PROVINCE OF BRITISH COLUMBIA TWENTY-FIRST ANNUAL REPORT OP THE PROVINCIAL BOARD OF HEALTH INCLUDING SIXTH ANNUAL REPORT OP MEDICAL INSPECTION OP PUBLIC SCHOOLS AND THE PORTY-PIPTH ANNUAL REPORT OP VITAL STATISTICS DEPARTMENT POR THE YEAR ENDING DECEMBER 31ST, 1917 AND PROCEEDINGS OP THE SECOND MEETING OP MEDICAL OFFICERS OF HEALTH OF BRITISH COLUMBIA HELD IN VANCOUVER, B.C., SEPTEMBER 12TH AND 13TH, 1917 PRINTED BY AUTHORITY OF THE LEGISLATIVE ASSEMBLY. VICTORIA, B.C.: Printed by William H. Cbllin, Printer to the King's Most Excellent Majesty. 191S. Provincial Board of Health, Victoria, B.C., April 1st, 1918. To His Honour Sir Frank Stillman Barnard, K.C.M.G., Lieutenant-Governor of the Province of British Columbia. May it please Your Honour: The undersigned has the honour to present the Twenty-first Annual Report of the Department of Public Health for the year ended December 31st, 1917. j. d. Maclean, Provincial Secretary. REPORT OF THE PROVINCIAL BOARD OF HEALTH. Provincial Board of Health, Victoria, B.C., February 12th, 1918. Doctor the Honourable J. D. MacLean, Provincial Secretary, Victoria, B.C. Sir,—I have the honour to submit the Twenty-first Annual Report of the Provincial Board of Health being for the year 1917. Before proceeding to lay the facts before you concerning the activities of the Board during the past year I would respectfully request your consideration of a change of the time for the presentation of the Annual Report. Under our present regulations we are obliged to present the annual report at the meeting of the Legislature. In this Province the practice has been for the Legislature to meet about the second week in January. "Under the circumstances it is difficult for the Department to present a report in a way that would permit of analysis of the returns received from the different sections of the Province. We have been obliged, as regards the Vital Statistics Branch, to note annually that returns have not been received from certain outlying districts; this not because of any fault on the part of the officials at these points, but owing to distance and uncertainty of the mail service. If the year embraced in the report was made to terminate the end of June, then our reports, particularly of the Vital Statistics Branch and the Medical Inspection of Schools, could be dealt with much more fully, comparisons made with the returns of the former year, and benefits noted. As it is, first, our returns are not complete, and, second, sufficient time is not allowed for other work in connection with them than their compilation for the report. The practice in the different States in the United States and in the other Provinces of Canada is to allow sufficient time from the beginning of the year to permit of a proper analysis of the facts submitted by the officials in the different departments. I am very much pleased to say that reports of the health conditions during the year 1917 deal more with the work which has been done along educational lines rather than a report of a series of epidemics. The health of the community has been exceptionally good. There have been no alarming reports during the year, yet such conditions may not continue. It is consequently better to be always prepared to act promptly in the matter of preventive measures in any emergency which may arise. Your Board recognizes the importance of this fact and are devoting their efforts to the promotion of the interest of the public at large In health matters. The time seems to be most opportune for stimulating the attention of the public to the teachings of the Board of Health. The universal enforcement of health regulations by the military authorities upon the troops in their charge and the beneficial results that have been obtained has brought forcibly home to the people the fact that the health authorities are not faddists when they say that disease can be prevented. Our troops have been living under conditions which in normal times would not be tolerated in any community. They have been subjected to intense physical strain, irregular hours, irregular meals, and insanitary conditions of living, yet by the strict enforcement of sanitary measures and the insistence upon inoculation against disease results have been brought about that have demonstrated conclusively the truth of the teachings of the health authorities, and has done more to rivet the attention of the public in a short time than could have been accomplished by another quarter of a century of patient teaching under normal conditions. With these results before us we have been able to direct the attention of the people to and to have awakened a lively interest in health questions. We were first shown by the rejection of men presenting themselves for service that there was unfortunately a very large percentage of men unfit for military service owing to physical defects. Secondly, we were shown that the health of the men who were accepted was much better under the enforcement of military health regulations, when the man was living under the highest pressure of effort, both mental and physical, than it would have been under previous conditions in civil life. G 6 British Columbia 1918 Consideration of these aspects of health-work has naturally led the people to a serious consideration of the influence of the individual as regards his relation to the community and his environment, and as regards the efforts that he must make individually to help in prevention of disease by attention to personal hygiene and education of himself and others in the idea of prevention of disease as distinct from its cause. The Department has taken advantage of the change in public opinion and is endeavouring in every way possible to provide information through societies by way of distribution of pamphlets, the enforcement of recording of contagious diseases, and by endeavouring to enlist the active interest of the medical profession in the health propaganda. With this object in view a meeting was called of the Medical Health Officers for the discussion of health subjects and to listen to papers read on pertinent subjects. The meeting was held in Vancouver in September, 1917, the sessions lasting for two days, and the interest manifested by those who attended was very gratifying. The Department feels under a very great obligation to the members who presented their papers, and particularly to President Wesbrook, of the University of British Columbia, for the great interest he took and the assistance he gave towards making the meeting a success. One of the first results that we have obtained from this meeting, which is particularly gratifying to the Department, is the increased interest manifested by the members of the profession in their work, and particularly so as regards the reports of the conditions in their districts. The reports have been much fuller and the comments made more general, making the reports differ very much from those that we previously received, which as a rule were more of a record of cases that had occurred. Causes are discussed and suggestions made. I have also -to acknowledge, with appreciation, the increased interest which has been taken in the question of health and the activities of the Board by the members of the Women's Institutes. They have evinced a very serious and earnest desire to co-operate with the Board, and I had the honour to meet and address the institute on three different occasions on health matters. The members of the institute expressed a desire to keep in touch with the Board and to further health interests in the localities by giving the matters their personal attention. The health of the Province for the year has been very satisfactory; so much so as to cause very favourable comments from those who are acquainted with the returns made by our Health Officers. Measles. During last year I had to deal at some length with the history of an epidemic of measles which occurred at the end of the year and was continued on into 1917. The greatest number reported was from the City of Victoria—some 3,000 cases in the city and the districts around. We cannot emphasize too strongly the fact that measles is the most prevalent and one of the most infectious of diseases, and one, from a health point of view, that is the most difficult to deal with. Unfortunately the public look upon measles as a very minor trouble, and their chief concern seems to be, when an epidemic does come, for all their children to have it and get it over with. This is very much to be regretted, and it is to be regretted that the general public, and even physicians, discount the seriousness of the disease. The danger lies not so much in the effect of the attack itself upon the child, but with the troubles that follow it, such as bronchopneumonia, eye and ear affections, and deaf mutism. Infantile Paralysis. Some concern was felt during the latter part of the summer, when reports of cases of infantile paralysis began to come in, in view of the great epidemic in the Eastern States in 1916. Fear was expressed that it had come to the West and that we would suffer proportionately as they had done. Fortunately the number of cases reported did not exceed those we might expect according to the number of population; in fact, thirty-seven cases in all were reported, thirty of which were in and around Vancouver. Prompt measures were taken by Dr. Underbill, Medical Health Officer in Vancouver, and with the knowledge we have of his efficient management no alarm was felt as to the outcome. Smallpox. During the past year there were a larger number of cases of smallpox reported as compared with 1916. In 1916 there were seven cases, as against sixty in 1917. The increase was accounted for by an epidemic at Grand Forks, forty-eight cases being reported. The cases were mild, with no deaths. It originated from one of the logging camps south of the border. Grand Forks, as 8 Geo. 5 Provincial Board of Health. G 7 the gateway for the Boundary country, has always been susceptible to slight epidemics. There were ten cases reported from the City of Vancouver; eight of these occurred during the early part of the year amongst stevedores and was due to infection from a ship from the Orient. These cases were severe, of the confluent type, and resulted in fatalities. Prompt measures were taken by Dr. Underhill, Medical Health Officer of Vancouver City, and the disease was confined to the eight cases. There was one case reported in North Vancouver and one in Victoria City. The presence of smallpox led to some agitation on the question of vaccination, anti-vaccina- tionists entering a protest as regards its enforcement. I would point out, however, that while we have enjoyed particular immunity from smallpox, yet at the same time this immunity is leading to carelessness in carrying on vaccination in the children, and when an epidemic does arrive the results will be unfortunate. That such an epidemic is possible and liable to be of a serious character is shown by the nature of the eight cases referred to above that were imported from the Orient. Tuberculosis. Tuberculosis is not hereditary; not Incurable; it is contagious; it is preventable; and under certain conditions curable. The recognition of these facts, for they are facts, has been brought about by the careful study of the disease, by a careful study of the different methods of treatment, and will form a basis for the work undertaken by the Provincial Board of Health in its efforts to combat the disease. This question was discussed in our last Annual Report, and I am pleased to say that, under the direction of the Honourable the Provincial Secretary, Dr. MacLean, greater efforts are to be made for the future. The sanatorium which was established at Tranquille has been doing splendid work, but this work is handicapped by the fact that they have been overloaded with advanced cases, with a result that accommodation is lacking for the early and curable cases. Dr. MacLean proposes to use local hospitals throughout the Province as centres for the handling of the cases in their immediate vicinity. The Government will increase the per capita grant to hospitals for these cases to $1 per day. Hospitals will be required to provide one-tenth of their bed accommodation for advanced cases. Tuberculosis is a reportable disease, and provision is to be made for the reporting of all cases by the medical men, to whom a small fee will be allowed for the work. A travelling Medical Officer of Health is to be employed for the work of supervision and to act as a consultant for the local Medical Officers of Health. There is to be established, with the co-operation of the Dominion Government, another sanatorium in the Province. This will be primarily for the care of the returned soldiers suffering from tuberculosis, but will ultimately revert to the Province. An effort will be made to stimulate public interest in the matter and a general campaign of education carried on. The expectation is that the public will be fully impressed with the fact that the disease is contagious, but more especially that it is preventable. Doubtful cases will be noted and can be kept under observation, and the beds of the sanatorium will be kept for cases in the early stages that, under sanatorium treatment, can be cured. The danger of infection from tuberculosis is much greater during childhood, and I would strongly recommend the advisability of concentrating as far as possible our efforts in guarding our children and to assist the child-welfare movement which is being organized in British Columbia. I would suggest that the School Boards of British Columbia, particularly in the cities, establish open-air school-rooms for weakly and pre-tubercular children. The establishing of such school-rooms is long past the experimental stage, and the results obtained from treatment by this means of such children in the Eastern schools are such as to justify an immediate adoption of the same plan in British Columbia. Venereal Diseases. The wastage of life in this war is rousing the public conscience in all nations to an extent where a solution has to be found for many of the cases which have been productive of serious loss of life and more particularly of efficiency in our population. Tuberculosis has been actively discussed by the people, but a false sense of modesty, false inasmuch as the health of the people is so fatally affected, has in the past prevented public attention being directed to the ravages caused by venereal diseases. Those who have closely studied the spread of such diseases point out that it is necessary, if widespread relief is to be obtained, for the public to be made to apprehend the imminence of the danger. The Governments in the different countries are acting in the matter, and while, as yet, there has not been arrived at a basis for conformity of action, G 8 British Columbia 1918 yet I would recommend to your serious consideration the conclusions arrived at by the Committee on Public Health of the Conservation Commission of Canada, which committee is of the opinion that legislation should be enacted providing for:— (1.) Registration of cases without name and address: (2.) Public registration and isolation of recalcitrants: (3.) Free treatment for all who apply for it: (4.) Free bacteriological and blood tests: (5.) Supervision of mental defects: (6.) The administration of the plan by a Dominion body through or in co-operation with Provincial Boards of Health. In the recommendation made by the Royal Commission appointed by the Government of Great Britain I would especially recommend to your attention their recommendation for " The necessity of educating the public to the gravity of the effect of the disease by securing the constant assistance of voluntary agencies engaged in prevention and rescue work." Such work has been begun in British Columbia, and I would especially mention and recommend the work of the Life Conservation League of Victoria City. This League has evinced an active interest in the matter, and through the press, the pulpit, and public meetings is endeavouring to arouse public conscience to the gravity of the situation. Water. A very important question came before the Board during the past year affecting- the water- supply of the City and District of North Vancouver and the City of Vancouver and adjoining municipalities, which get their water from the same sources. In 1905 reservations were placed upon the watersheds by the Government reserving all alienated lands within the bounds of the watersheds. Unfortunately alienations had been made previous to this by lumber and mining companies. Their holdings had lain dormant until the last year, when they began active operations. As they were in possession of certain portions of the watersheds, the Board of Health was asked to take such measures as would safeguard the water-supply. Conferences were held with the Government and as a result arrangements were arrived at. Regulations governing the companies working on the watersheds were issued, an Inspector was appointed, and every effort was made to safeguard the health of the community. From the measures taken there is no doubt that this will be done, but I beg leave to suggest that the whole question of the watersheds for the Burrard Peninsula be dealt with as a whole; that a Water Board be established along similar lines to the present Sewerage Board of Vancouver, having control of the watershed, the supply and the distribution of the water. During the year plans for the following were examined and approved :— Sewerage plans: Vancouver Trunk Sewer, Trail, and B.C. Sulphite Co., of Howe Sound. Water-supplies: Revelstoke and Trail. Cemetery-sites: Okanagan Mission, Squamish, Fort George, Duncan, and Mapes. Three hundred and eighty-five doses of typhoid vaccine, 1,280 vaccine points for vaccination, and 658,000 units of antitoxin were distributed. Work for the Provincial Laboratory was done for us by the laboratory of the Vancouver General Hospital, and I have to thank Dr. Mullin, who is in charge, for the very full reports which we received of the work that he did for us. The Provincial Laboratory was not in use owing to the fact that we had been unable to secure the services of a bacteriologist, and also to the fact that the Honourable the Provincial Secretary had under consideration a rearrangement of this work. We append a table showing returns made by Medical Health Officers of cases of contagions in the different parts of the Province. I am also incorporating reports from the Vital Statistics Branch, Sanitary Inspection, Hospitals Inspection, and the School Report. The matters more particularly in connection With these inspections are dealt with in the reports. I would commend to your favourable notice the great interest which is taken iii the work of the Department by all the members of the staff. 