.
Electro-Cardiograph Report, Form No. 62-A—
This is the report of the Heart Station on all heart cases in the
hospital. This department is. of course, in charge of a specialist who
reports with his heart findings the essentials of history and laboratory
as they have bearing on the heart condition. He combines X-Ray of
Heart and Electro-Cardiograph in the one report.
Operating Room Reports, Forms  Nos. 32E  and  32F—
The Operating Room Reports require more detailed notice. They
are the most important feature which has been introduced and are, I believe, unusual in a general hospital. The first, Form 32E, we call the
Operating Room Report. It is designed to go with the patient to the
Operating Room in order to give the anaesthetist the essential information about his patient, and to go back to the ward with the patient, so
that the ward nurse knows what has been done whilst he was out of her
95 care. The resident anaesthetist on duty examines the patient the night
before operation and makes necessary notes as to Heart, Lungs and
Kidneys. In the Operating Room the anaesthetist fills in the second
part. The chart in the centre is used for Pulse and Respiration. The
figures on the right for Blood Pressure are provided for cases of Spinal
Anaesthesia. Finally the nurse in charge of the sponges and instruments.
states her accounting of the instruments, sponges and packings.
The second, Form No. 32F, the Report of Operation, is for a detailed description of the operation. First is stated, mechanical details
for reference; sutures, drainage and packings. The pre-operative diagnosis
is always stated when the surgeon enters the patient for operation. The
post-operative diagnosis is his opinion of confirmation or correction.
The stenographer goes to the surgeon in the Operating Room immediately
after the operation and takes from his dictation a report of the operation
done and what he found. Finally all specimens removed are sent to the
Pathological Laboratory, and the Pathologist, on the same sheet, reports
his findings. Thus the Pathological diagnosis shows a confirmation or
otherwise of the clinical diagnosis.
If the operation is done at an hour when the stenographer is not
on duty, the head nurse sees to it that the surgeon writes his report in a
book kept for that purpose, in the operating room. From this report or
the dictation of the surgeon the stenographer writes her report in triplicate and sends it to the Pathological Laboratory for their report. The
original is attached to the patient's chart. One copy is sent to the
surgeon and one is on file in the laboratory.
The Laboratory Sheet, Form No. 18—
The laboratory report sheet is for routine urinalysis and such laboratory reports as a Wassermann. These come over from the laboratory in
a group report for the day or on small slips. They are copied and the
copy is initialled by the nurse doing it. The original report is kept so
long as the patient is in the hospital.
Charts-
Temperature Charts, Medication Charts and Nurse's Notes are the
customary forms. We provide one Temperature Chart, which the nurse
may rule for the two-hour or any interval that is ordered. Our main
chart is so ruled that it may be used either for four-hour or morning and
evening record.
Medication Notes—
Are  made out  entirely by the nurse.    The  doctor writes  all orders
for his patient in an order book and the nurse notes them on the Medication Chart and in her notes.
The  Nurses's  Notes—
These are ruled to show hour of observation, urine and stools, nourish- ■
ment, medicine and remarks. Under Remarks the nurse notes symptoms,
result of treatments and anything that may be of value in the record
of the patient's progress. She is supposed to give a brief description of
her patient as she first sees him, noting his complaint. She is expected
to refer to points in this description in subsequent notes showing improvement or otherwise. Her notes should be a continuous story of the
patient as she sees him. In this hospital the head nurse is responsible,
but for the purpose of training and to divide the work she generally delegates the actual keeping of the notes to a senior.
Filing—
After getting our reports, came the problem of making them available for the first two purposes mentioned in this paper, namely, the
benefit of the patient and the benefit of medical science. As already
stated, the charts are filed according to serial number. An alphabetical
index is made, so that should the record of any patient be required it
can be easily found.
Classification of Disease—
The next problem was making them available for medical science.
This meant a cross index for disease and the preparation of statistics.
96   The first difficulty  with  which we were  faced was a nomenclature.
We wrote to all the biggest hospitals on the  continent and apparently  a
good nomenclature does not exist.    So we are working on a nomenclature
of our own.   We propose to work with it in this hospital for a sufficient
. time to be sure that it is complete and correct, and then have it published.
The sheet shown for classification or disease-indexing is original,
(Form No. 9-X), and I believe, unique. These classification pages are
arranged alphabetically in loose leaf binders and as the cards come to
that stage the patient's number—sex—result of treatment and days in
hospital are entered under the proper disease.
We list all diseases as:
Primary,
Primary, with complications, or
Secondary.