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Sie,—In presenting the Seventh Annual Report pertaining to the work of sanitary inspection for the year ending, I beg to preface it by reminding you of the fact that this branch of the public health service was the first to suffer in man-power through war conditions, and as each member of the staff removes the vacancy still remains as such, in the hopes of an early termination of the great conflict, when it is presumed that the staff may regain its original strength. Much extra time and labour has been pressed upon the remnant left to carry on the service: in the meantime industrial development has made such strides, as predicted in my last report, that to-day there are 100,000 people employed outside of the cities and in what has been fitly termed the vast " outdoors " of British Columbia. The larger part of these new industries are located near tide-water on islands or inlets, many of them off the regular traffic routes. For reasons already given the sanitary welfare of these numerous industrial camps has not received the desired attention during the past two years, although in the Interior sanitary-inspection work has been attended to by the Provincial police, who are ex-officio Sanitary Inspectors. Complaints have been numerous and reference made in the press, one editorial of a widely circulated " daily " pointing out most emphatically that in view of the expansion taking place some more adequate measure of sanitary welfare for logging and other camps is imperatively necessary. This is undoubtedly true, and is further emphasized by the records of the large city hospitals, which show that the majority of typhoid and other infections come from the outside districts, where conditions are conducive to the spread of infection. Through the efforts of the Honourable the Provincial Secretary means are being provided whereby a thorough and persistent campaign will be taken up for enforcing the regulations dealing with such conditions. Among the numerous new industrial enterprises under way and in contemplation, mention should be made of what promises to be the largest pulp and paper mills in the world, located at Port Alice, Quatsino Sound. Others have been brought into operation at Port Mellon, Swanson Bay, and Ocean Falls. The Powell River plant is operated at capacity limit, and the B.C. Sulphite Co., at Howe Sound, are enlarging to double present capacity. A large number of copper and zinc properties are being developed at different points, whilst the logging industry is only limited by labour procurable. Spruce and fir to the amount of $50,000,000 has been contracted for by the Munitions Department, in addition to an increased commercial demand. Space forbids enumerating to any extent the tremendous development going on, and I have merely mentioned facts to show the necessity of providing means and waysi to protect and promote health conditions at the points selected for the industrial camps in unorganized territory, where no governmental supervision exists beyond the nearest Provincial constable or Government Agency, sometimes one or two days' travel distant. However, the men behind these large enterprises are shrewd enough to recognize the fundamental value of selecting sanitary sites for the housing of their employees. The Powell River Townsite is a good sample of such foresight. The larger the enterprise the less trouble for our Inspectors in enforcing the Provincial regulations. With few exceptions, the small and medium-size camp operators, employing from 10 to 100 men, are the most difficult to convince of the necessity of observing sanitary regulations. The greatest outstanding feature to the credit of all employers operating camps with kitchen and bunk-houses is the fact that without exception the food provided is the best obtainable and without stint. In the past we have not had occasion to give much credit for the manner of housing and other comforts provided to employees in the small camps. In future a greater consideration in that respect will be demanded. Another need for all camps is educational pamphlets dealing with the increasing prevalence of syphilis, also the value of typhoid prophylactic inoculation, and for the rural settlements similar literature or posters for the attention of parents, guardians, and school-teachers in reference to prevention of common ailments common G 12 British Columbia 1918 s to children; and again I would respectfully suggest that an amendment be made to the " Land Act," prohibiting the registration of any subdivision for townsite or residential purposes until the approval of the Provincial Board of Health has been obtained. The lack of such is shown in the almost insurmountable insanitary conditions of several of our newer towns established during the late boom. Such an amendment would prevent " history repeating itself " in that respect; furthermore, our sister Provinces and States have adopted such legislation. The State of California provides that all land sold or subdivided for residential use must be provided with pure water-supply, facilities for sewage-disposal, graded streets, lanes, and approved sidewalks. During the early part of 1918 the service of this Department was invoked for the purpose of protecting a community from the serious endangering of a water-supply through the inefficiency of a supposedly well-designed and built septic system used for the drainage from a large institution. One fatal case of typhoid had already occurred. Upon investigation it was found, first, that the septic action of the tanks had been nullified by the lack of grease-traps; second, no provision had been made for rest and clean-outs; third and worst feature was the fact that the outlet from tanks was straight to a fresh-water stream used by neighbours for domestic purposes. The first and second defects were remedied in the usual manner, and a well-laid sub-irrigation system adopted for the discharge, the old discharge-pipe being removed entirely. The results have been very satisfactory. At Vernon during the past few years the residents of a splendidly improved farming community have been subject to a nuisance caused by the periodical removal of sludge from the tanks of a sewage plant owned by the city. The Government was petitioned and the matter was placed with this Department for attention. Arrangements were made with the city authorities that I should be on hand during the next clearing operation. This was done, with the results that by suggested minor changes in equipment and method the nuisance has been eliminated 90 per cent, and the cost of operation likewise reduced, the results being much appreciated. Details of this work are on file and would be good reading to any one interested in the varied angles of sludge-removal. During the early part of last summer the Municipalities of Armstrong and Spallumcheen complained to the Board in regard to a very offensive odour arising from Otter Lake. The Water Rights Branch were also appealed to. Mr. F. W. Groves, C.K., and the writer made a joint survey of the lake and its sources. The nuisance or annoyance was found to be caused by decaying algse known as Hydrus fwtitus, its presence causing a very offensive smell. The lake is shallow and sluggish. As a remedy it was suggested that the outlet of the lake be cleared to promote action and a small quantity of bluestone, 1 to 10,000 parts, be used in those portions of the lake where the growth of alga? is noticeable. During last September a serious outbreak of typhoid occurred in a logging camp in the Crowsnest country; total number of cases, 20; fatal, 6. As soon as notified, this Department inspected the camp and at once condemned the site as insanitary. Repeated visits have been made by the Provincial police under instructions from the Provincial Board of Health to see that the camp is not used again under -the old conditions. From investigation made it appears that one of the employees had suffered from typhoid fever in an adjoining State a year ago. The general conditions of the camp were insanitary, no fly-screens provided or any disinfecting precaution being thought of, manure allowed to accumulate, and everything was favourable for the propagation of the greatest typhoid-carrier, the fly. There were several sources of good water available, but the poorest, was most convenient and that was the choice. The question of the contamination of watersheds and sources of water-supply of the Cities of Vancouver and North Vancouver has assumed an immediate importance owing to the fact that timber limits lying in the watershed area are being worked and mines are to 'be developed. The enforcement of regulations for the protection of the water-supply will throw an increased responsibility on your staff. In the fish- and food-canning supervision by this Department I regret to say that the recent expected big year was to many canners a disappointment. The sanitary conditions of these establishments on the lower part of the Mainland Coast have been satisfactory except in an isolated case. The salmon-canneries located on the Nass and Skeena Rivers, Rivers Inlet, Smith Inlet, and Johnstone Strait were visited during the early summer per regular steamer. The general sanitary conditions were found to be good. A few requests were made where needed regarding 8 Geo. 5 Provincial Board of Health. G 13 bunk-houses and conveniences. The regulations in reference to the disposal of fish-offal has not so far been rigidly enforced owing to the fact that the majority of them are isolated, and also the purchase of the necessary machinery to handle the offal is at this time impossible owing to war conditions. There are two responsible companies contemplating the erection of fish guano and oil plants to serve these northern canneries just as soon as conditions permit. In the meantime we are demanding that many of the existing offal-chutes be extended in order to prevent the accumulation of fish-offal upon the foreshore which may be exposed at very low tides. There have been many complaints of abominable odours caused by the careless disposal of offal at the northern canneries. There is no necessity for such, and we are endeavouring to see this annoyance abated without hardship to the canners or fishermen. Were it not for prevailing abnormal conditions in securing material and labour for such work, drastic action would be taken. On the Lower Fraser River inspection visits were made to the following canneries: Scottish Canadian, Lighthouse Cannery, Gulf of Georgia, Steves-ton Cannery, Columbia Cod. Storage, Imperial Cannery, Phoenix Cannery, Britannia Cannery, Gosse-Millard Cannery, Colonial Cannery, Richmond Cannery, Great West Cannery, Vancouver Cannery, also Nanaimo Cannery and Great Northern Cannery on Burrard Inlet. The strict enforcement of our regulations governing canneries and the hearty co-operation given by the cannery-men has brought about almost perfect methods in the handling of this important food staple, so much so as to elicit most favourable comments from tourists and experts visiting these canneries. The automatic handling of the fish by machinery is gradually bringing about an ideal condition of sanitation as regards the preparation of the salmon for the market. The machines Installed are most ingenious, almost human in their perfect work, cutting, washing, slicing, and filling into solderless sanitary cans under the closest scrutiny of skilled artisans. Colouring or chemical artifices* have never been introduced into the salmon-canneries of British Columbia. In the past 'season our work in this direction was curtailed to some extent owing to the launch acquired from the Forestry Department needing extensive repairs. Lack of labour and material necessary for such work was not readily available owing to existing war conditions. The difficulty is now being overcome, and through the agency of this long-needed equipment the Department will be in an improved position to cope with the increasing demands for sanitary supervision in cannery and other industrial camps and settlements scattered along the 5,000 mile coast-line of this Province. During August complaints were heard in reference to the insanitary conditions existing at some of the fruit and vegetable canning and evaporating plants of the Okanagan Valley. In many instances I found the complaints justified. Toilet and lavatory arrangements provided for the employees were insanitary and inadequate. This was my first visit, and in justice to the managers it is only fair to say tht my inspection was welcomed, and nearly every one expressed a wish to carry out any official suggestions which would promote efficiency and improve the comfort of the employees. Most of these plants are located within municipal limits, but the local authorities are inclined to think the Provincial Board of Health should exercise a supervising control in so far as sanitary conditions are concerned where food products are prepared for Provincial and export consumption. I beg to suggest the formulating of suitable regulations governing these establishments similar to those used for the salmon-canneries, which have been found to work in a highly satisfactory manner. Our flies show inspection reports and correspondence on the following establishments: Graham Evaporating Co., Armstrong; Graham Evaporating Co., Vernon; Dominion Fruit Cannery, Vernon ; Western Canning Co., Kelowna; B.C. Evaporating Co., Kelowna; Independent Fruit Cannery, Peachland; Western Canners Co., Ltd., Penticton. The total number of employees approximate some 800; 20 -per cent, women, 50 per cent, boys and girls, 10 per cent, white skilled mechanics, and 10 per cent. Oriental. The past fruit season has been very successful in the great Okanagan Valley for growers and canners alike. Several large canning and preserving plants are expected to be built to take care of the increased crop expected during the coming season. During the early part of the past summer complaints were lodged with this Department regarding insanitary and inadequate conveniences and lack of drinking-water for employees at the Shaud Works, on James Island. Several special visits were made, and it was found that the company had already recognized the needs and was taking practical steps to remedy the G 14 British Columbia 1918 grievance (since completed). This concern employs several hundred men and is gradually building up a model town. A very competent first-aid man is continually on the works and special facilities provided for quick medical attendance in case of accident. Complaints have recently been lodged regarding water-pollution at several seaside summer resorts well patronized by Vancouver and New Westminster citizens. These places will have our attention before the coming season. In reference to the requirement of provision of first-aid in industrial camps, I find that the smaller camps are the principal offenders in their neglect of such provision. There is a great improvement in this respect, however, since we have been able to avail ourselves of the services of the Provincial police as Sanitary Inspectors in the outlying districts. A complete list of the existing camps has been supplied by a careful canvass of the different police districts, and also through the courtesy of the Forestry Department, who supplied us with a list of the logging camps. Under the present system of reporting by the police we are able to keep in touch with all new camps and to give immediate attention to complaints. The operators have shown a great willingness to carry out all suggestions offered, and the provisions of section 2 of " An Act for the Protection of Workmen engaged in Industrial Operations " are being observed to a much greater extent than formerly. The section referred to is as follows :—■ " 2. Every employer of labour directly or indirectly operating any mine, camp, construction- work, or industry employing more than thirty persons, and being situated more than six miles from the office of a medical practitioner, shall at all times maintain in or about such industry or works at least one person possessing a certificate of competency to render first aid to the injured, and shall also provide a good and sufficient ambulance box or boxes." I would recommend that the above, in so far as requiring the provision of an ambulance- box, should apply to railway-trains and also to steamers on inland waters. The importance of antiseptic treatment of even slight wounds and of other first aid in cases of emergency is now generally recognized. Many thousands of dollars compensation, the Workmen's Compensation Board's statistics will show, might be saved by preventing blood-poisoning and other serious consequences by the proper use of " first-aid services." In conclusion, permit me to remind you that the office files will show that the work of this branch of the Department has been carried on in a systematic manner and the varied conditions dealt with as presented, and I am pleased to be able to say that without exception most courteous treatment is accorded to our Inspectors wherever their duties call them. I have, etc., Fbank DeGbey, Chief Inspector. HOSPITAL INSPECTION. Victoria, B.C., February 1st, 191S. H. E. Young, M.D., Secretary, Provincial Board of Health, Victoria, B.C. Sib,—In submitting for your consideration the Fifth Annual Report on Hospital Inspection in British Columbia, I am pleased to say that no serious event has occurred in hospital circles here to mar the report of the capable management shown during the past year. The following licensed private hospitals have 'been periodically inspected and any changes or improvements suggested have been carried out:— Arnold Maternity Home (Matron, Mrs. M. Arnold), 316 Robson Street, Nelson, B.C. Bent Sanatorium (Matron, Mrs. E. Bent), 245 Fenwick Avenue, Cranbrook, B.C. Britannia Hospital (Superintendent, Dr. Burke), Britannia Beach, Howe Sound, B.C. Bass Maternity Home (Matron, Mrs. M. C. Bass), 2625 Prior Street, Victoria, B.C. Bute Hospital (Superintendent, Mrs. M. E. Johnson), Bute and Robson Streets, Vancouver, B.C. Bell Nursing Home (Matron, Mrs. L. Bell), 756 Cloverdale Avenue, Victoria, B.C. Convalescent Home (Matron, Miss E. O'Brien), 67 Wellington Avenue, Victoria, B.C. Coquitlam Hospital (Superintendent, Dr. Sutherland), Port Coquitlam, B.C. 8 Geo. 5 Provincial Board of Health. G 15 Corbman Maternity Home (Matron, Mrs. E. Corbman), S55 Eleventh Avenue East, Vancouver, B.C. Down Maternity Home (Matron, Miss Rose Down), Battle Street West, Kamloops, B.C. East Kootenay Hospital (Superintendent, Dr. Garner), Jaffray Street, Fernie, B.C. Grandview Hospital (Superintendent, Dr. E. Hall), 1090 Victoria Drive, Vancouver, B.C. Handley Maternity Home (Matron, Mrs. J. Handley), 1218 Queen's Avenue, Victoria, B.C. Harbour View Sanatorium (Matron, Miss E. M-cLeash), 370 Second Avenue East, North Vancouver, B.C. Impey Maternity Home (Matron, Mrs. M. A. Impey), 243 Eighth Avenue West, Vancouver, B.C. Kitsilano Private Hospital (Superintendent, Miss Annie Scott), 2494 Third Avenue West, Vancouver, B.C. Lonsdale Private Hospital (Matron, Mrs. M. D. Schultz), 1900 Lonsdale Avenue, North Vancouver, B.C. Moore Nursing Home (Matron, Mrs. E. Moore), Baker and Falls Street, Nelson, B.C. More Maternity Home (Matron, Mrs. C. More), 949 Fisgard Street, Victoria, B.C. McGuffie Maternity Home (Matron, Mrs. M. A. McGuffie), 628 Columbia Street, Kamloops, B.C. McKenzie Nursing Home (Matron, Mrs. F. McKenzie), 1781 Second Street, Victoria, B.C. Rutherford Maternity Home (Matron, Mrs. E. Rutherford), 2321 Shakespeare Street, Victoria, B.C. Roadley Nursing Home (Matron, Mrs. L. Roadley), 360 Battle Street, Kamloops, B.C. Roy-croft Private Hospital (Matron, Miss Roycroft), 1036 Haro Street, Vancouver, B.C. Ross Convalescent Home (Matron, Miss E. G. Ross), 1145 Faithful Street, Victoria, B.C. Salmon Maternity Home (Matron, Mrs. A. Salmon), Garden Avenue, Cranbrook, B.C. South Vancouver Private Hospital (Superintendent, Mrs. Jane Webb), 129S Fifty-first Avenue, South Vancouver, B.C. Skelland Nursing Home (Matron, Mrs. E. Skelland), 2316 Lee Avenue, Victoria, B.C. St. Luke's Home (Superintendent, Sister Francis), 309 Cordova Street, Vancouver, B.C. Sunnyview Sanatorium (Superintendent, Dr. Irving), Powers Addition, Kamloops, B.C. Toniley Maternity Home (Matron, Miss L. Tomley), 129 Twenty-second Avenue West, South Vancouver, B.C. Victoria Private Hospital (Superintendent, Miss J. B. Archibald), 1116 Rockland Avenue, Victoria, B.C. West End Hospital (Superintendent, Miss H. G. Tolmie), 1447 Barclay Street, Vancouver, B.C. Witt Maternity Home (Matron, Mrs. A. C. Witt), 1845 Forty-sixth Avenue East, South Vancouver, B.C. Winters Nursing Home (Matron, Mrs. M. Winters), 1020 Harwood Street, Vancouver, B.C. Improved means of fire-escape and protection for every hospital and safer repositories for medicines or drugs have 'been persistently advocated with gratifying results. One sanatorium (Neal Institute) has closed its doors through lack of patients, and one convalescent home has closed for the same reason. Four private maternity hospitals have voluntarily closed through those in charge having tendered their services for hospital-work overseas. Three new licences have been granted and a number of applications considered, but not granted owing to lack of necessary qualifications on the part of the applicant or to the premises not being suitable. One licence has been temporarily suspended. A number of illegal so-called maternity or lying-in homes have been suppressed in various parts of the Province, demonstrating the necessity of constant vigilance in carrying out the provisions of the " Hospital Act Amendment Act." The large public institutions, being under control of a Governing Board, with two of the memibers representing the Government, are not subject to the same inspection visits except for specific reason. A cordial co-operation exisits, however, and much valuable information furnished for the purpose of tracing infection sources in the outlying districts. The following Government-aided charitable and public institutions were visited:—• St. Paul's Hospital, Vancouver, B.C. Alexander Orphanage, Vancouver, B.C. G 16 British Columbia 1918 Children's Aid Society, Vancouver, B.C. Monastery of Our Lady of Charity, Vancouver, B.C. Salvation Army Maternity Home, Vancouver, B.C. Providence Orphanage, New Westminster, B.C. St. Mary's Hospital, New Westminster, B.C. Orange Orphans' Home, New Westminster, B.C. Quamichan Boys' Protectorate, Quamiehan, V.I., B.C. St. Ann's Orphanage and School, Nanaimo, B.C. St. Joseph's Hospital, Victoria, B.C. The existing war-time conditions have brought to these institutions increased burdens without a corresponding increase in income. Indeed, it is a marvel how exceedingly well these homes are managed in the face of such depressing conditions which they have to meet, especially in view of the extra calls upon the societies who volunteer their services in assisting such charities. I have, etc., Fbank DeGbey, Chief Inspector. MEDICAL INSPECTION OF SCHOOLS. Victoria, March 22nd, 1918. Hon. J. D. MacLean, Provincial Secretary, Victoria, B.C. -Sik,—I beg leave to submit the Report of the Medical Inspection of Schools which has taken place during the past six months. There has been a break in the continuity of the work of the Department. In 1916 the matter was up before yourself as to the continuance of the inspection of schools, and it was decided at the time not to proceed for the time being, pending Investigation. In 1917, however, I was instructed to begin the inspection again, and the consequence is that the report submitted is only for the latter part of the year 1917. The practice heretofore had been for the examination to be made once during the scholastic year, and while the appointments of the medical men were made in September it was not possible, owing to the lateness of the season, in many of the outlying districts to have the inspection made. The consequence is that only one-half of the schools have been reported, and the other half will be inspected during the spring term. These reports will not be received until the midsummer. But when these reports are received it will enable us to make a full report for the year September, 1917, to September, 1918, by embodying the reports already received with those which will be received within the next few months. I have, in my Report for the Board of Health, suggested to you the advisability of having the annual report of this Department issue at midsummer on account of the difficulty of receiving the returns at the beginning of the year in time for presentation in the House. Should this suggestion be adopted it would not only benefit us in our report of the Vital Statistics Office, but especially so in our report on schools. I would beg leave to suggest that the Inspection of Schools Branch of the Department be continued and a further effort be made to interest local associations in the work. 8 Geo. 5 Provincial Board of Health. G 17 It is the intention in Great Britain and in the United States to concert the attention of all departments upon child-welfare and to reduce infant mortality, and this Department hopes that by co-operating with the central portions of this country that we may take our part in this nation-wide movement. To accomplish results, however, it will he absolutely necessary that all local organizations, more especially Women's Institutes, will lend their efforts to the furthering of the movement. It is the intention of the Department to make an especial appeal to the medical men who are doing the work to endeavour to appreciate its importance, to advise with the Department, and more particularly to work in conjunction with the parents in an endeavour to render effective an educational campaign. I would also suggest for your consideration a recommendation to the School Boards of the establishment of open-air school-rooms for weakly and pre-tubercular children. The work already done along these lines has been so satisfactory that I feel justified in urging the adoption of similar methods in British Columbia. I beg leave to submit a detailed report of the work done by the Department, and also copy of a report from the Inspectors of the different schools. I have, etc., H. E. Young, Secretary, Provincial Board of Health. SCHOOLS INSPECTED. Rural and Assisted Schools. Schools inspected: 1916, 331, at a cost of $5,653.82; 1917, 129, at a cost of §2,112.75. Schools not inspected: 1936, 117; 1.917, 367. Pupils inspected: 1916, 7,945; 1917, 3,518, a decrease of 4,427. Cost of inspection per pupil: 1916, 71% cents; 1917, 60% cents. Percentage of defects : 1916, 78.50; 1917, 75.64, less 2.86. Medical Inspectors: 1916, 28 Medical Inspectors; 1917, 82 Medical Inspectors. Medical Inspectors: 1916, S9 reports from the Medical Inspectors; 1917, 35 reports from the Medical Inspectors. Graded City Schools. Cities, 35. 1916: Reported, 27; not reported, 6. 1917: Reported, 14 ; not reported, 21. Pupils inspected: 1916, 25,254; 1917, 22,564, a decrease of 1,690. High Schools. High schools, 38. 1916: Reported, 19; increase of 181 pupils inspected. 3917: Reported, 16; increase of 54 pupils inspected. Rubal Municipal Schools. Municipalities: 1916, 2S; reported, 22; not reported, 6. 1917, 27; reported, 12; not reported, 3.5. Pupils inspected: 1916, 10,469, a decrease of 1,093; 1937, 9,012, a decrease of 1,457. G 18 British Columbia 1918 HIGH Name of School. Medical Inspector. School Nurse. V o s cu 'ft fa's d .5 ci o OJ Ol Q ei 0) n ~h *> d B a '3 ^ "rt s> £ o cu P *f "o B CD 42 o bo No report 1917. 102 62 52 99 58 52 1 2 2 Cumberland No report 1917. W. Truax 1 3 1 1 7 1 Enderby Kamloops M. G. Archibald No report 1917. W. J. Knox 1 4 1 4 14 12 1 1 8 1 l 8 1 4 4 30 74 91 120 296 110 28 50 56 22 2 3 8 2 7 No report 1917. R. H. Post 79 91 160 327 110 30 50 56 26 Mat.squi VV. F. Drysdale 6 E. H. McEwen 16 No report 1917. c Prince Rupert ! J. C. Cade J. W. Coffin 3 No report 1917. 3 Vancouver: Girls Belle H. Wilson 387 750 297 290 203 223 170 287 1 6 22 16 8 14 8 12 3 10 4 1 4 2 2 13 13 /F. W. Brydone-Jack. ) \ Mrs. M. P. Hogg- f Pupils not examined. L. 0. Griffin .. 3 H. Bone No report 1917. GRADED CITY 370 425 358 375 4 3 1 6 4 5 8 24 22 2 2 2 18 6 17 13 2 8 14 20 24 1 2 6 1 1 5 1 1 8 17 7 8 20 10 38 5 21 7 15 71 62 21 7 16 16 29 Kamloops M. G. Archibald 67 W. J. Knox 17 G. H. Tuthill 233 120 156 416 297 725 327 391 316 222 112 152 407 289 679 296 355 268 11 Nanaimo : W. F. Drysdale 20 Middle Ward 97 119 106 74 New Westminster: E. H. McEwen 16 4S „ 54 8 Geo. 5 Provincial Board of Health. G 19 SCHOOLS. a cu cu Q a) o ra cs 3 TJ cu GO ,3 ta H 1 io' 21 1 1 11 2 HH 'o O 24 2 15 5 1 7 30 Other Conditions, specify (Nervous, Pulmonary, Cardiac Disease, etc.). £ 0) 1 3 6 ft £ i o d s Acute Fevers which have occurred during the Past Year. Condition of Building. State if crowded, poorly ventilated, poorly heated, etc. Closets. State if clean and adequate. Good Yes. Very poorly ventilated and badly heated ; entirely inadequate to the number of pupils Well ventilated and heated Good 2 Smallpox, 23 6 inadequate for the pupils. 3 Wood and cement. Good... .y. Fair All in good condition Good Ventilation improved Adequate in all respects Satisfactory Fairly good. Ample room 12 Measles, 1 Yes. 28 Good. 35 Yes. 90 39 1 47 44 Chicken-pox, 25; scarlet fever 1 ; mumps, 46 31 23 1 1 Cardiac, 1; nervous, 1 Boils, S *> Good Good. 4 2 2 cement pit, clean. i 4 4 24 21 15 17 8" 84 42 65 Chicken-pox, 1; diphtheria, 1 Good. SCHOOLS. 68 192 21 120 58 84 215 138 414 90 92 71 10 2 67 40 29 36 28 3 Yes. Ample air-space; well ventilated and heated Excellent, modern Satisfactory Fair Clean as plans and construction of building allow Yes. Chronic Bronchial catarrh, 7; cardiac, 4 Cardiac lesions, 2 1 1 8 3 1 3 Chicken-pox, 35; whooping-cough, 2; measles, 86 Diphtheria, 3 ; chicken- pox, 4 Diphtheria, 1; chicken- pox, 1 Measles, 1 ; chicken-pox, 17; pertussis, 9 Chicken-pox, 3; pertussis, 4 Chicken-pox, 24; scarlet fever, I Chicken-pox, 25; scarlet fever, 1; mumps, 46 Good in 1-6 div. Poor in 7-8 u Good. 1 1 3 4 7 21 31 31 9 9 150 2 Good Heart murmur, 7; infantile paralysis, 1; talipes, 2; chorea, 1 3 39 47 5 44 Yes. G 20 British Columbia 1918 GRADED CITY Name of School. New Westminster.