We do not use the word "secondary" in the strict sense, but as including
associated disease. Thus a patient has influenza, an associated pregnancy
and a secondary broncho-pneumonia. If the patient recovers and does
not abort, the influenza is classed primary and cured, the broncho-pneumonia secondary and cured. The pregnancy is disregarded. If she
aborts the pregnancy is shown as a secondary condition and cured.
If, however, it is a full term pregnancy and she is delivered, it is classed
.as a primary disease with complications. We would thus have two
primary diseases and one secondary.
By this means we have a classification of diseases which can be used
for the purposes of statistics and medical research. In my office at the
present time, if you asked for statistics of influenza I can tell you in a
few minutes, up to the end of last month the number of cases of influenza uncomplicated and of influenza with complications, with the total
days treatment and the result in each class. If you want further to know
the complications of influenza and the results the problem would be
more difficult. We have the list of patients who have had influenza
with complications and can, by referring to their cards, tell what the
complications were and the results.
I will not go into arguments for or against this system. There
are arguments both ways, and if we were only considering the current
year, it would not be the best system; but we are considering the good
of the patient as of primary importance, and so have adopted the system
which renders all previous records most readily available from the
standpoint of the patient.
Classification of Operations—
The same classification pages are used for operations done in the
hospital. The Secretary's Office keeps a record of all operations. To
save duplication of work we make use of this record for purposes of
classification. We have made a nomenclature of operations done, classifying first under name of operation with a secondary classification for
region and diagnosis.    Thus:
Amputation Arm Cellulitis
Amputation Breast Carcinoma
In  our operative  record  we  attempt only to  give the  immediate result of the operation.    We classify all  operative  cases  as  discharged or
died.   They leave the hospital too soon after operation to give an opinion
as to whether they are cured, improved or unimproved.
Deaths-
Deaths occurring in the hospital are all entered in the Death Book in
the Admitting Office.    From this we make a classification  monthly, using
the classification" authorized by the Provincial Board of Health.
Other Departments—
All branches of the hospital are handled as outlined, except the outdoor clinic. This is run as a separate department. The records are
kept in the department by the orderlies and medical officers. They use a
card. On one side of it is the sociological data, diagnosis, result, family-
history, personal history, present condition of the patient, using special
headings  for  references   to  the  various   organs  which  may  be   diseased.
97
•   7 The back of the cards is ruled to allow dates of attendance and notes
of treatment, and at the end is placed a space for the condition on discharge. The diseases in the outdoor department are classified in the
Records Office the same as in all other departments of the hospital.
Follow-up System—
It has been more than once stated that the first consideration of _ the
ideal hospital which we have in mind is the ultimate good of the patient.
We feel that for various reasons, many cases leave the hospital which
are not carried to a conclusion. These we desire to follow up. Hence
we have evolved our follow-up system. When checking through case
records and cards I see many such cases. These I note on a card which
is filed under the proper month, three to six months ahead. When the
time comes the follow-up letter is sent to the patient and the reply, if
received, is filed with the patient's chart. If the patient's chart is already
bound, the follow-up report will be bound with the earliest unbound
charts and the serial book will show where it is. It carries the original
chart number. If on receipt of a reply further enquiry is necessary, this
will be handled in the same manner as was done with the original follow-up.
Checking the Work Done—
We have so far considered the Records Department only from the
standpoint of the patient and medical research. In the early part of this*!
paper I spoke of the effort to see that every patient got the best possible
treatment. It is along this line that I spend most of my time. The staff
of this hospital have issued the following instructions, and the Medical
Association have endorsed the resolution. The director of medical records
is instructed to investigate all cases in the hospital where the patient
is not doing well, and if there is an avoidable reason for this, he notifies
the superintendent who will appoint a committee of the staff to investigate.
If blame is attached to the medical men, it will be reported to the staff
who will either deal with the case or report it to the board of directors,
as may be necessary. Further than this the housemen and the nurses
have instructions to report to me any accidents which may occur in the
course of treatment so that I may investigate the cause, place the blame,
if any, where it belongs and see that the error is rectified, if possible.
This does not mean that we have in any sense of the word, espionage or
censorship. Such a system would defeat our real intentions. We do not
want any tattling and there is none. In a good many cases the attending
physician himself comes to me and tells me of his unsuccessful case in
natural search for the remedy. In the rest I see them in my daily rounds.
Perhaps our best check and method of preventing bad work lies in the$
system of reporting results. From time to time I report to the staff
the results of treatment of any class of cases. Lately I reported to the
Obstetrical Department a summary of their work for the last five months.