•-Concluded: Richard McBride Lord Lester Lord Kelvin. Queensboro Prince Rupert: Borden Street King Edward. Seal Cove., Revelstoke: Central ., Selkirk .. . Rossland: Central Cook Ave Sandon Vancouver: Aberdeen Alexandra Bayview Beaconfield Cecil Rhodes Central Charles Dickens Children's Aid Dawson Fairview Florence Nightingale . Franklin General Gordon Grandview Hastings Henry Hudson Kitsilano Laura Secord Livingstone Macdonald Model Mount Pleasant Nelson Roberts Seymour Simon Fraser Stratheona Medical Inspector. E. H. McEwen. J. C. Cade (acting). J. H. Hamilton. J. W. Coffin .. W. E. Gomm . School Nurse. W. Brvdone-Jack ) H. Wilson ) W. Brydone-Jack. ... I, H. Wilson j" W. Brydone-Jack I P-Hogg / W. Brydone-Jack P.Hogg W. Brvdone-Jack ■> p. Hogg r W. Brydone-Jack \ H. Wilson / W. Brydone-Jack H. Wilson W. Brydone-Jack H. Wilson VV. Brydone-Jack | H. Wilson / W. Brvdone-Jack P. Hogg W. Brydone-Jack H. Wilson. W. Brvdone-Jack P. Hogg W. Brydone-Jack. . P- Hogg W. Brydone-Jack,.. P- Hogg W. Brydone-Jack... H. Wilson W. Brvdone-Jack... P- Hogg W. Brydone-Jack... P. Hogg W. Brydone-Jack... H. Wilson W. Brydone-Jack... H. Wilson W. Brydone-Jack. . H. Wilson W. Brvdone-Jack... H. Wilson W. Brydone-Jack... H. Wilson W. Brydone-Jack... H. Wilson W. Brvdone-Jack... H. Wilson W. Brvdone-Jack... H. Wilson W. Brydone-Jack... H. Wilson W. Brydone-Jack... H Wilson M. A. McLellan A. Jeffers M. A. McLellan. j A. Jeffers ' M. Cruickshanks i' M. Ewart.. E. G. Breeze } M. Ewart X M. Cruickshanks / A. Jeffers I E. G. Breeze / M. A. McLellan. M. A. McLellan. ) M. Ewart f M. Ewart ] A. Jeffers / A. Jeffers | M. Cruickshanks 1 M. A. McLellan. ! ■} A. Jeffers j- A. Jeffers \ M. Cruickshanks ( M. A. McLellan. ) M. Ewart I M. A. McLellan A. Jeffers 1 M. Cruickshanks t M. Ewart 1 M. Cruickshanks / A. Jeffers ) M. Cruickshanks t M. Ewart \ M. Ewart.. A. Jeffers . E. G. Breeze... M. A. McLellan E. G. Breeze... M. Ewart E. G. Breeze... 348 261 315 86 390 216 42 334 526 242 176 344 509 274 122 831 593 629 168 347 467 420 458 409 308 328 362 497 639 602 837 489 494 306 203 328 216 30 285 458 230 188 355 433 268 176 726 479 530 192 2S3 478 460 375 349 288 302 329 464 505 537 741 479 463 644 5 52 1 41 30 26 i 32 6 42 6 59 4 20 2 12 7 67 4 60 1 55 2 33 6 42 2 45 1 25 8 67 7 61 3 10 2 17 2 26 5 68 3 40 1 45 5 54 9 91 2 58 9 88 8 Geo. 5 Provincial Board of Health. G 21 SCHOOLS.—Continued, 121 73 50 189 112 169 49 46 140 151 92 52 81 110 124 118 148 180 188 121 157 202 Other Conditions, specify (Nervous, Pulmonary, Cardiac Disease, etc.). Nervous, 2 ; pulmonary, 2 ; cardiac, 1; anaemia, 1; otitis media, 1 Nervous, 2 ; pulmonary, 2 ; Brights, 1 Nervous, 1; ansemia, 1 Absence left palate, 1 Cleft palate, 1; osteo-myelitis, 1; myocarditis, 1 Cardiac, 2 Cardiac, 2 Vaccinated, 2 Vaccinated, 1 Vaccinated, Vaccinated, 1 Vaccinated, 2 Vaccinated, lung, 1 Vaccinated, 1 \ accinated, Vaccinated, ung, 12 Vaccinated, lung, 6 Vaccinated, 2 Vaccinated, 2 Vaccinated, 4 Vaccinated, 2 Vaccinated, Vaccinated, 3 Vaccinated, 12 Vaccinated, Vaccinated, 1 Vaccinated, Vaccinated, lung, 1 Vaccinated, Vaccinated, 1 Vaccinated, lung, 1 Vaccinated, lung, 9 Vaccinated, lung, 8 Vaccinated, lung, 5 72; cardiac, 5; lung, 66; cardiac, 4 ; lung, 25 ; cardiac, 7 30; cardiac, 6; lung, 63; cardiac, 7 ; lung, 115 ; cardiac, 8; 29; cardiac, 2; lung, 14; cardiac, 7 168; cardiac, 19; 94; cardiac, 10; 72; cardiac, 9; lung, 56; cardiac, 2 ; lung, 75 ; cardiac, 4 ; lung, 53; cardiac, 7; lung, 45 ; cardiac, S 63; cardiac, 7; lung, 53; cardiac, 6 ; lung, 40; cardiac, 1 66; cardiac, 5; lung, 50; cardiac, 3 66; cardiac, 13; 44; cardiac, 5 49; cardiac, 8; lung, 193; cardiac, 13; 84; cardiac, 13; 41; cardiac, 11; 135 ; cardiac, 8 ; Acute Fevers which have occurred during the Past Year. Scarlet-fever, 1; chicken- pox, 1; tonsilitis, 1; T. B. spine, 1 Tonsilitis, 1; chicken-po.x, 6 ; measles, 2 ; influenza, 1 Chicken-pox, 2 Whooping-cough.. Whooping-cough.. Communicable diseases in children of school age in Vancouver City:— Chicken-pox 287 Diphtheria 21 Measles 67 Mumps 493 Scarlet fever 32 Whooping-congh 51 Infantile paralysis 3 Condition of Building. State if crowded, poorly ventilated, poorly heated, etc. Good Adequate, fairly heated and ventilated Adequate, well- heated and ventilated Adequate, well- heated and ventilated Good. Satisfactory Good [.'.['. Closets. State if clean and adequate. Yes. Good. Yes. G 22 British Columbia 1918 GRADED CITY ■6 .. u d c a te, Is a bib s -— ti IT rt = Name of School. Medical Inspector. School Nurse. Bj g* ciS 5 a o A > tc ^ rt £ a =jjjj OJ > 1 8 1 1 2 1 7 5 2 1 2 2 1 i i 3 2 1 2 5 3 3 5 8 2 5 3 4 5 2 5 4 4 1 7 6 4 8 10 1 1 "i i T "i 1 1 2 1 1 1 3 1 8 7 7' 2 4 6 6 9 4 5 27 1 2 8 1 1 2 1 2 i 1 2 10 9 6 5 6 e i 7 1 6 2 2 2 4 4 2 1 14 3 2 1 7 l 2 5 2 6 9 8 4 30 8 2 i 2 2 3 2 4 1 14 7 14 5 "l 1 2 2 i 3 1 1 2 2 1 3 2 6 2 1 1 1 4 1 1 li 15 5 3 2 5 2 9 3 1 1 S 3 i 2 2 5 8 Geo. 5 Provincial Board of Health. G 23 SCHOOLS. —Concluded. H3 CU CU H I o CU "cu 0 03 3 ■a. bo il 13 63 20 2 1 1 4 'o O 8 2 Other Conditions, specify (Nervous, Pulmonary, Cardiac Disease, etc.). .9 3 O 6 cu ft £ K O & bo d jg 1 1 Acute Fevers which have occurred during the Past Year. Condition of Building. State if crowded, poorly ventilated, poorly heated, etc. Closets. State if clean and adequate. 95 Vaccinated, 64; cardiac, 8; lung, 6 Measles and chicken-pox Measles and chicken-pox Measles and chicken-pox Good 14 2 V Yes 80 "2' 76 4 1 SCHOOLS. 116 3 7 .... 7 .... 4 .... 4 .... 8 .... 2 .... Eczema, 1; uncleanliness, 7 ; hronchitis, 2; heart-trouble, 5 ; wax in ears, 4 ; rhinitis, 1; thickened nasal septum, 3 2 2 Chicken-pox, 40; measles, 3 ; mumps, 1; diphtheria, 2 Good Yes. 12 8 Uncleanliness, 1; pulmonary, 1; tuberculosis, 1; wax in ears, 1 ; rhinitis 1 20 19 " 9 Scarlet fever ; mumps, 1 53 2 7 1 3 3 .. 4 .. 4 .. 3 .. 1 .. 1 .. 1 '.'. "b .. 1 .. 10 .. 10 2 .... 3 4 29 4 Good. 18 .. Good 34 .. 5 6 .. Yes. 10 .. 3 .. 3 .. 3 .. . 9 . 21 .. 12 .. 9 2 3 2 . . 5 1 .... 2 5 13 1 .... 4 14 .. 4 .. " 9 .. 3 10 50 8 .... 5 18 1 1 2 1 1 .... 22 Chicken-pox. 27 Chicken-pox, 10 ; whooping-cough, 2 Chicken-pox, 15 Good Yes. 12 24 2 1 1 .... 2 3 10 8 2 .... 6 .. 5 .. 2 1 2 2 Measles and chicken-pox 15 .. .. 1 Lame from infantile paralysis, 1 Yes. 2 .. Good 6 .. - • Yes. 5 .. 4 7 .. .. 1 7 1 2 .... Cretin, 1 4 .. Bad Good.. 28 3 9 23 7 .... Whooping-cough, 5; mumps, 1 Mumps, 1; chicken-pox, 2 3 ... 10 13 3* ... G 24 British Columbia 1918 RURAL MUNICIPALITY Name of School. Maple Ridge.—Concluded Haney Yennadon Haney, Superior.... Maple Ridge, Senior Maple Ridge, Junior. Hammond Matsqui: Aberdeen Bradner Clayburn Dunach Glenmore Jubilee Mount Lehman Peardonville Poplar Ridgedale Oak Bay: Monterey Willows Pitt Meadows: Pitt Meadows Richardson Point Grey: Eburne Magee Lord Kitchener Shaughnessy Queen Mary. Kerrisdale Saanich: Keating Mackenzie Avenue... Royal Oak North Dairy Craigflower Cedar Hill Cadboro Bay Tillicum Road Saanichton Prospect Saanich, West Gordon Head Strawberry Vale .... Tolmie Vancouver, North: Lynn Valley- Keith Lynn Capilano . North Star Vancouver, South: Lord Selkirk Tecumseh Carleton Medical Inspector. G. Morse . R. H. Port. F. T. Stainer.. G. Morse Andrew Lowrie . C. D. Holmes E. A. Martin. L. O. Griffin . School Nurse. 64 17 27 25 61 32 61 57 17 23 7 46 27 19 45 278 147 40 16 248 122 224 157 187 52 119 75 123 72 14 26 33 17 55 37 167 34 35 85 460 54 15 17 25 57 29 57 62 12 13 38 24 11 245 139 31 12 243 96 221 154 181 45 80 16 49 30 43 343 167 34 35 85 525 458 1 5 11 104 67 8 Geo. 5 Provincial Board op Health. G SCHOOLS.—Continued. 4 . cu CD H a) o CD CD 0 ■a B ci 3 CD 50 t. .CS *c a 3 'o 0 Other Conditions specify*, (Nervous, Pulmonary, Cardiac Disease, etc.). CJ 1 a d _bxi ft o •50 a 3 Acute Fevers which have occurred during the Past Year. Condition of Building. State if crowded, poorly ventilated, poorly heated, etc. Closets. State if clean and adequate. 33 Diphtheria, 2; mumps, 15 Good 9 8 1 4 3 8 12 Diphtherial; mumps, 2; whooping-cough, 7 14 4 1 1 2 i 3 9 Yes 3 Tubercular bone, 1; bronchitis, 1 2 1 2 Good 3 1 Whooping-cough, 10 1 4 3 1 Good 2 3 7 136 24 11 1 4 1 2 3' 73 14 Whooping- cough, 10; chicken-pox, 1 Good. ... 8 79 15 4 12 11 12 8 2 9 3 4 5 4 29 17 19 33 21 32 2 5 1 1 2 3 Nervous, 1; cardiac, 4; pulmonary, 1 ; orthopaedic, 1; skin, 1 Cardiac, 3; nervous, 1 ; pulmonary, 1 ; skin, 1 ; nephritis, 1 Nervous, 1 ; cai'diac, 3 ; skin, 1; orthopaedic, 1 Nervous, 3; cardiac, 4; pulmonary, 2; orthopaedic, 4 Nervous, 1; cardiac, 2 ; skin, 1; pulmonary, 2 ; orthopaedic, 4 Cardiac, 6 ; pulmonary, 2 ; orthopaedic, 1; skin, 2 9 2 4 Chicken-pox, 6; scarlet- fever, 2 Scarlet fever, 4 ; measles, 3; chicken-pox, 1; influenza, 3 Scarlet fe\ er, 2 ; tuberculosis, 1; measles, 9, typhoid 1; mumps, 3 Scarlet fever, 1; mumps, 24; chicken-pox, 2 Chicken-pox, 25; measles, 2 ; scarlet fe^er, 1 Chicken-pox, 23; scarlet fever, 25 ; measles, 6 16 36 4 Excellent, ventilation improved Overcrowded in Div. II. Small building overcrowded Good except Div. III. overcrowded Good » 44 34 49 18 2 2 " 32 Measles Measles and chicken-pox Measles Measles ; diphtheria, 1.. Measles Measles 20 1 in order. (W » 29 21 Catarrh of throat, 1 ; eczema, 1 1 2 No water supply.. 12 4 4 2 3 2 3 12 4 1 1 1 50 23 23 13 1 2 10 No water supplv.. Good No water supply.. 14 Measles Measles Measles Measles; chicken-pox; mamps Measles and chicken-pox Measles and chicken-pox Measles and chicken-pox Measles and chicken-pox Mumps, 33; chicken-pox, 24; wrhooping-cough, 2 Measles, 7; mumps, 1; chicken-pox, 1; whooping-cough, 1 Measles, 2 ; mumps, 5 ; chicken-pox, 6; scarlet fever, 1 10 19 4 14 1 125 Infantile paralysis, 1; acne, 3 ; catarrh, 1; eczema, 11; otorr- hcea, 1 ; defective speech, 1; stammering, 1 Yes. 55 IS 19- " 21 382 339 282 4 16 7 Nervous, 1; pulmonary, 1; cardiac, 4; anaemia, 10; unclean, 1 Nervous, 2; pulmonary, 3; cardiac, 9 ; anaemia, 5 ; unclean, 4 Pulmonary, 2; cardiac, 3; anaemia, 1 6 13 9 3 8 9 13 3 Lighting fair it .... Good, n G 26 British Columbia 191S 1 RURAL MUNICIPALITY Name of School. Medical Inspector. School Nurse. <5 "3 u c Q 2 1 a o "Eo a; CJ ty Ol 18 12 11 20 6 15 7 1 2 13 6 ti OS CD X V > O a> CJ ft 17 8 12 12 6 12 5 1 8 2 .-, ci cS.5 £ H= Bjj CJ CD CD CD B 5 12 9 22 5 11 8 1 2 16 4 3 'o c CD "d CD a B CD CJ CD o 1 bo _c 'E rt CD X CO CJ CD CJ 0 1 rt E Cj fD ■i& CD CD CJ O 1 CO *d '0 B cd -d < 1 0 H *d CD bo ■a 92 15 20 25 49 18 41 11 12 8 10 112 21 15 279 8 8 23 52 8 9 43 13 20 38 35 14 103 22 20 28 24 11 33 39 9 11 76 23 66 14 20 15 9 41 59 40 13 25 35 150 103 23 39 13 42 33 8 8 18 42 12 67 70 89 13 18 23 44 15 40 9 8 7 9 113 19 11 260 8 8 13 50 7 8 41 13 20 37 32 11 100 18 18 26 23 9 22 38 9 10 72 22 66 11 18 15 9 38 55 39 12 22 33 150 100 17 36 9 41 22 8 6 17 38 12 60 66 47 Fife 4 W. Truax "i" 1 1 1 3 T 1 3 2 1 i' 1 1 1 5 3 D. Black 4 C. Ewart 9 1 Mrs. Campbell 13 D. Black 1 1 1 4 3 3 28 6 2 12 2 4 3 24' 9. Happy Valley L. Broe Miss McTaggart .. 27 3 2 "i" 1 13 9 4 T. J. McPhee Miss C. Collishaw7. 65 Hat Creek.. H. D. Leitch 1 Heffley Creek H. H. Murphy Robert Elliott 9 Hedley . . 4 2 3 3 1 5 Hillier 1 J. C. Elliott 3 1 1 2 1 3 5 4 4 P. W. Turner 2 1 "i i 2 5 D. Black 14 No report 1916-17. Robert Elliott 3 1 2 1 4 6 9 D. McCaffrey 1 1 6 2 1 2 2 '0 Langford 5 5 4 1 5 3 "i" 3 2 9 2 3 2 m H. R. Fort 2 John Nay Mrs. Campbell 5i 3 i 1 2 2 11 D. Black l i i 4 Nanaimo Bay T. J. McPhee "s 2 1 2 i 6 7 12 1 2 1 1 2 i 6 2 2 9 Robert Elliott 2 2 2 Mrs. Campbell 3 North Bend H. R. Fort 4 5 10 1 3 1 1 i i 10 1 2 1 8 Northfield T. J. McPhee 4 6 Olalla Robert Elliott Otter Point W. D. Calvert 2 3 1 6 2 3 10 20 50 D. McCaffrey .... 20 2 3 2 1 2 G. R. Baker 1 1 3 1 2 3 3 1 2 3 St. Elmo.. J. C. Elliott . .... 3 1 3 3 1 1 3 3 Mrs. Campbell 8 3 1 1 3 4 2 1 1 7 8 Geo. 5 Provincial Board of Health. G 29 SCHOOLS.—Continued. l-H 35 ii 7 CM 8 32 6 31 7 6 o 35 24 12 21 17 1 22 2 16 11 lie a c: 42 3 16 8 1 2 48 4 19 6 104 IO © -. 34 4 10 4 1 48 4 16 7 100 <2 c <5 39 4 15 6 2 1 45 6 11 2 110 | 63 26 21 4 10 53 9 22 26 217 00 8 72 9 29 5 6 1 33 11 19 5 162 33 44 41!) Oh 09 55 18 14 16 1 69 12 30 10 168 46 36 450 o 5j 102 16 23 14 7 1 74 51 31 5 164 61 42 580 92 23 68 31 11 C-l cs 99 15 36 12 13 CO cc 85 27 35 18 11 H* cr. 42 23 11 3 1 32 9 11 ii c. 23 .37 18 1 12 C: 24 21 19 7 6 3 53 7 45 17 224 92 36 664 *c? O hi 974 258 386 162 104 8 1,040 234 430 211 2,952 763 671 8,193 54.11 Whooping-cough 14.33 21.44 9.00 5.77 0.44 38 6 11 98 29 4 13 3 102 30 6 11 6 155 53 24 80 10 237 86 60 724 130 23 39 10 258 124 63 822 113 24 10 11 105 66 51 648 108 13 45 11 188 04 47 B61 72 14 34 IS 167 62 47 470 35 14 20 36 228 140 49 622 57.77 13.00 Purulent infection and septicaemia 23.9 11.72 Pneumonia 164.00 76.30 22 274 26 280 22 812 19 260 24 277 16 243 20 261 47 408 37.28 * Bronchopneumonia does not appear to have been segregated until 1908 ; consequently the average is for 10 and not 18 years. Re cancer: The following statement is self-explanatory. The total number of deaths, 24S, is 6.36 of all deaths and 0.65 per thousand of population. Victoria Division .. .., New Westminster Division Nanaimo Division Beatou Croup Alberni Group Ashcroft Group Fairview Group Vancouver Division Totals Male. 128 120 28 33 61 14 9 23 4 3 7 5 5 10 3 2 5 i3 '7 20 61 61 122 248 Re tuberculosis: Deaths from tuberculosis, all forms, are shown below, being 10.6 of all deaths and 1.08 per thousand of population. Total deaths, 413, Male. Female. Total. 39 27 10 19 5 5 38 111 18 17 7 9 4 3 31 70 57 44 17 28 9 8 69 181 Totals 254 159 413 Reference to both tuberculosis and cancer is made elsewhere. G 36 British Columbia 1918 The following information is presented as a comparative statement re the ages of decedents for the years 1916 and 1917 :— 1916. 1917. Under 1 year 601 587 1 to 2 years 121 S2 2 to 5 years 108 107 5 to 10 years 70 76 10 to 20 years 104 154 20 to 30 years 29S 329 30 to 40 years 451 473 40 to 50 years 486 451 50 to 60 years 450 456 60 to 70 years 413 461 70 to 80 years 348 341 80 to 90 years 175 158 90 years and up 22 18 Age not given 37 28 Age and sex not given 2 Totals 3,686 3,721 In the above figures the still-born are not included with deaths under one year. There were 201 still-births reported in 1916 and 175 in 1917. In connection with the above, it is worthy of note that, notwithstanding the heavy showing of infant mortality in each year, if we take the columns of each year, from infancy to 39 years, the totals are respectively 1,753 and 1,808, whilst the columns from 40 to final age returns stand respectively 1,933 to 1,913. This shows a wonderful evenness and calls attention to the longevity of the people of the Province. From the age of 60 years up, we have 958 in 1916 and 978 in 1917. In compiling this report we have, necessarily, been compelled to scan the annual reports of this Department for several years back. Whilst so engaged we chanced upon a paragraph in the report for 1914 : " Another piece of work undertaken and almost completed has been the arrangement and placing in alphabetical order of all the returns received by this office since 1872. The documents from each district have been gathered together and bound, so that what belongs to Victoria, or any other place, may be found by itself under its proper year and letter. The undertaking entailed no little labour, but the results certainly justify the course pursued." The staff takes it for granted that all persons are entitled to rejoice when they have successfully accomplished an important undertaking. In this case the end of the task is so near that we announce its completion, and hold all returns duly placed under their respective districts and arranged in alphabetical order. In the same report we find allusion to church registers. The different denominations have generally responded cheerfully, and for their co-operation we take this occasion to thank them; yet the greatest is still behind. Arrangements have finally been made whereby we have had placed at our disposal the records of the Church of England antedating the Oregon award by several years. With these documents duly classified and arranged, it is held that the Province of British Columbia may with pride compare records with any Province in the Dominion of Canada. Re the matter of vital statistics of the Indians of British Columbia : Up to the year 1916 the registration of births, deaths, and marriages among Indians received no recognition at the hands of this Department, section 3 of the " Vital Statistics Act" preventing such registration :— " 3. The provisions of this Act shall apply to every person resident within this Province, whether such residence be permanent or temporary, and shall apply to all races and nationalities except persons who are Indians within the meaning of the Act of the Dominion Parliament respecting Indians." In 1914 the Department of Indian Affairs at Ottawa took the matter up with the Government of this Province and urged amendment of our Act to the end that Indians should receive the same recognition under the Act as that accorded all other peoples. After considerable correspondence, which need not be introduced here, extending over a period of two years, a compromise was 8 Geo. 5 Provincial Board of Health. G 37 effected, and the following amendment to the Act was made in 1916 and became a part of the laws of the land:— " 2. Section 3 of the ' Vital Statistics Act,' being chapter 81 of the Statutes of 1913, is hereby repealed, and the following is substituted therefor:— "'3. (1.) The provisions of this Act shall apply to every person, of whatever race or nationality, resident within this Province, but shall not, except as herein provided, apply to the persons who are Indians within the meaning of the Act of the Dominion Parliament respecting Indians. "'(2.) For the purpose of compiling statistics of births, deaths, and marriages of such Indians, the Registrar may accept returns to be made monthly by the respective Indian Agents in the Province, and such returns shall be kept separate and apart from the other returns authorized or required by this Act, and shall be made according to the forms specially prepared by the Registrar.' " From and after the passage of the amendment everything was done in regular order; the first thing, naturally, was the appointment of the various Indian Agents as Registrars, etc., for Indians only, as follows:— " Provincial Secretary's Office, October 26th, 1916. " His Honour the Lieutenant-Governor in Council has been pleased to appoint the undermentioned Indian iVgents to be Registrars under the ' Marriage Act,' and District Registrars of Vital Statistics, for Indians only :— Name. Agency. Address. AV. R. Robertson Cowichan Duncan. C. A. Cox West Coast Alberni. R. E. Loring Babine Hazelton. Ivor Fougner Bella Coola Bella Coola. John F. Smith Kamloops Kamloops. R. L. T. Galbraith Kootenay Fort Steele. H. Graham Lytton Lytton. Chas. C. Perry Nass Prince Rupert. Peter Byrne New Westminster New Westminster. J. R. Brown Okanagan Vernon. Thos. Deasy Queen Charlotte Masset. W. S. Simpson Stikine Telegraph Creek. W. J. McAUan Stuart Lake Fort Fraser. Isaac Ogden Williams Lake Lac la Hache. W. M. Halliday *.. Kwawkewlth Alert Bay." Special forms were printed, all necessary books and other supplies furnished and forwarded to the different agencies, in addition to which the Indian Department at Ottawa notified its various agents by circular letter of the amendment to the Act, etc., closing the letter with the following paragraph:— " You will therefore receive instructions from the Registrar of Births, Deaths, and Marriages, fully instructing you in your duties as Registrar, and I am to inform you that the Department confirms your appointment as such and will be glad if you will endeavour to carry out any instructions that may be sent you by the Provincial Registrar." Whilst the foregoing work was under way, our " exchanges " were closely watched in the hope that something bearing on Indian vital statistics might appear. The most pertinent coming under observation contains the following:— " It has been generally believed that the white man's civilization was inimical to the red man. ... It seems now that these conclusions were without basis in fact, and that the race is really Increasing nearly as fast as the white race." If such a condition has been rendered possible on one side of a national 'boundary-line, there is every reason to believe that it can be done on this side, and that the line itself will never rise and say: " Thus far shall civilization of the Indian come, and no farther." G 38 British Columbia 1918 In justification of the position assumed in the foregoing paragraph, we must be permitted to quote from the Annual Report of the Department of Indian Affairs. Therein is found that:—- British Columbia has an Indian population of 25,399 British Columbia has land under crop, acres 11,603 British Columbia has produced grain, roots, bushels 567,528 British Columbia has produced hay, tons 24,847 Representing a total value of $598,329 Ontario, the premier Province, has an Indian population of 26,162 Ontario has land under crop, acres 16,1S0 Ontario has produced grain, roots, bushels - 495,767 Ontario has produced hay, tons 31,958 Representing a total value of $506,648 British Columbia standing above her nearest competitor by $91,681. And her Indian population is treated as a negligible quantity. It may be urged that this trifling critique is out of place, but the facts tempted me and I wandered. The reports from the Indian Agents as a whole are not satisfactory. In some cases the Agents have evidently taken considerable trouble, even gone out of their way, to comply With the instructions issued from this office, whilst others (particularly Okanagan and Williams Lake) have ignored the business entirely—no notice of any kind having been received for the whole year. In other cases, instead of reporting monthly, as per their instructions, the Agents apparently await the accumulation of a batch sufficiently large to fill an envelope before attempting to forward the documents to this office. However, this is only the first year, and hope still lives. The following is a brief summary of the returns as received:— Births 144 Deaths 310 Marriages 67 / Total 521 Total registrations made for the year, 521 for a population of 25,399, the number given in the Report of the Department of Indian Affairs for 1915. The deaths exceed the births by 160, and we have record of only 67 marriages. Evidently there is a laxness somewhere which must be overcome. The cash receipts for the year amount to $1,430.15, being $225.65 in excess of 1916. Certificates issued for military purposes, as nearly as can be arrived at, stand between 4,000 and 5,000. The number is assumed because the offices in Victoria and Vancouver together have issued 3,455, to which must be added what was issued by the different District Registrars. The above certificates are issued free of charge. The various forms of tabulated statements used in last year's report have been retained and some new ones introduced. Letters received and dealt with in 1917, 4,590; notices received of marriage licences issued, 2,864; notices of births received from physicians (for Victoria Division only), 1,038. Whilst on this topic it may not be out of place to point out that, in addition to the regular work, the staff has in the last four years indexed, classified, and arranged in alphabetical order returns of births, deaths, and marriages numbering 184.525 lines. I have the honour to be, Sir, Your obedient servant, M. MILLER, Deputy Registrar, Births, Deaths, and Marriages. 8 Geo. 5 Provincial Board of Health. G 39 BIRTHS, 1917. Mining Division. Ainsworth— Kaslo Arrow Lake— Nakusp ... Atlin— Atlin Ashcroft— Ashcroft Alberni— Alberni Bella Coola— Bella Coola Cariboo— Barkerville Fort George Tete .laune Cache Clayoquot— Clayoquot Clinton — Clinton Fort Steele— Cranbrook Fernie Greenwood— Greenwood Grand Forks— Grand Forks Golden— Golden Kamloops— Kamloops Liard— Porter's Landing .... Lardeau— Beaton Lillooet— Lillooet Nicola— Nicola Nelson— Nelson New Westminster— New Westminster.. . Burnaby Chilliwack Outside Nanaimo— Nanaimo Alert Bay Comox Ladysmith )yoos— Fairview Omineca— Hazelton Fort Fraser Portland Canal— Stew-art Peace River— Fort St. John Hudson Hope Pouce Coupe Quesnel— Quesnel 150-Mile House Quatsino— % Quatsino Queen Charlotte- Queen Charlotte City Revelstoke— Revelstoke Similkameen— Princeton.. Slocan— New Denver... Slocan City Division — Slocan City Stikine— Telegraph Creek Carried forward Registrations in 1917. 3 18 21 5 21 8 1 9 69 98 *7 47 2 35 119 258 85 63 196 160 7 88 37 43 21 1 3 12 13 6 11 64 16 14 5 1 Female. 11 6 4 17 19 11 34 7 105 34 30 18 154 1 1 223 75 71 179 150 11 78 44 16 11 1 2 7 14 3 68 11 15 Sex not given. Total Registrations. 1917. 24 14 7* 35 40 16 55 16 137 203 81 77 40 303 1* 3 5 70 226 481 160 134 375 310 18 166 81 37 17 2* 5* 19 27 9 4 19 122 27 29 7 3,501 26 25 2 16 34 15 2 79 13 3 18 161 243 97 81 41 326 9 8 55 235 438 210 143 303 205 61 60 12 31 9 7 12 129 11 25 3 2 1,581 Births in 1917. 13 3 2 7 15 4 iii 8 1 4 50 82 34 33 20 100 1 1 23 170 67 44 132 70 23 IS 3 1 1 10 9 51 14 8 6 1,287 Female. Sex not given. 7 4 4 8 12 9 3i 7 1 4 54 77 26 28 10 104 1 1 2 20 82 152 58 52 122 106 7 56 33 31 1 14 6 i 6 9 1 2 i 49 7 12 2 1 1,228 Total Births. 1917. 1916. 20 7 6* 15 27 13 50 15 104 159 60 61 30 204 1* 2 3 49 162 322 125 96 254 125 56 32 9 1* 2» 16 18 4 4 13 100 21 20 7 1* 2,516 21 19 2 12 26 12 2 70 11 3 13 118 198 74 63 35 249 304 141 99 224 261 24 168 49 40 10 7 26 5 5 11 105 9 19 2 2 2,722 G 40 British Columbia 1918 BIRTHS, 1917—iConcluded. Mining Division. Brought forward. Skeena— Prince Rupert Anyox Trail Creek— Rossland Trail Trout Lake— Trout Lake Vernon— Vernon Vancouver— Vancouver City North Vancouver City North Vancouver District.. South Vancouver West Vancouver Point Grey Unorganized Richmond Victoria— Victoria City Cowichan Esquimalt.." Oak Bay Saanich Windermere— Wilmer. Yale- Yale Totals 4. Registrations in 1917. 105 3 Female. 1,691 74 4 192 1,424 1,246 74 56 21 13 251 229 2 6 73 49 39 27 71 76 517 478 49 53 36 44 22 22 94 S3 7 15 19 16 4,479 Sex not given. Total Registrations. 1917. 179 7 67 162 418 2,670 131 34 480 8 122 66 147 995 102 80 44 177 9,450 1916. 181 97 100 166 40 579 16 139 86 154 1,106 101 62 53 194 21 20 9,840 Births in 1917. Male. 1,287 82 3 21 70 165 1,064 63 17 197 1 46 SO 62 381 37 * 29 18 56 Female. 62 4 18 64 944 42 10 193 5 38 21 62 35 32 15 60 12 11 Sex not given. Total Births. 1917. 2,516 144 7 39 134 2,008 1,992 106 136 27 34 390 421 6 11 84 116 51 72 124 131 744 836 72 86 61 50 S3 45 116 150 19 21 22 14 6,994 7,475 1916. 2,722 65 91 * December returns not received. 8 Geo. 5 Provincial Board of Health. G 41 DEATHS, 1917. Mining Division. o a . •- d - t, 1J Jj on 1.9 u 2 2 fH CS . O o o eo 1 | OJ o m o HH c 4 1 cl 0) O © B 0 H3 Ol Ainsworth— Arrow Lake— Atlin— Atlin 1 Ashcroft— 3 3 1 1 3 1 1 2 2 1 1 4 1 2 4 1 1 1 2 3 2 1 1 1 Alberni— 1 2 Bella Coola— Cariboo — 1 1 5 3 2 1 1 2 1 1 2 1 Clayoquot— Clinton— 1 16 42 13 9 1 12 2 4 9 2 5 2 19 3 29 104 24 24 9 100 Fort Steele- 2 7 7 3 3 1 4 4 1 1 1 4 2- 1 4 5 22 2 1 2 22 5 22 1 2 2 31 5 14 2 4 1 15 5 9 4 2 3 1 1 4 5 4 1 Greenwood— Grand Forks- Golden— Kamloops— 13 18 9 1 Liard— Lardeau— 3 6 22 74 212 47 47 147 114 11 84 24 31 21 9 1 Lillooet— 1 1 1 9 15 3 8 12 1 12 3 2 1 1 1 5 7 30 5 23 11 4 16 2 3 T 3 14 38 1 3 18 15 1 14 2 7 1 2 1 4 13 20 *y 19 11 1 8 1 9 5 1 1 1 12 34 4 6 25 10 1 7 21 7 6 25 9 1 4 11 1 11 5 2 2 4 "i' "i' i i 4 11 72 146 24 25 130 60 8 63 9 22 18 5 3 1 6 34 97 11 12 50 89 3 20 16 9 7 4 5 17 106 243 35 37 180 99 11 83 25 31 25 9 3 Nicola— Nelson — Nelson New Westminster— New Westminster 17 44 10 10 33 17 4 4 7 1 5 2 1 4 2 1 7 6 "i* 6 3 5 1 2 1 9 12 1 4 5 2 4 18 Outside Nanaimo— Nanaimo "a 1 2 2 4 1 5 1 1 9 1 4 9 2 1 7 2 2 1 2 1 1 1 Osoyoos— Omineca— i 1 Portland Canal- Peace River— 1 i i i i 2 3 195 2 1 i 1 1 2 4 3 1 5 30 5 11 2 1032 1 2 1 10 7 9 2 485 3 4 5 2 5 40 12 13 4 1517 4 14 2 1 10 42 16 10 5 1425 Quesnel— 150-Mile House 1 1 Quatsino— 1 1 3 4 1 146 Queen Charlotte- Queen Charlotte City .. Revelstoke— ' Revelstoke Similkameen— 1 14 1 1 1 284 1 3 1 1 2 2 1 59 6 1 3 1 183 l 4 1 3 1 3 1 2 1 l Slocan— 36 1 1 52 22 Slocan City Division— Carried forward... 164 171 127 49 4 21 44 G 42 British Columbia 1918 DEATHS, 1917— Concluded, Mining Division. •cl Js a . — c ." *-■ ll JH *** £ *=» 1-s 0 1 CO OI o in io o cc ***! OH r-l © O CO t- 9 © OH O HH © cc V © CO o 5h 5 CJ "Hi © o © CO b rt 9 © io o HH © rt 9 o CO o © iO rt V o o HH © CO rt © CO o HH o s- o"> © © o © CO 49 g S rt g 4 a CH *£c 2

■& O c X © 0 H 1517 4 63 1 31 33 2 85 1307 58 12 88 4 29 30 21 476 33 26 15 39 4 18 3896 cd © HH 0 H 1425 2 52 45 40 146 1240 36 11 112 4 38 33 32 533 36 26 19 40 5 12 3887 © B O .c HH w Brought forward .. Stikine— 284 36 52 22 59 146 195 2 14 183 9 164 6 171 2 6 127 44 Skeena— 14 1 4 10 ^ 1 7 1 1 2 1 Trail Creek- 1 2 3 1 5 1 10 177 4 1 9 "i" 2 5 37 3 4 6 4 1 6 163 5 1 5 1 4 3 4 54 6 1 9 6 5 1 1 1 1 1 19 25 2 64 810 28 8 50 2 17 20 17 279 27 18 8 23 4 15 2514 1 Trail Trout Lake— 2 1 2 Vernon— 12 273 13 2 27 1 8 3 3 89 3 1 3 9 3 24 1 5 3 28 1 2 3 28 4 4 6 49 5 1 5 8 100 3 2 2 1 10 157 9 3 3 1 7 2 3 61 4 11 160 6 jo 8 103 6 1 12 3 49 1 1 4 2 5 1 Vancouver- North Vancouver North Vancouver Dist.. South Vancouver 84 7 i2 1 4 5 3 1 2 1 1 1 1 8 1 4 12 1 1 12 4 2 11 2 4 3 3 40 i 1 Victoria- 56 5 3 8 1 461 56 5 5 2 9 35 3 2 2 3 4 "i 1 1 20 1 Windermere— 1 1 1 2 1 2 329 1 1 473 3 2 451 3 8 456 Yale- Yale 2 762 1 341 1 158 18 2 28 Totals 82 107 76 154 175 8 Geo. 5 Provincial Board of Health. G 43 MARRIAGES, 1917. Groom and Bride same Denomination. Denomination. Adventist Agnostic Anglo-Catholic Atheist Baptist Brethern Buddhist Calvinist Cambellite Christian Christian Brethern Christian Baptist Christian Science Christadelphian Church of God Church of England Confucian Congregational International Bible Student. Jewish Carried forward... Number of Marriages. 4 1 2 1 45 9 2 1 1 7 6 1 4 1 1 1 11 Denomination. Brought forward Latter Day Saints Lutheran Mennonite Methodist None Not given Non-Sectarian Orthodox Orthodox (Greek) Penticostal tt... . Presbyterian Protestant Reformed Episcopal Roman Catholic Salvation Army Theist Universalist.. Total Number of Marriages. 1 89 ] 209 3 6 1 1 8 1 366 28 2 368 8 1 1 1,591 Groom and Bride of different Denominations. Groom. Bride. Number of Marriages. Groom. Bride. Number of Marriages. Church of England... Baptist Bible Student 30 1 2 1 8 1 2 11 68 1 1 2 1 112 5 45 293 2 1 8 3 6 4 24 3 2 4 1 10 1 1 2 2 3 2 1 8 1 34 4 2 4 6 163 1 12 227 337 Brought forward Presbyterian—Con. .. 227 49 1 1 3 33 1 1 7 1 5 1 5 1 4 6 2 1 1 1 1 1 2 22 1 1 1 12 19 3 13 2 38 7 2 61 2 1 1 2 7 123 337 Methodist None Not given M Greek Orthodox .. Roman Catholic Theosophist Baptist ii Methodist Prote 316 Not given I. Church of England , Methodist Not given Church of England Methodist Church of England Roman Catholic ii Church of England Methodist Roman Catholic Church of England.... Presbyterian Roman Catholic : Refoi Spirit Lutb med Episcopal.. 30 3 3 . ,, Church of England ... Disciples of Christ Dutch Reformed Latter Day Saints .... Methodist ,, Roman Catholic Church of England Anglo-Catholic Baptist t| ii Meth ii c xlist 75 Baptist Church of England.... Evangelican ,, ,, Christian Science Church of England „ Latter Day Saints ,, Carried forward. arried forward. 764 G 44 British Columbia 1918 Groom and Bride of different Denominations—Concluded. Brought forward Methodist—Con Baptist. Buddhist. Christian. Christian Science . Carried forward. Bride. Jew Not given Presbyterian Protestant Quaker Roman Catholic Church of England. Methodist Presbyterian Quaker Roman Catholic Adventist Brethern Christian Christian Science Church of England. Congregational Lutheran Methodist , Presbyterian Protestant Roman Catholic Salvation Army... . Christian Methodist Adventist Baptist Church of England. Lutheran Methodist Presbyterian Reformed Episcopal Roman Catholic Spiritualist Universalist Baptist Church of England. Congregational Methodist Number of Marriages. 1 1 79 2 1 23 1 1 1 1 16 3 2 24 15 2 13 1 1 1 1,111 Groom. Brought forward Theosophist Unitarian. Adventist American Epis. Ch... Anglo-Catholic Brahmin Brethern.. Catholic Apostolic... Church of Ireland Confucian Dunker Epis. Ch. of Scotland. Freethinker Liberal Materialist Mennonite Moriron Nondescript Orthodox Quaker Salvation Army Socialist Undenominational.., Universalist Roman Catholic . Bride. Christian Spiritualist., Methodist Church of England Lutheran , Methodist Presbyterian Methodist Church of England.. Presbyterian Congregational Church of England.. Church of England.. Christadelphian Methodist Lutheran Presbyterian Christian Friends.. . Presbyterian None Lutheran Presbyterian Presbyterian Christian Methodist Church of England.. Methodist Church of England., Methodist Adventist Baptist Christian Church of England... Congregational German Evangelical.. Greek Catholic Inter. Bible Student. Lutheran. Methodist None Presbyterian Protestant Quaker Number of Marriages. 