They will  do  their own  criticizing.
The director of medical records is further instructed to keep track
of all interesting cases and of cases where unusual skill is shown and
from them to see that cases are reported to the Medical Association. It
is manifestly impossible for one man to know all patients in a hospital
of this size. So to carry out the above instructions, the nurses and
housemen have instructions to report interesting cases on the ward, and
by enquiring and observation on my rounds I am able to find any cases
which are not doing well and which could not be reported to me without
an appearance of tattling. I think the result of all this will be that we
will have very few cases of bad work to report and many cases of
good work.
Cost of the System—
The complete system as I have outlined it may seem expensive, and
to be beyond the means of an ordinary hospital. The first and second
part _ of the scheme, the getting and classifying of records, is worked with
the idea of having it done by the housemen, medical attendant and clerks.*:
of ordinary ability and ordinary carefulness, trained in this special line,
The  complete system  requires  in addition practically all  the time of a
98 medical man. In the Vancouver General Hospital of 1,300 beds, with an
average of admittances and discharges of forty per day, the daily routine,
including reporting operations and X-Ray reports, is done by three
stenographers. The printer informs me that our charts average about $5
a thousand, and that they can supply them to other hospitals for about
the same price All the supervision I personally have to give to the
records work averages about one hour a day The rest of my time is
spent on_ the wards and in the operating room, supervising the work of
the hospital.
Conclusion's—
(1) Records are necessary to efficiency and proper care of patients
in a modern hospital.
(2) The difficulty which we have met and overcome shows that any
hospital can keep records.
(3) The system we have evolved provides a complete and inexpensive
system adapted to any size of a hospital.
(4) Nearly all the work can be done by good stenographers. A
hospital of 1,300 beds requires the average daily time of one hour from a
medical man, and full time from three clerks.
(5) The attending physicians will back up the work as soon as they
see that it is to their own advantage.
(6) The records must be considered confidential.
DISCUSSION
DR. H. B.  ROGERS,   Victoria—
I cannot see that this subject, so ably and comprehensively discussed
by Dr. Ponton, admits of very much discussion. The advantage of having
Case Records established in our hospitals applies in two ways; first, the
patient benefits from the establishment of such a system, both immediately
and ultimately, as Dr. Ponton has pointed out; the hospital benefits both
in its wards by getting better service and better results by having statistics. Case Records are one of the first essentials, but although this is
very desirable, it is not in every instance, I think, as easily attainable
as Dr. Ponton would have us think. In the larger institutions where
funds are not such a consideration as they are in the small ones, where
there are sufficient housemen, where stenographers and typewriters are
at the disposal of any man at any time, I can see that the difficulties are
not as great as they are in the smaller institutions, for their internes are
very few, if anv, and the funds will not stand the added strain of a record
office staff and machinery, and therefore the onus of maintaining the
system must be on the attending doctors. They are very busy men, and
very often men with fixed habits and it is hard sometimes to steer them
into the unaccustomed ways. In the Provincial Royal Jubilee Hospital
we have inaugurated a staff of consultants and advisory men, and we
have drawn up a set of rules. These special rules call for Case Records
in every case, but it is not an unqualified success. Men are coming into
line, they are doing it more and more every day; we are struggling and
hoping to establish a satisfactory system in time, but it requires a lot of
coaxing and a lot of imploring to get the men to alter their ways to such
an extent. We have got the men pretty well to accept the filling up the
Operating Room Reports. They are required first to give their preoperative diagnosis and immediately after the_ operation they fill in the
book themselves and sign, and record a description of the operation and
post-operative diagnosis. These they are carrying on very well. We put
the histories necessary on the patient's chart. The attending man before he can see his chart has to see the blank form for his history. I do
not think it need be abandoned, even though they cannot afford medical
men, clerks, etc. As to the forms devised in the Vancouver General Hospital and shown so well by Dr. Ponton today, of course, I am not familiar
enough with to criticize. I do not know whether it is the intention of the
convention of the Hospital Association to have a set of standard forms'
used in all hospitals. I hardly think it can be. I cannot see the advantage
of having identical forms used in all our hospitals, although there would
99 be a certain economy worked in our purchasing department. There may
be local conditions belonging to such an institution which would prevent
such forms being used. I should say that if a standard set of forms used
in all hospitals is decided upon, that before deciding on them, a committee
should study conditions prevailing in other communities and draw up a
form to serve the greatest number.