2 1 1 1 1 1 1 1 1 J 1 1 1 1 1 1 1 1 1 1 1 1 1 10 1 1 1 1 9 23 2 35 4 1 Total 1,270 Bridegroom and Bride same denomination 1,591 Grand total 2,861 8 Geo. 5 Provincial Board of Health. G 45 PRELIMINARY TABLES SHOWING BIRTHS FOR DIVISIONS. Ashcroft Group. Ashcroft Barkerville Fort George Tete Jaune Cache Clinton Lillooet. Quesnel 150-Mile House Yale Totals Faii-view Group. Fairview Greenwood Grand Forks Kamloops Nicola Princeton Vernon Totals Beaton Group. Beaton Cranbrook Fernie Golden , Kaslo Nakusp Nelson New Denver Revelstoke Rossland Slocan Trail Trout Lake Wilmer Totals Victoria Division. Victoria City Cowichan Esquimalt Oak Bay Saanich Totals Nanaimo Division. Nanaimo City Alert Bay Comox Ladysmith Totals New Westminster Division. New Westminster City Burnaby Chilliwack Outside Totals Vancouver Division. Vancouver City South Vancouver Point Grey North Vancouver City North Vancouver District West Vancouver Richmond Unorganized Totals Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 1 1 1 2 4 1 1 1 1 2 2 i 6 3 4 4 4 5 4 5 4 6 1 i 2 i 1 2 5 2 4 1 2 1 3 4 1 3 1 3 1 2 3 1 3 2 2 12 14 7 1 1 2 1 1 4 1 5 5 12 13 11 8 10 16 10 13 14 14 2 5 10 2 6 4 5 7 4 3 4 5 6 7 14 4 5 5 3 1 2 7 3 6 5 14 7 1 5 6 4 1 14 15 24 11 16 23 20 12 28 21 19 1 2 5 6 4 2 3 7 6 7 6 1 4 1 3 4 3 1 2 2 20 25 24 25 15 16 36 85 28 29 41 32 2 43 67 69 54 57 76 59 79 85 73 1 1 1 2 8 10 8 5 7 20 14 10 8 11 7 14 13 14 13 16 14 16 21 16 9 6 1 4 5 2 1 1 2 4 6 1 3 3 4 4 1 1 3 3 1 1 1 1 1 3 2 4 8 21 9 15 2*2 15 9 29 11 17 1 2 1 1 1 3 1 2 3 5 1 11 7 9 13 13 11 12 4 6 4 9 1 3 3 2 4 3 4 4 6 7 2 1 4 1 1 5 9 15 18 4 6 7 12 11 19 14 14 1 20 1 2 2 3 5 2 2 i 48 70 87 58 65 69 88 73 99 58 68 16 45 58 62 59 63 102 86 65 59 88 51 6 4 8 8 7 5 5 8 12 6 3 2 8 1 7 3 7 6 9 7 9 2 2 3 5 1 5 4 3 1 2 4 3 3 4 3 10 8 6 12 16 11 17 19 21 2 57 76 86 16 83 84 130 116 84 20 87 124 78 11 26 20 18 17 23 27 21 19 2 2 1 1 2 1 6 9 18 17 11 11 9 5 11 13 15 1 7 5 7 D 5 4 4 3 28 6 4 5 40 3 24 40 43 44 34 33 37 46 38 6 11 23 28 38 32 24 20 40 43 26 31 5 11 9 7 12 13 12 8 15 13 12 8 9 3 10 5 8 5 7 8 6 16 19 3 18 18 24 22 32 22 ■ 24 20 83 20 29 22 14 49 53 69 77 85 63 59 82 83 80 44 92 148 146 178 200 185 164 149 294 205 203 8 26 36 29 42 38 43 30 30 45 38 25 1 9 5 9 9 9 10 6 8 8 10 1 3 13 10 6 12 11 12 5 14 7 12 5 2 2 1 4 2 3 1 1 2 4 2 2 2 11 8 11 19 10 9 9 11 9 14 13 1 3 9 8 2 8 7 5 3 5 252 65 133 231 219 250 282 268 233 204 381 278 Totals. 50 15. 8 3 18 4 22 61 204 49 21 291 749 2 104 159 30 20 7 162 20 100 39 7 134 744 72 61 220 9 125 322 125 96 254 797 2,003 390 84 106 27 6 124 51 2,796 G 46 British Columbia 1918 Preliminary Tables showing Births for Divisions—Concluded. Alberni Group. Alberni Anyox *AtIin Bella Coola Clayoquot Fort Fraser Hazelton *Fort St. John.... *Hudson Hope , .. Pouce Coupe ^Porter's Landing. Prince Rupert .. Quatsino Queen Charlotte.. Stewart *Telegraph Creek. Totals. Grand totals. Jan. Feb. Mar. April. May June. July. Aug. Sept. Oct. Nov. Dee. 2 3 2 'l 4 4 1 1 2 i 3 2 2 1 5 2 4 2 '2 1 1 3 2 '2 3 4 1 2 2 2 u 4 3 2 i 3 3 2 5 1 4 4 1 2 2 2 2 6 15 1 1 14 9 14 i 7 3 2 27 i 36 11 14 io '5 15 6 9 24 26 23 28 19 22 25 36 24 136 368 673 611 602 646 668 670 563 812 716 629 27 7 9 32 1 2 16 1 144 4 13 1 278 6,994 * No returns received for December. 8 Geo. 5 Provincial Board of Health. G 47 PRELIMINARY TABLES SHOWING DEATHS FOR DIVISIONS. Jan. Feb. 41 5 4 4 Mar. April. May. June. July. Aug. Sept. Oct. 27 3 2 1 3 Nov. Dec. Totals. Victoria Division. 44 1 3 3 2 53 2 2 1 61 31 4 1 1 2 40 3 3 5 37 3 2 3 28 2 4 6 41 5 2 3 45 1 'i 2 87 2 1 1 6 52 0 4 3 2 476 33 Oak Bay 26 15 89 53 54 39 15 's 51 45 40 51 49 36 5 3 7 3 47 63 589 Nanaimo Division. 9 5 2 10 2 9 3 10 4 3 9 1 7 2 6 ii 2 9 4 7 2 9 7 2 6 4 2 4 9 1 1 5 3 99 11 83 25 16 24 17 23 19 19 22 18 12 18 14 16 111 11 1 6 1 5 4 139 ' 218 Vancouver Division. 132 16 2 8 2 2 1 89 9 5 5 2 2 140 6 2 5 2 1 4 3 163 19 1 3 19 42 128 6 4 2 2 1 111 3 1 7 5 2 116 11 2 2 1 1 3 136 85 7 6 2 4 104 65 5 5 6 i 6 1 95 6 2 1 2 128 4 6 6 i 107 5 5 1 '2 1 1,307 88 29 58 12 4 30 21 Totals 162 112 143 31 6 3 19 129 89 106 145 121 17 2 5 13 1,549 New Westminster Division. 25 5 3 18 16 2 4 8 15 4 5 11 20 4 2i 15 1 5 13 19 4 2 11 15 1 1 15 22 3 1 17 29 2 5 15 243 85 37 New Westminster (outside) 180 Totals 51 30 2 2 1 59 35 45 1 2 34 36 32 43 i 2 2 5 5 3 4 17 2 2 11 37 51 495 Ashcroft Group. 1 i i '2 1 9 i 1 2 i 2 i i i 2 3 2 'i i 2 3 i 2 i '2 4 i 2 1 i 1 1 4 i 11 2 16 10 3 5 4 150-Mile House 5 Yale 18 3 5 12 3 3 6 12 3 8 35 5 5 3 8 7 3 4 3 3 '4 5 1 3 io 2 1 5 22 9 7 74 Fairview Group. 2 1 2 29 1 7 42 5 3 6 14 6 1' 8 6 8 1 14 1 8 1 2 1 16 3 9 3 2 3 13 2 1 4 1 9 11 i 2 13 's 1 2 2 5 '2 4 32 32 155 17 85 43 3 2 i4 9 4 i 38 32 23 28 17 44 24 16 Beaton Group. ii 2 7 1 10 3 3 3 1 5 i ii 1 3 6 '5 3 '2 7 10 1 3 i3 3 4 3 '2 3 28 1 1 2 9 2 1 4 5 6 4 3 1 12 1 3 3 i i '2 6 1 5 2 i 3 2 1 23 3 11 'i 8 2 2 3 2 32 9 12 i 1 '4 6 11 i io 1 4 3 6 6 10 2 8 7 1 1 4 15 j 2 6 1 3 5 1 10 106 31 Trail 33 Totals 60 33 34 46 61 40 32 42 39 41 G 48 British Columbia 1918 Preliminary Tables showing Deaths for Divisions—Concluded. Alberni Group. Alberni *Atlin Bella Coola Clayoquot Fort Fraser Hazelton *Fort St. John *Hudson Hope Pouce Coupe * Porter's Landing Prince Rupert Anyox Quatsino Queen Charlotte Stewart. .... ^Telegraph Creek . Totals Grand totals Jan. Feb. Mar. April. May. June. July. Aug. Sept. Oct. Nov. Dec. 3 2 i 2 3 1 1 1 2 1 1 1 i 4 1 2 1 1 1 1 1 2 1 1 2 4 2 2 2 1 i 2 i 3 2 3 1 4 '5 '7 i 5 2 1 "i 7 '6 i 6 2 3 8 2 5 i 2 16 2 1 5 '2 13 14 12 8 12 11 16 9 16 4 13 390 315 376 361 334 322 275 259 274 349 295 346 Totals. 16 1 11 1 9 25 63 1 2 5 3 4 * No returns received for December. 8 Geo. 5 Provincial Board of Health. G 49 MARRIAGES, 1917. Number of Marriages. Victoria Division— 382 16 19 14 449 112 1,394 279 44 2,278 Fairview Group— Cone hided. 41 2,278 16 Alberni Group— Atlin 66 IS 15 Nanaimo Division— 63 6 74 218 28 15 1,191 8 5 3 Vancouver Division— Fort St. John 7 97 12 58 38 3 4 3 4 61 1 164 4 Beaton Group— 34 20 1 107 Ashcroft Group— 61 8 2 16 1 2 3 6 3 32 40 10 6 5 83 7 150-Mile House Trail ... 30 17 Yale Fairview Group— 3 26 15 41 , 3 23 Total 2 2,861 Bridegroom and Bride born in same Country. Austria 9 Canada 562 China .* 4 Denmark 1 England 238 Finland 12 France 2 Galicia 3 Germany 5 Greece 2 Holland 1 Hungary 1 Ireland 15 Italy 24 Japan : 11 Carried forward 890 Brought forward 890 Newfoundland I New Zealand 2 Norway 8 Poland 2 Roumania l Russia 6 Scotland 891 Servia l Sweden 25- United States of America 296 Wales l Not given 2. Total - 1,32* G 50 British Columbia 1918 MARRIAGES, 1917—Continued. Bridegroom and Bride born in different Countries. Place of Birth. England. Total Australia British West Indies. Barbadoes Ceylon Channel Islands . East Indies Total. Scotland. Argentina Australia Bohemia Canada Channel Islands China Denmark Egypt France Germany ., Ireland Mexico Newfoundland Norway , Poland Portugal Russia Scotland South Africa Sweden , Switzerland Tasmania United States of America Wales Not given Number of Marriages. Canada England United States of America Canada England Scotland Canada United States of America Alaska Australia Canada Channel Islands England Ireland New Zealand South Africa Switzerland United States of America Wales 1 173 1 1 2 1 1 3 22 1 3 1 1 1 3 66 1 4 1 1 52 7 2 I 1 65 1 53 8 2 1 1 16 2 29 18 (t 1 6 1 .. United States of America 6 Total 61 Place of Birth. Gibraltar... Isle of Man. India Total. England . Canada . United States of America Number of Marriages. Canada. Australia Austria Belgium Channel Islands China Denmark England Finland France Germany Iceland Ireland Italy Newfoundland New Zealand Norway Russia Scotland South Africa Sweden Syria , United States of America Wales Not given Total. Austria Canada Denmark United States of America Wales United States of America 9 6 1 1 2 United States of America 3 Total 22 Total Australia Canada England Finland France Germany Iceland Ireland Italy Japan Norway Poland Russia Scotland Servia South Africa . Sweden Sweden.. Total. Canada Denmark England Finland Holland Iceland Ireland Norway Russian Poland. Scotland United States of America 2 1 1 1 2 126 1 2 16 1 2 1 1 2 76 1 5 1 152 8 1 3 198 68 1 4 2 6 3 1 1 3 1 3 19 1 1 11 1 4 1 1 1 1 1 1 8 Geo. 5 Provincial Board of Health. G 51 MARRIAGES, 1917—Concluded. Bridegroom and Bride born in different Countries—Concluded. Place of Birth. Number of Marriages. Place of Birth. Groom. Bride. Groom. Bride. Marriages. Canada United States of America Wales 3 2 1 France 5 2 .. . 1 United States of America Total 6 . 2 Total England United States of America 4 2 2 Total 8 Switzerland United States of America 1 ,, 2 2 I 1 1 1 Total New Zealand United States of America 7 5 1 England 1 Straits Settlements Italy 1 Canada England France Hungary United States of America 2 1 1 1 3 1 Austria Canada England 14 5 1 Scotland ■. United States of America 8 Total 29 6 1 7 United States of America 14 Total 9 1 4 1 1 1 1 England 5 United States of America 8 Total 7 40 Note.—Grand total, 2,861. G 52 British Columbia 1918 CAUSES OF 6 S3 S ca CJ 6 CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) S it ■e B 5 9 N O ea m o HH 5 to 10 years. l VICTORIA DIVISION—VICTORIA CITY. I.—General Diseases. M. ft M. F. M. F. M. F. 8 1 1 "% 9 1 10 14 2 1 18 20 28 1 1 1 28a 29 30 1 1 30A 34 34A 37 39a 39b 390 39d 40 41 42 43 44a 44b 45 45a 45b 46 1 47 48 60 1 50A 51 52 54a 1 56 61 II.—Diseases of the Nervous System. 1 1 6lA 1 61b 1 63 64 1 1 68 69 71 3 1 1 77 III.—Diseases op the Circulatory System. 77a 78 78a 1 79 1 79a 79b .... 79c 79d 80 81 82 8 Geo. 5 Provincial Board of Health. G 53 DEATH, 1917. dt OJ © CM o o I-H CJ >, © CO O © CM ci 3 o -Hi O © CO oj ea *H% o io o HH o H* S 0 CO O O iO CO ca CJ 0 0 0 co E ci CJ >. s 0 HH O CO B ci CJ O CJ O O CO t3 E fin 3 a c3 O a' 9 ■a M O c CJ bo -*** CJ 0) r-G .£* 0 H g "be HH O B y, CJ 02 cc a *ci OJ 1 0 H M. F. M. F. M. 1 F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. 1 1 3 1 1 1 1 30 F. 1 1 1 1 1 5 2 4 1 1 2 6 3 1 1 1 6 ...... H 1 1 2 2 1 3 8 3 1 1 1 4 3 5 2 2 39 1 1 1 1 3 5 2 2 1 1 2 2 1 1 1 1 1 1 1 1 ..... 1 1 1 1 1 1 1 1 7 4 1 1 "2 1 3 1 2 3 1 3 1 2 2 1 1 1 2 1 1 1 8 4 6 4 15 1 8 1 6 1 4 1 1 2 1 1 1 2 2 1 1 1 1 1 9 1 1 1 1 2 1 3 1 1 3 4 1 1 1 1 1 1 2 2 1 1 5 1 1 1 1 1 1 3 1 1 2 3 1 1 2 1 1 1 1 1 • 1 1 3 1 1 2 1 9 5 1 1 1 1 1 1 3 1 1 1 4 4 1 4 1 "i 1 14 2 23 7 1 1 1 1 4 1 3 3 1 11 6 1 1 1 1 3 6 1 2 2 1 3 1 1 1 2 2 1 1 1 1 3 1 1 1 1 1 6 2 1 1 1 1 1 "i" 3 i 3 3 "i' 2 2 13 1 8 1 1 1 1 1 3 2 4 2 1 6 1 1 4 5 2 1 1 1 1 3 G 54 British Columbia 1918 CAUSES OF d .2 1 55 ca D CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) ea 9 CJ "0 B P I CM O tH ca 9 10 O ea 5 to 10 years. 89 VICTORIA DIVISION—VICTORIA CITY.—Continued. IV.—Diseases of the Respiratory System. M. F. 2 M. F. M. F. M. F. 90 91 5 2 "2' 1 1 92 92a 92b 920 2 1 1 92d 1 92e 92p 92o 1 93 94 96 98A 102 V.—Diseases of the Digestive System. 103 103a 104 i 2 1 105 2 1 i 108 109 109a 1 111 116 117 117a 118 118a 118b 118c 1 1 1 1 119 VI.—Non-venereal Diseases of Gexito-urinary System and Annexa. 120 122 126 129 130 135 VII.—The Puerperal State. 137a 138 141A 141b 142 VIII.—Diseases of the Skin and of the Cellular Tissue. 146 IX.—Diseases of the Bones and Oroans of Locomotion. X.—Malformations. XI.—Diseases of Early Infancy. 8 5 1 1 12 7 1 4 4 1 151 1 8 4 163C 8 Geo. 5 Provincial Board of Health. G 55 DEATH, 1917'—Continued. oo E ei CJ >t O . © O © 90 and upwards. B CJ > "Si O B CJ CJJ CJ V, CJ CO ti HO ■ea o B CJ t*. "be o B X CO CO B ci OJ o "ea o M. F. M. F. M. F. M. ft M. ft 1 M. ft M. F. M. F. 2 M. ft M. ft M. F. 5 2 6 2 1 1 6 14 3 6 1 1 3 1 3 1 2 2 2 16 1 2 1 1 1 4 1 1 1 1 1 1 1 5 2' 1 1 1 "i" l "i" 1 1 1 1 1 1 1 2 1 1 2 1 1 1 1 3 1 1 1 1 1 1 2 1 1 3 1 1 3 1 3 1 1 1 3 2 6 1 1 4 3 1 1 1 4 1 1 .„. 1 1 2 1 1 2 1 1 1 1 3 1 9 2 1 1 1 2 1 1 1 1 2 2 1 4 1 2 1 1 1 1 1 1 1 1 1 2 2 16 1 1 1 3 1 2 1 4 1 4 2 1 3 1 i 1 1 1 5 3 1 1 20 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 5 1 9 5 1 1 12 7 1 i 1 4 4 13 1 1 8 4 2 20 11 1 G 56 British Columbia 1918 CAUSES OF o to a .2 1 5 "ffi B O CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) s 3 s rt cu CM O oj ca 9 io O HH ©a 5 to 10 years. 154 VICTORIA DIVISION—VICTORIA CITY.—Concluded. XII.—Old Age. M. F. M. F. M. F. M. F. 155 XIII.—-Affections produced by External Causes. 157 167 1 169 172 173 174 1 175 1 187 XIV.—Ill-defined Diseases. 187a 53 36 6 2 7 5 6 6 32a 40 41 42 45a 45 b 51 77a 79a 79b 81a Purulent infection and septicaemia Tuberculosis of the lungs Tuberculosis of spine Cancer and other malignant tumours of the stomach, liver Cancer and other malignant tumours of the peritoneum, intestines, rectum . Cancer and other malignant tumours of the female genital organs Cancer of prostate Cancer of bronchial glands Exophthalmic goitre 113 151 152a 153a VICTORIA DIVISION—COWICHAN. I.—General Diseases. II.—Diseases of Nervous System and Organs of Special Sense. Cerebral hsem.orrh.age, apoplexy III.—Diseases of the Circulatory System. Myocarditis Mitral regurgitation Mitral regurgitation complicated hy nephritis. Aneurism . IV.—Diseases of the Respiratory System. Pneumonia. Pleurisy V.—Diseases of the Digestive System. Cirrhosis of the liver VI.—NON-VENEREAL DISEASES OF GeNITO-URINARY SYSTEM AND ANNEXA. Uremia. XI.—Diseases of Early Infancy. Congenital debility, icterus, and sclerema. Atelectasis Premature XII.—Old Age. Senility . 8 Geo. 5 Provincial Board of Health. G 57 DEATH, 1917— Continued. t cS « >» o CJ o e rt V t*l o CO o o u rt SI o ^*J" o o eo CJ o IQ o o ca 9 © © o © io ca © o © © ci 9 © CO O o CO t. ea CJ © © -S s *g Ci E Ph ■8 C ei © © a* 3 *5JD o c to <5 Total by Sexes. e CJ > o a CJ CO Co Q *ei HH o H M. F. M. F. M. F. M. F. M. F. M. F. M. 2 F. 2 M. 6 F. 1 M. F. 2 M. F. M. 8 1 1 1 2 3 1 2 2 1 1 1 1 F. 5 1 13 1 1 1 2 1 1 1 1 1 9 1 1 3 1 1 1 1 2 1 1 2 1 1 1 1 1 2 1 1 1 1 2 i i 6 3 3 1 1 1 1 1 2 29 1 1 38 18 33 3 1 23 1 1 2 1 8 6 25 15 21 16 34 20 32 18 17 1 3 1 5 279 197 476 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 2 2 1 1 1 2 3 2 1 1 1 1 2 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 i 1 1 2 1 2 1 1 1 1 1 1 1 l 2 % 1 1 1 1 1 1 G 58 British Columbia 1918 CAUSES OF d to c .2 It a <5 rt O CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) h rt Oj u OJ 0 CM O o5 rt OJ Si HO c CM o o 169 VICTORIA DIVISION—COWICHAN.—Concluded. XIII.—Affections Produced by External Causes. M. F. M. F. M. F. M. F. 172 3 1 14 28 34 40 77a 78a 79 80 81a 105 113 169 169 170 VICTORIA DIVISION—ESQUIMALT. L—General Diseases. II.—Diseases of Nervous System and Organs of Special Sense. III.—Diseases of the Circulatory System. IV.—Diseases of the Respiratory System. V.—Diseases of the Digestive System. 1 VI.—Non-venereal Diseases of Genito-urinary System and Annexa. VIII.—Diseases of the Skin and of the Cellular Tissue. 1 XII.—Old Age. XIII.—Affections produced by External Causes. 1 1 28 victoria division—oak bay. I.—General Diseases. » 42 44a 64 II.—Diseases of Nervous System and Organs of Special Sense. 78 III.—Diseases of the Circulatory System. 81A 8 Geo. 5 Provincial Board of Health. G 59 DEATH, 1917—Continued. rt OJ 8 O o o CO o o 5 9 © O © CO ea © o © OJ o ■to o o •o o5 E rt O o o CO rt v £ © ei 9 © © o © 00 ■a ci c ci § Age not given. CJ X CJ CO >, *3 o H B 9 > •5 o X CO oj X HH ca CJ a la o H M. F. 1 M. F. M. 1 F. M. 1 F. M. F. M. F. M. F. M. F. M. F. M. F. M. 2 1 F. 1 3 1 1 -IL 1 1 ~ -777. 2 1 6 777. 2 2 4 1 4 1 3 27 6 33 1 i_ i 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 1 1 2 4 i 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 i 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 i 1 2 1 18 1 1 1 2 1 2 4 4. 1 2 1 4 1 2 1 2 8 26 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 G 60 British Columbia 1918 CAUSES OF d to © 1 s "So a 3 CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909. a V 9 a rt CM o ei •u >> in o CM a c o 96 VICTORIA DIVISION—OAK BAY.— Concluded. IV.—Diseases of the Respiratory System. M. F. M. F. M. F. M. F. 102 V.—Diseases of the Digestive System. 119 VI.—Non-venereal Diseases of Genito-urinary System and Annexa. 126 150 X. —Malformations. 1 1 1 153A XL—Diseases of Early Infancy. Still-born 154 XII.—Old Age. 2 1 24 39a 40 41 42 45 77A 79a 79b 80 84A 85 90 92 92a 104 113 115 120a 151 151b 153a VICTORIA DIVISION—SAANICH. I.—General Diseases. Whooping-cough Tetanus, neonatorum Cancer of neck Cancer and other malignant tumours of the stomach, liver Cancer and other malignant tumours of the peritoneum, intestines, rectum Cancer and other malignant tumours of the female genital organs Cancer and other malignant tumours of other organs, and of organs not specified. IL—Diseases of Nervous System and Organs of Special Sense. Cerebral haemorrhage, apoplexy Ill,—Diseases of the Circulatory System. Myocarditis , Chronic valvular disease Mitral regurgitation Angina pectoris Hodgkin's disease Haemorrhage IV.—Diseases of the Respiratory System. Chronic bronchitis. Pneumonia Lobar pneumonia.. V.—Diseases of the Digestive System. Diarrhoea and enteritis (under 2 years).. Cirrhosis of the liver Other diseases of the liver VI.—Non-venereal Diseases of Genito-urinary System and Annexa. Uremia. XL—Diseases of Early Infancy. Congenital debility, icterus, and sclerema.. Non-assimilation of food Premature 8 Geo. 5 Provincial Board of Health. G 61 DEATH, 1917—Continued. ei a o CM © O c4 B © eo o o CM rt V o o o CO ei cu o O © ei © CD O O ea © o © © *- ei 9 £ o © ea CJ © © o o 00 ci lie &. 9 1 rt o a s •& o c fcD «*i OJ X CO >> *""*! O H B HH O B X CJ CO CO .g a la o M. F. M. F. M. F. M. F. M. F. M. F. M. 1 F. M. F. M. F. M. F. M. 1 F. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 2 3 6 2 8 7 15 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 3 1 1 1 1 1 1 1 1 1 1 1 3 1 1 1 2 1 1 1 1 1 1 i 1 1 1 1 1 l 1 1 1 l 1 1 1 1 1 1 1 l l i l 1 1 1 1 2 2 2 G 62 British Columbia 1918 CAUSES OF 6 & © ei o ea "S % o CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) Under 1 year. rt £ CM O TO ei o> © CM © o 154 VICTORIA DIVISION—SAANICH- Concluded. XII.—Old Age. M. F. M. F. M. F. M. F. 169 XIII.—Affections produced by External Causes. 189 XIV.—Ill-defined Diseases. 4 5 1 1 .... 1 NEW WESTMINSTER DIVISION—NEW WESTMINSTER CITY. L—General Diseases. 9 1 20 2 20A 28 1 1 30 1 30a 34a 37 39a 40 41 Cancer and other malignant tumours of the peritoneum, intestines, rectum 44 50A 63A IL—Diseases of Nervous System and Organs of Special Sense. 1 1 1 67 68A 1 1 71 1 77a III.—Diseases of the Circulatory System. 78 79 IV.—Diseases of the Respiratory System. 1 1 1 98a 8 Geo. 5 Provincial Board of Health. G 63 DEATH, 1917—Continued. i © CM p © oj CJ © CO O © CM 5 CJ *>) © o © CJ © io O © OJ iC ei CJ © © O HH © io ca © o o © 70 to 80 years. oj © © o I -o t- s Ph Ti B ea © © d CJ '&£ HH o Q bo ■3 Total by Sexes. B 'Si O a cj CO £ ca Cy « 1 O H M. F. M. F. M. F. M. F. M. F. M. F. M. F. 2 M. 1 F. M. F. M. F. M. 1 3 1 F. 2 3 1 1 1 1 1 1 1 3 1 2 1 2 1 2 1 4 3 5 4 23 16 39 1 1 1 1 4 1 10 1 1 1 3 1 1 4 1 1 2 1 1 1 4 1 17 1 4 1 1 2 2 2 2 1 1 1 7 2 3 1 1 1 1 1 1 1 1 I 1 1 2 1 '"i" 1 1 1 i' 2 1 2 1 1 1 2 1 2 2 1 1 1 1 2 1 1 1 1 1 1 1 1 1 2 1 '"e" 9 8 2 2 4 3 l 1 1 2 6 7 8 1 1 1 6 1 3 2 1 1 3 "b 3 1 1 1 1 *k 2 12 16 1 3 1 2 2 3 1 1 1 1 "i 1 3 1 2 3 1 3 3 1 10 4 3 1 i 2 1 1 1 l 3 2 1 1 1 1 2 1 1 1 1 1 1 2 1 2 1 4 5 1 2 1 1 1 0 1 1 1 2 1 2 1 4 4 1 1 1 1 1 1 l 1 2 1 1 1 1 l 1 '"i" 1 1 1 1 1 " i' l 1 l 1 i G 64 British Columbia 1918 CAUSES OF 102 103 103a 105 108 108a 109 110a 110b 110c 113 117 118 119 120 120a 122 126 131a 132 137 137a 140 142 145 160 151 151B 153a 153b 153c 154 157 159 165 169 169a 170 174 185 CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) NEW WESTMINSTER DIVISION—NEW WESTMINSTER CITY.—Concluded. V.—Diseases of the Dioestive System. Ulcer of the stomach Other diseases of the stomach (cancer excepted) Hemorrhage of bow-els ". Diarrhoea and enteritis (2 years and over) Appendicitis and typhlitis Appendicitis (gangrenous) Hernias, intestinal obsti uctions Ileocolitis Intussusception Abscess of the liver Cirrhosis of the liver Simple peritonitis (non-puerperal), Other diseases of the digestive system (cancer and tuberculosis excepted) . VI.—Non-venereal Diseases of Genito-urinary System and Annexa. Acute nephritis. Bright's disease. Uremia. Other diseases of the kidneys and annexa Diseases of the prostate Pyonephrosis Salpingitis and other diseases of the female genital organs. VII.—The Puerperal State. Puerperal septicaemia Induced abortion Following childbirth (not otherwise defined).. VIII.—Diseases of the Skin and of the Cellular Tissue. Gangrene Other diseases of the skin and annexa.. M. IX.—Diseases of the Bones and Organs of Locomotion. Toxic Absorption (osteomyelitis) X.—Malformations. Congenital malformation (still-births not included) XI.—Diseases of Early Infancy. Congenital debility, icterus, and sclerema.. Non-assimilation of food Still-born Premature Haemophilia neonatorum XII.—Old Age. Senility . XIII.—Affections produced by External Caus Suicide by hanging or strangulation Suicide by firearms Other acute poisonings Accidental drowning Traumatism in logging camp and sawmill. Traumatism by firearms Traumatism by machines Fractures (causes not specified). Other external violence F. 8 Geo. 5 Provincial Board of Health. G 65 - DEATH, 1917—Continued. | 5 3 5 B CJ > 'So p a X CO ei 9 © CM P © 20 to 30 years. u c3 CJ © o HH © CO Li ei CJ >> © iO p © ei 9 © p © © u a o CO o © ei £ o CO oj •e E ei a 1 rt s d 9 "£c o c OJ SB Total by Sexes. J ci CJ i P H M. F. M. F. M. F. M. F. M. F. 1 M. F. M. F. M. F. M. F. M. F. M. F. 1 1 1 1 1 2 2 1 1 3 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 »1 1 1 2 1 1 1 1 9, 1 1 5 1 1 7 1 1 1 1 1 2 1 2 1 1 1 2 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 7 4 1 1 2 11 3 6 18 7 1 1 1 2 2 1 1 1 1 1 1 4 4 1 1 2 1 1 1 1 1 3 1 1 1 1 5 1 1 1 1 1 2 1 22 8 10 5 16 14 21 17 15 5 12 13 8 8 3 2 - ~ 777. 4 146 97 243 G 66 British Columbia 1918 CAUSES OF d a S CAUSE OF DEATH. $ 3 QJ rt 9 ei 9 en ei (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) 9 T3 CM O © © O O D H CM m NEW WESTMINSTER DIVISION—BURNABY, M. F. M. F. M. F. M. F. I,—General Diseases. 5 27 32A 39a 42 IL—Diseases of Nervous System and Organs of Special Sense. 64 71 1 1 III.—Diseases of the Circulatory System. 77a 79a 79b 79c IV.—Diseases of the Respiratory System. 91 1 92a 1 V.—Diseases of the Digestive System. 104 1 VI.—Non-venereal Diseases of Genito-urinary System and Annexa. 119 1 X.—Malformations. 150 2 XI.—Diseases of Early Infancy. 15lB 1 1 2 153 a XIII.—Affections produced by External Causes. 157 169 1 175 9 1 2 1 40 51 64 68 71 77a 78 79 NEW WESTMINSTER DIVISION—CHILLIWACK. I.—General Diseases. Leprosy Tuberculosis of the lungs Cancer and other malignant tumours of the stomach, liver . Exophthalmic goitre IL—Diseases of Nervous System and Organs of Special Sense. Cerebral haemorrhage, apoplexy .. Other forms of mental alienation . Convulsions of infants III.—Diseases of the Circulatory System. Myocarditis Acute endocarditis Organic diseases of the heart. 8 Geo. 5 Provincial Board of Health. G 67 DEATH, 1917—Continued. 10 to 20 years. E ci CJ © CO p © ci 9 © h*i P © CO ea V © IO p © ea CJ s p © io c3 OJ © P © © CJ © 00 p © 80 to 90 years. 90 and upwards. B '& p B CJ be < * CJ CO *« "o H B '& P a X CJ CO HO HH ca CJ n .■« p H M. F. M. F. M. F. 1 M. 1 F. M. F. M. F. M. F. M. F. M. F. M. F. M. 1 1 F. 1 2 1 1 1 1 1 1 1 1 1 1 1 2 1 2 1 1 2 2 1 3 2 1 1 1 1 1 1 1 1 1 1 1 1 2 3 1 1 4 1 1 1 2 1 1 2 1 1 3 1 1 1 2 2 1 1 2 1 1 1 2 3 1 3 3 2 1 1 3 4 3 1 24 11 35 1 2 1 2 1 1 1 1 1 1 1 1 1 3 1 5 1 2 1 1 1 1 1 2 1 1 1 1 1 1 1 1 2 1 1 1 G 68 British Columbia 1918 CAUSES OF 6 fe d .2 n 5 * 1- O CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) u ei >* 0J a p u5 rt CM O rt 9 o (M 5 to 10 years. 91 NEW WESTMINSTER DIVISION—CHILLIWACK.—Concluded. IV.—Diseases of the Respiratory System. M. F. 1 M. F. M. F. M. F. 92 97a 103a V.—Diseases of the Digestive System. 1 105 1 120 VI.—Non-venereal Diseases of Genito-urinary System and Annexa. 150 X.—Malformations. 1 1 1 1 151 XL—Diseases of Early Infancy. 153a 1 154 XII.—Old Age. Senility '. 169 XI11.—Affections produced by External Causes. 170 175 175a 178a 5 5 1 NEW WESTMINSTER DIVISION—OUTSIDE. I.—General Diseases. 1 10 20 1 28 1 Cancer and other malignant tumours of the peritoneum, intestines, rectum 41 45A 46 61 II.—Diseases of Nervous System and Organs of Special Sense. 64 67 68 69 1 71 1 1 1 III.—Diseases of the Circulatory Syste.m. 77a 1 78 1 79b 79c 85a 8 Geo. 5 Provincial Board of Health. G 69 DEATH, 1917—Continued. t» % © CM O O DD ei 9 £ O HH © oj ei Cj © hh P © CO oj ca CJ © io p HH © oj ca © © p © IO oj ci CJ © p © © ci £ o £ cc CJ CJ © © o o 00 oj -p £, ca p, C ca s B CJ 'So ^> p CJ be < Total by Sexes. c CJ > HH P G X CJ CO oj J HH Ci CJ e "ci J-ff p H M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. 1 1 2 2 1 •9 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 2 1 2 1 1 1 1 1 1 1 1 1 1 1 5 1 1 3 5 2 2 3 1 1 3 25 12 37 1 2 1 3 10 2 1 2 1 1 1 2 2 1 1 2 1 1 3 2 2 1 1 2 1 4 14 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 6 1 3 4 3 1 1 1 4 1 3 2 1 15 3 4 2 1 1 4 5 2 4 1 2 1 1 1 1 3 3 1 4 1 2 1 9 1 1 1 1 1 I 1 1 2 1 1 1 5 9 1 1 2 1 1 5 2 1 4 1 1 1 1 1 3 1 1 1 1 1 2 1 1 i 1 G 70 British Columbia 1918 CAUSES OF 91 92 92a 92b 92c 94 97a 103 104 105 106 108 109 110a 113 118 119 120 120A 126 137 139 151 151a 152a 153a 153b 159 167 169 169a 170 171a 174 175 185 186 187a 189 CAUSE OF DEATH. {After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) NEW WESTMINSTER DIVISION—OUTSIDE. -Concluded. IV.—Diseases of the Respiratory System. Acute bronchitis.. Bronchopneumonia Pneumonia Lobar pneumonia Bronchopneumonia following whooping-cough . Hypostatic pneumonia Pulmonary congestion, pulmonary apoplexy... Pulmonary embolism OEdema of lungs Suppurative tonsilitis V.—Diseases of the Digestive System. Other diseases of the stomach (cancer excepted) Diarrhoea and enteritis (under 2 years) Diarrhcea and enteritis (2 years and over) Ankylostomiasis .... Appendicitis and typhlitis Hernias, intestinal obstructions Enterocolitis Cirrhosis of the liver Other diseases of the digestive system (cancer and tuberculosis excepted). VL—Non-venereal Diseases of Genito-Urinary Syste.m and Annexa. Acute nephritis.. Bright's disease . Uremia.. Diseases of the prostate. V1L—The Puerperal State. Puerperal septicaemia Puerperal phlegmasia alba dolens, embolus, sudden death... X.—Malformations. Congenital malformation (still-births not included) XL—Diseases of Early Infancy. Congenital debility, icterus,and sclerema. Accident of labour Atelectasis '. Still-born Premature XII.—Old Age. Senility. XIII.—Affections produced by External Causes. Suicide by firearms Burns (conflagration excepted) Accidental drowning Traumatism in logging camp and sawmill Traumatism by firearms Traumatism by falling tree Traumatism by machines Traumatism by other crushing (railroad, landslides, vehicles, etc.). Fractures (causes not specified) Other external violence XIV.—Ill-defined Diseases. Dropsy Cause of death not specified or ill-defined. 8 Geo. 5 Provincial Board of Health. G 71 DEATH, 1917—Continued. ei © CM O © c rt P £ © i rt © o © CO ci © io p © Htl ca © © © iO ca 9 © p © © oj cl .CJ © X P O I— ei CJ © © P © CO -p Ph ■a B o © d CJ > 'bo p < CJ CJ CO HP *ci P H B CJ "Si) HH P S X CJ CO 5 HH ei CJ 0 *3 0 H M. F. M. F.| M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. 1 6 3 1 F. "'5' 1 1 1 1 1 2 1 1 2 11 1 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 4 1 2 2 1 1 1 1 1 2 2 1 2 1 "i" 1 1 1 2 i 1 1 1 1 1 2 2 1 1 1 1 6 1 1 1 1 2 2 2 1 1 1 1 1 1 3 1 3 1 1 2 1 1 3 1 2 2 1 3 4 6 5 1 1 2 2 i 1 2 1 1 1 1 3 1 1 1 1 1 2 3 1 1 4 1. 1 1 1 1 1 1 1 1 1 1 2 1 2 3 1 1 1 20 1 2 6 2 18 6 15 3 16 3 20 5 5 6 5 3 130 50 ISO G 72 British Columbia 1918 CAUSES OF p is 1 a CJ 3 B rt O CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) m ei 9 9 a P ei 9 CM © 2 to 5 years. oj ei CJ © p io 1 NANAIMO DIVISION—NANAIMO CITY. I.—General Diseases. M. F. M. F. M. F. M. F. 8 1 1 1 1 9 28 39a 39b 40 42 47 1 50 50A 54a II.—Diseases of Nervous System and Organs of Special Sense. 61 1 61A 64 71 1 1 77a III.—Diseases of the Circulatory System. 78 79 79a 81a 81b 87 IV.—Diseases of the Respiratory System. 89 1 90 91 1 1 92 1 2 92A 98a 102 V.—Diseases of the Digestive System. 104 1 108 113 114 117 119 VI.—Non-venereal Diseases of Genito-urinary System and Annexa. 120A 137 VII.—The Puerperal State. 141A XL—Diseases of Early Infancy. 151 2 1 3 1 152a 153a 1 154 XII.—Old Age. 159 XIII.—Affections produced by External Causes. 169 175 182 a 186 1 8 Geo. 5 Provincial Board of Health. G Ti DEATH, 1917—Continued. d CJ © OJ p © 4 >> © CO p © OJ oj 1 © *** p © oj ei CJ © p © hH 2 o © © p S oj ei CJ © P © © oj i 9 © CO © © rt cu © © o 1 V 3 "s= p- B **C c ci 8 Q CJ '& p P CJ bo CJ X CJ CO ho1 P H c Ol '5 p a CO j ci CJ a *3 p H M. F. M. 1 F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. 1 F. 1 2 1 4 2 1 4 1 1 2 2 2 3 1 2 8 1 1 1 1 1 1 2 1 i 1 1 'i' l 1 1 1 1 1 1 1 1 1 1 1 1 3 1 2 1 1 1 2 l l l l 2 4 2 1 i l 1 1 3 1 1 1 1 4 1 6 1 1 1 1 8 1 1 1 1 1 1 1 1 1 4 1 1 1 1 1 1 1 2 2 2 2 1 1 6 1 1 1 1 1 1 1 2 1 1 1 1 l 1 1 1 1 1 1 1 5 1 1 1 1 1 4 1 1 1 2 3 1 1 1 1 2 1 9 1 2 1 3 1 1 5 1 1 1 3 1 1 1 1 1 SI 1 1 2 1 1 1 2 G 74 British Columbia 1918 CAUSES OF CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909. 1 1 "Eo I o rt 9 9 •6 3 CM © rt "be p a y. CO ei 9 © OJ p © oj C3 CJ © CO p © Ol E ei CJ © ■* .P © oj CJ © io p © s ci OJ >, 8 O © E ei © P O © E ci CJ © CO p © ei 9 © © p © CO ■p g P. P -P a ci © © ci "bB P bo < Total by Sexes. HP ca CJ a *« p M. F. M. F. M. F. M. F. M. F. M. F. M. F. 1 3 M. F. M. F. M. F. M. F. 1 1 6 6 7 4 8 7 7 4 10 6 = 2 2 60 39 99 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 2 1 1 1 3 1 1 1 8 3 11 1 2 2 1 1 1 2 1 1 T 1 1 2 2 4 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 1 1 3 3 3 1 1 1 2 1 1 3 1 1 1 1 2 1 2 1 3 1 1 1 3 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 1 1 G 76 British Columbia 1918 CAUSES OF 6 X % 1 CJ % i 6 CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) ei 9 >> ta © a ei 9 (M O 1 s lO © CM E ei 9 © O lO 117 NANAIMO DIVISION—COMOX.— Concluded. V.—Diseases of the Digestive System. M. F. M. F. M. F. M. F. 119 VI.—Non-venereal Diseases of Genito-urinary System and Annexa. 120 a 137a VII.—The Puerperal State. 142 VIII.—Diseases of the Skin and of the Cellular Tissue. 153A XI,—Diseases of Early Infancy. 1 154 XIL—Old Age. 160 XIII.—Affections produced by External Causes. 165 168 169 169a 171a 173 175 181 182 185 189 XIV.—Ill-defined Diseases. 2 2 1 2 1 9 NANAIMO DIVISION—LADYSMITH. I.—General Diseases. 1 28 1 64 II.—Diseases of Nervous System and Organs of Special Sense. 70 1 77a III.—Diseases of the Circulatory System. 89 IV.—Diseases of the Respiratory System. 91 1 2 2 1 92 93 108 V.—Diseases of the Digestive System. 1 119 VI.—Non-venereal Diseases of Genito-urinary System and Annexa. 8 Geo. 5 Provincial Board of Health. G 77 DEATH, 1917—Continued. oj 5 s © OJ. © © oj ca CJ © CO p © Ol oi ci CJ © -ci o © CO oj ca 3 © p © H*l oj el 9 © © P © io >> g p © © oj ca 9 | o 8 ca 9 8 O © CO **o £ ei is Ph B ■a B ca © © 'Sb p CJ bo < Total by Sexes. Sex not given. Total Deaths. M. F. M. F. M. F. M. F. 1 M. F. M. F. M. F. :m. F. M. F. M. F' M. F. 1 1 1 1 1 1 ...... .. 1 1 1 1 1 2 1 1 i' 1 i i 1 1 2 1 1 1 3 10 1 7 1 1 1 1 4 1 2 1 1 1 1 1 2 5 2 1 1 1 1 2 10 1 1 4 1 1 1 1 7 i 1 2 1 4 1 1 1 10 1 2 11 1 16 4 4 4 6 3 5 2 i 1 1 l 3 63 20 . , 83 1 1 1 1 3 2 2 .. 1 3 1 1 1 4 2 1 1 2 1 1 2 1 1 1 1 1 1 1 1 1 1 1 G 78 British Columbia 1918 CAUSES OF © fe .2 CJ CAUSE OF DEATH. ei 9 ei . 3 GJ « 9 (After the Bertillon Classification Causes of Death, Second International U CM m rt Decennial Revision, Paris, 1909.) jo O o © 6 P *-" (M in NANAIMO DIVISION—LADYSMITH.—'Concluded. VII.—The Puerperal State. • M. F. M. F. M. F. M. F. 137 VIII.—Diseases of the Skin and of the Cellular Tissue. 145A X.—Malformations. 1 XL—Diseases of Early Infancy. 153 a 1 XIII.—Affections produced by External Causes. 169 1 1 6 1 1 2 2 - ~ 1 20 28 30 41 64 68a 70 71 77a 78 79 81 1)1 92 104 108 109 118 150 153a 153b 153c BEATON GROUP—CRANBROOK. I.—General Diseases. Typhoid fever Purulent infection and septicaemia Tuberculosis of the lungs Tubercular meningitis Cancer and other malignant tumours of the peritoneum, intestines, rectum. Other tumours (tumours of the female genital organs excepted) Addison's disease IL—Diseases of Nervous System and Organs of Special Sens: Locomotor ataxia Cerebral hemorrhage, apoplexy.. Paralysis from bite of wood tick.. Convulsions (non-puerperal) Convulsions of infants III.—Diseases of the Circulatory System. Myocarditis Acute endocarditis Organic diseases of the heart . Diseases of the arteries iv.—Diseases of the Respiratory System. Bronchopneumonia.. Pneumonia Asthma V.—Diseases of the Digestive System. Diarrhoea and enteritis (under 2 years) Appendicitis and typhlitis Hernias, intestinal obstructions Other diseases of the digestive system (cancer and tuberculosis excepted).. X.—Malformations. Congenital malformation (still-births not included) XL—Diseases of Early Infancy. Still-born Premature Injury by forceps at birth. 8 Geo. 5 Provincial Board of Health. G 79 DEATH, 1917—Continued. ei 9 >> © > IfS O -•*= CM m 3 0J o © 169 BEATON GROUP— CRANBROOK.—Concluded. XIII.—Affections produced by External Causes. M. F. M. F. M. F. M. F. 173a 174 8 8 2 1 2 1 1 BEATON GROUP—FERNIE. I.—General Diseases. 1 6 1 1 8 3 1 1 1 20 28 40 42 45 50 1 56a 56b 61 II.—Diseases of Nervous System and Organs of Special Sense. 1 1 70 71 2 2 77a III.—Diseases of the Circulatory System. 78 78b IV.—Diseases of the Respiratory System. 1 1 1 "i* i 1 1 1 V.—Diseases of the Digestive System. 4 4 1 1 1 1 VI.—Non-venereal Diseases of Genito-urinary System and Annexa. 131 137 150 VII.—The Puerperal State. X.—Malformations. 2 8 Geo. 5 Provincial Board of Health. G 81 DEATH, 1917—Continued. ei OJ © CM O © OD ei © CO o -iO 8 ci 9 © -si p © ci © io p © OJ E ci CJ © © p O io oj 9 © p O © ca CJ © 00 p © ea OJ © © p © 00 ca *S Ph B -P P eS © © d "bo "p C CJ to •>3 Total by Sexes. B 9 "bo p p CJ CO HH ei CJ a ■"ei p M. P. M. 1 F. M. 1 F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. 1 1 1 F. 1 1 1 2 1 4 1 3 2 5 2 4 1 2 29 19 48 3 1 1 1 6 1 1 2 7 1 4 1 1 6 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 1 2 1 1 2 2 2 1 1 1 1 o 1 1 2 1 1 2 1 4 I 1 1 3 1 1 2 1 i 1 1 1 2 1 2 1 1 1 2 1 1 1 5 1 3 1 1 2 2 1 1 1 1 1 2 2 4 3 1 1 1 4 9 1 1 1 1 1 1 1 1 1 2 1 1 2 1 2 1 2 1 2 2 2 G 82 British Columbia 1918 CAUSES OF © fe 5 rt £j (*» ei 5 CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) rt 9 o 9 < Total by Sexes. p CJ 'bo p P CJ CO oj jP ei a *ei p H 1 1 8 3 1 9 3 32 1 1 1 140 M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. 1 F. 1 5 3 1 8 1 3 32 1 1 1 2 4 1 1 9 1 1 i 1 1 1 14 1 2 1 0 1 1 1 12 1 22 17 5 2 9 6 3 3 1 3 3 104 36 1 1 1 1 1 1 1 1 1 1 2 1 10 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 2 1 2 1 - 1 9 1 1 1 "T i 1 1 1 1 4 1 3 3 1 1 1 1 1 1 2 1 4 1 3 2 1 1 1 1 1 1 1 2 1 1 1 1 1 i 1 1 G 84 British Columbia 191S CAUSES OF c?8i g* Classification No. CO J. CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) ei 9 0J -g c p BO S- ei 9 CM O i- ri 9 LO © ■M 5 to 10 years. BEATON GROUP— KASLO.—Concluded. XI.—Diseases of Early Infancy. M. F. 1 M. F. M. F. M. F. Still-born 1 XIII.—Affections produced by External Causes. 1 1 1 1 34a 44a 50a 64 79a 117 119 151B BEATON GROUP—NAKUSP. I.—General Diseases. 1 II.—Diseases of Nervous System and Organs of Sfecial Sense. < III.—Diseases of the Circulatory System. V.—Diseases of the Digestive System. VI.—Non-Venereal Diseases of Genito-urinary System and Annexa. XI.—Diseases of Early Infancy. 1 1 1 — 7 8 24a 24b 28 30 40 46 50 5*2 54A 56a 61a 64 69 71 77a 78a 79 79a 79b 82 BEATON GROUP—NELSON. I.—General Diseases. 2 1 1 1 1 II.—Diseases of Nervous System and Organs of Special Sense. 1 1 III.—Diseases of the Circulatory System. 1 8 Geo. 5 Provincial Board of Health. G 85 DEATH, 1917—Continued. i « 9 © 0 © ei i © CO o © CM 9 © -* O © CO a CJ © © © -* ci 9 © © o © d O I*- O s i ei © 00 O O ct © © O 00 ei ft a c © © e o c ■bo Total by Sexes. c CJ 'bb p p CJ CO O p M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. 1 1 1 2 1 1 1 1 2 1. 1 1 4 1 5 2 2 5 2 1 r ~ 20 4 24 1 i 1 i 1 1 1 1 l l 1 1 1 1 l l 1 1 1 l 1 1 1 2 1 1 4 4 8 1 1 1 1 2 1 1 4 1 1 1 1 o 1 3 1 1 1 1 2 1 1 1 1 i 1 1 2 1 1 7 1 1 1 1 1 1 1 1 1 1 1 1 1 1 9 1 1 3 1 1 2 2 1 1 i 2 i i i i i ' • 1 G 86 British Columbia 1918 CAUSES OF p p p H CJ S ei 0 89 91 92 94 97a 102 108 104 108 110a 113 120 120a 137a 140 150 151 153A 153B 154 160 167 169 173 175 178a 186 187a 189 CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) ei 9 o> ei C-l P oj j- ca s ICC p CM 5 to 10 years. BEATON GROUP—NELSON.- Concluded. IV.—Diseases of the Respiratory System. M. 2 F. M. F. M. F. M. F. 1 V.—Diseases of the Digestive System. 1 1 1 VI.—Non-venereal Diseases of Genito-Urinary System and Annexa. 1 • VII—The Puerperal State. 1 X.—Malformations. XI.—Diseases of Early Infancy. 1 1 3 1 1 1 Still-born j\II.—Old Age. XIII.—Affections produced by External Causes. 1 1 XIV.—Ill-defined Diseases. «9 8 1 4 2 3 1 28 29 6lA 79 79A 92 BEATON GROUP—NEW DENVER. I.—General Diseases. • II.—Diseases of Nervous System and Organs of Special Sense. 1 III.—Diseases of the Circulatory System. IV.—Diseases of the Respiratory System. 8 Geo. 5 Provincial Board of Health. G 87 DEATH, 1917—Continued. Sh ca CJ j*. © CM P © ea CJ >> © CO p © c-l in ci 9 © HH P © ci CJ © 1C3 P © ci 9 © © p 5 0) © p © © ci OJ £ p © ci 9 © © p HH © OO -P ei £. B ■P P © © B CJ 'ft P P CJ to < CJ jc CJ cc H= *c? P H c CJ •a HH P X CJ CO oj HP -in > © o lO 169 BEATON GROUP—REVELSTOKE—Concluded. XIII.—Affections produced by External Causes. M. F. M. F. M. F. 1 M. F. 175 186 186a 11 3 1 2 1 20 28 30 61a 62 64 77a 78a 79a 78b 110a 117 151 153a 169 186 BEATON GROUP—ROSSLAND. I.—General Diseases. Purulent infection and septicaemia Tuberculosis of the lungs Tuberculous meningitis IL—Diseases of Nervous System and Organs of Special Sense. Cerebral tumor Locomotor ataxia Cerebral haemorrhage, apoplexv . III.—Diseases of the Circulatory System. Myocarditis Endocarditis following rheumatism Mitral regurgitation. Dilatation of heart IV.—Diseases of the Respiratory System. Pneumonia Capillary bronchitis Pleurisy OSdema of lungs V.—Diseases of the Digestive System. Enterocolitis , Simple peritonitis (non-puerperal) . VI.—Non-venereal Diseases of Genito-urinary System and Annexa. Other diseases of the kidneys and annexa X.—Malformations. Congenital malformation (still-births not included) XL—Diseases of Early Infancy. Congenital debilitv, icterus, and sclerema.. Still-born XII.—Old Age. Senility. XIII.—Affections produced by External Causes. Accidental drowning Other external violence . XIV.—Ill-defined Diseases. Ill-defined organic disease . 8 Geo. 5 Provincial Board of Health. G 91 DEATH, 1917—Continued. 9 © CM o © o5 rt 9 o CO o o (M rt 9 © o © CO rt © o © 9 © © O © iO u5 9 © © © © ei 9 >> © O © ei V o © o © CO ft G rt S "So o c o X 9 02 ~ei I P CJ > 'bo p X CJ CO oj .C CJ a *ce p H M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. 1 1 1 1 1 1 1 1 1 1 1 1 1 3 0 6 3 1 2 1 1 1 30 10 40 "i" 1 1 1 1 1 1 2 1 1 1 1 1 1 1 2 1 1 1 1 2 1 "i" 1 4 2 1 1 I 5 1 1 1 1 1 1 1 1 1 1 1 " i' 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 1 2 1 1 2 1 5 1 5 4 3 1 1 1 1 19 12 31 G 92 British Columbia 1918 CAUSES OF o" fe G .2 '■£ d © s *3*j s 5 CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) 9 9 TS C ei o u ei 9 iO o ■5-1 5 to 10 years. 64 BEATON GROUP—SLOCAN CITY. IL—Diseases of Nervous System and Organs of Special Sense. M. F. M. F. M. F. M. F. 91 IV.—Diseases of the Respiratory System. 1 120a IV.—Non-venereal Diseases of Genito-urinary System and Annexa. 153a XL—Diseases of Early Infancy. 1 1 1 20 28 45 50 92 94 102 104 151b 153a 153b 153c 169 169a 173 181 BEATON GROUP—TRAIL. I.—General Diseases. Whooping-cough followed by nephritis and convulsions Purulent infection and septicaemia Tuberculosis of the lungs Cancer and other malignant tumours of other organs, and of organs not specified. Diabetes II.—Diseases of Nervous System and Organs of Special Sense. Convulsions of infants III.—Diseases of the Circulatory System. Organic diseases of the heart . Angina pectoris IV.—Diseases of the Respiratory System. Acute bronchitis Pneumonia Pulmonary congestion, pulmonarj apoplexy.. V.—Diseases of the Digestive System. Ulcer of the stomach Diarrhcea and enteritis (under 2 years). VI.—Non-venereal Diseases of Genito-urinary System and Annexa. VIL—The Puerperal State. Puerperal embolism. XL—Diseases of Early Infancy. Non-assimilation of food. Still-born Premature Difficult parturition XIII.—Affections produced by External Causes. Accidental drowning Traumatism in logging camp and saw-mill. Traumatism in mines and quarries Electricity (lightning excepted) Other external violence XIV.—Ill-defined Diseases. Cause of death not specified or ill-defined 8 Geo. 5 Provincial Board of Health. G 9J DEATH, 1917—Continued. 10 to 20 years. CJ © CO o © CJ © p © ecj 40 to 50 years. 15 a 9 © © p © irj 60 to 70 years. ci CJ o CO P © 9 © © p © 00 *p ei P. •3 B ca © © G 09 *s> 0 0 bo <; Total by Sexes. B CJ "bo "p p X CO HP CJ a *rt P H M. F. M. F.J M. F. M. 1 F. M. F. M. F. M. F. M. F. M. F. M. F. M. 1 F. 1 1 1 1 1 1 1 1 1 1 2 2 4 1 1 1 1 1 1 1 1 1 1 1 1 i 2 1 1 1 1 1 1 1 1 l 2 1 2 1 1 1 3 2 1 1 1 3 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 o 2 1 1 1 1 1 1 1 9 2 2 1 1 1 2 1 5 3 1 5 1 1 1 8 25 33 G 94 British Columbia 1918 CAUSES OF p 1 rt (gj *55 ci a CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) Under 1 year. 1 to 2 years. 2 to 5 years. 3 9 O o IO 163 BEATON GROUP—TROUT LAKE. XIII.—Affections produced by External Causes. M. F. M. F. M. F. M. F. 189 XIV.—Ill-defined Diseases. 64 BEATON GROUP—WILMER. II.—Diseases of Nervous System and Organs of Special Sense. 79 III.—Diseases of the Circulatory System. 96 IV.—Diseases of the Respiratory System. 39a 50 79 79a 81 91 92 97a 98a 137 ALBERNT GROUP—ALBERNI. L— General Diseases. Diphtheria and croup. Cancer of the bladder . Diabetes IL—Diseases of Nervous System and Organs of Special Sense. Cerebral haemorrhage, apoplexy III.—Diseases of the Circulatory System. Organic diseases of the heart. Fatty degeneration of heart.. Diseases of the arteries IV.—Diseases of the Respiratory System. Bronchopneumonia Pneumonia Pulmonary haemorrhage OZdema of lungs VII.—Tub Puerperal State. Puerperal septicemia XL—Diseases of Early Infancy. Non-assimilation of food XIV.—Ill-defined Diseases. Cause of death not specified or ill-defined ALBERNI GROUP—ATLIN. I.—General Diseases. Alcoholism, acute. 8 Geo. 5 Provincial Board of Health. G 95 DEATH, 1917—Continued. ca 9 © en p © rH p ci 9 © CO p © 30 to 40 years. ci CJ © io p © 50 to 60 years. 60 to 70 years. ei 9 © 00 p © 80 to 90 years. 90 and npwards. ci CJ 'bo p p CJ bo < Total by Sexes. B 'bo p P X CO a ■ci p H M. F. M. F. M. 1 F. M. F. M. F. M. F. M. F. M. • .F. M. F. M. F. M. 1 1 F. 1 1 1 1 1 2 9 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 4 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 i 1 1 1 1 1 2 1 3 3 1 1 1 1 1 2 1 1 2 1 1 1 1 1 9 7 16 1 1 1 1 G 96 British Columbia 1918 CAUSES OF 6 fe g .2 "rt © eg M s CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) ei 9 0) •a B ei 9 CM © a >o © CM rt 09 © © IO i ALBERNI GROUP—BELLA COOLA. I.—General Diseases. M. F. M. F. M. F. M. F. 41 77a III.—Diseases of the Circulatory System. 109 V.—Diseases of the Digestive System. 120a VI.—Non-venereal Diseases of Genito-urinary System and Annexa. 169 XIII.—Affections produced by External Causes. 1 1 79 ALBERNI GROUP—CLAYOQUOT. III.—Diseases of the Circulatory System. ALBERNI GROUP—FORT FRASER. I.—General Diseases. 1 77 III.—Diseases of the Circulatory System. X. —Malformations. XIII.—Affections produced by External Causes. 1 1 175 178a 1 1 1 28 40 ALBERNI GROUP—HAZELTON. I.—General Diseases. Tuberculosis of the lungs Cancer and other malignant tumours of the stomach, liver II.—Diseases of Nervous System and Organs of Special Sense. Oedema of brain Cerebral haemorrhage, apople.xy 8 Geo. 5 Provincial Board of Health. G 97 DEATH, 1917—Continued. 9 O CM © © rt O O o CM ei 9 O *»# O o g QJ O IO o © -C-H oj ci CJ © © p © ci CJ © p © © £ 09 O 00 o -w o ei 9 O © © © CO ■3 a ft G a rt © © c a; 'So c G bo •< a) m 2 o H a; "So o G X tU ■£ ei 9 o H M. F. M. F. M. 1 F. M. F. M. F. M. F. M. . F. M. F. M. F. M. F. M. 1 1 F. 1 1 1 1 1 1 1 1 1 3 2 1 1 1 1 1 1 3 1 1 2 9 1 3 1 1 2 1 1 10 1 11 i 1 l 1 l 1 1 1 1 l 1 1 1 4 9 G 98 British Columbia 1918 CAUSES OF d fe .2 CJ m 5 CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) ei CU •a G rt cu >. CM O -4J ei 9 iO c CM 9 © O lO 77a ALBERNI GROUP—HAZELTON.—Concluded. III.—Diseases of the Circulatory System. M. F. M. F. M. F. M. F. 79 79a 79b 93 IV.—Diseases of the Respiratory System. 120a VI.—Non-venereal Diseases of Genito-urinary System and Annexa. 126 142 VIII.—Diseases of the Skin and of the Cellular Tissue. 150 X.—Malformations. 1 1 1 152a XL—Diseases of Early Infancy. 169 XIII.—Affections produced by External Causes. 173 175 178a 186 XIV.—Ill-defined Diseases. 1 4 1 1 ALBERNI GROUP—POUCE COUPE. I.—General Diseases. 1 117 V.—Diseases of the Digestive System. 187 XIV.—Ill-defined Diseases. 1 ALBERNI GROUP—PRINCE RUPERT. I.—General Diseases. 45 Cancer and other malignant tumours of other organs, and of organs not specified . II.—Diseases of Nervous System and Organs of Special Sense. 66 S Geo. 5 Provincial Board of Health. G 99 DEATH, 1917—Continued. 3 © CJJ o © ca CJ o CO p © CJ] 3 © HH o © 9 © io p -in © hC 5 CJ © © p © 5 9 © p © © ca CJ © CO p o ci CJ © © p o CO -p c ci PH P -P P ci © © 'bo p B CJ bo < Total by Sexes. B CJ 'bo o M CJ CO ci CJ a la p H Mi F. M. F. M. F. M. F. M. F. M. F. 1 M. F. M. F. M. F. M. F' M. F. 1 1 1 1 1 1 3 1 3 1 1 1 1 1 1 1 1 1 1 1 1 i 1 1 1 1 1 1 1 1 1 1 1 1 2 • 1 1 1 1 1 1 1 1 1 1 1 1 1 1 5 4 6 1 1 1 18 7 25 ' 1 i 1 1 1 2 1 1 i 1 1 3 1 2 1 1 3 1 1 4 1 1 1 " i' 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 2 1 i 1 G 100 British Columbia 1918 CAUSES OF d fe 3 ri o £ rt 5 CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) a C P 5 CM O T-H oj s >> C 5 to 10 years. 79a ALBERNI GROUP—PRINCE RUPERT.—Concluded. III.—Diseases of the Circulatory System. M. F. M. F. M. F. M. F. 79b 81 8lA 81B 1 91 IV.—Diseases of the Respiratory System. 1 92 1 93 97a 1 1 104 V.—Diseases of the Digestive System. 109 114 119 VI.—Non-venereal Diseases of Genito-urinary System and Annexa. 1 120a 145 VIII.—Diseases of the Skin and of the Cellular Tissue. 1 2 1 150 X.—Malformations. XL—Diseases of Early Infancy. 1 151 151c 1 1 152 a 153a 1 1 1 153b 153c 153d 1 159 XIIL—Affections produced by External Causes. 169 169a 170 171a 173 175 180 189 XIV.—Ill-defined Diseases. 10 4 1 1 1 ALBERNI GROUP—ANYOX. XL—Diseases of Early Infancy. 8 Geo. 5 Provincial Board of Health. G 101 DEATH, 1917—Continued. rt © (M O © a 9 © CO © © CM s 9 © O o CO ei 9 >i o lO o © P c3 01 © © p © irj ea CJ >i © p o © C ei CO © X P o CJ © © o © CO ■§ ca S g. ei © © S fe. 'B p p CJ bo 01 ■Jl >, jp j p r* B '& P P 0) CO oj HP HH ca o a *ci p M. F. M. F. M. F. M. F. M. F. M. 1 F. M. F. M. F. M. F. M. F. M. 1 1 1 1 2 1 F. 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 i l 1 1 1 1 1 l i l 2 1 1 i 1 1 1 1 1 1 1 1 1 1 1 2 1 1 2 1 1 1 3 2 1 5 2 1 1 l 7 l 1 1 1 1 1 1 1 1 13 1 1 1 2 8 1 3 1 3 1 1 5 1 1 1 2 52 11 1 l G 102 British Columbia 1918 CAUSES OF 7 35 78 a ALBERNI GROUP-QUEEN CHARLOTTE. I.—General Diseases. Scarlet fever Disseminated tuberculosis, specify organ III.—Diseases of the Circulatory System. Endocarditis following rheumatism XL—Diseases of Early Infancy. Premature XIV.—Ill-defined Diseases. Cause of death not specified or ill-defined 6 fe .2 ei 9 £ ei o CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909. rt o> >> s p a CD CM O ei 9 IO O 5 to 10 years. 79 ALBERNI GROUP—QUATSINO. III.—Diseases of the Circulatory System, M. F. M. F. M. F. M. F. 169a XIII.—Affections produced by External Causes. 172 178A ALBERNI GROUP—STEWART. XIII.—Affections produced by External Causes. Traumatism by fall. Exposure ALBERNI GROUP—TELEGRAPH CREEK. I.—General Diseases. Anaemia, pernicious XIII.—Affections produced by External Causes. Accidental drowning XIV.—Ill-defined Diseases. Cause of death not specified or ill-defined 28 35a 52 ASHCROFT. L—General Diseases. Tuberculosis of the lungs . Tuberculosis not specified.. Addison's disease II.—Diseases of Nervous System and Organs of Special Sense. Convulsions of infants 8 Geo. 5 Provincial Board of Health. G 103 DEATH, 1917—Continued. a o Ol © © s- « 9 O CO O © (M 09 © o © CO a >> © >o o © a 9 © © © © 1 © o o CD a 09 © CO o © ei 9 © © O o CO ■-© a ei © © a 'So o §0 ■5 Total by Sexes. bo O M 9 w rt OJ Q "rt ~o H M. F. M. F. 1 M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. 1 1 1 1 1 1 1 777.7. 1 1 9 l i i i l 1 1 l 1 1 i l 1 l 6 5 i 1 2 1 l l l l 2 l 3 3 1 1 2 1 2 2 1 2 2 4 1 1 1 1 1 1 1 1 1 1 G 104 British Columbia 1918 CAUSES OF d c .2 § S a O CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) s- a 9 ■73 5 a 9 >*-> CM © 9 c rt © o lO 78b ASHCROFT.—Concluded. III.—Diseases of the Circulatory System. M. F. M. F. M. F. M. F. 89 IV.—Diseases of the Respiratory System. 1 1 91 170 XIII.—Affections produced by External Causes. 174 175 2 1 109 BARKERVILLE. V.—Diseases of the Digestive System. 120 a VI.—Non-venereal Diseases of Genito-urinary System and Annexa. 28 FORT GEORGE. I.—General Diseases. 77a III.—Diseases of the Circulatory System. 91 IV.—Diseases of the Respiratory System. 1 92 92a 94 110 V.—Diseases of the Digestive System. 1 1 152a XL—Diseases of Early Infancy. 169 XIII.—Affections produced by External Causes. 170 187 XIV.—Ill-defined Diseases. 1 189 1 1 4 8 Geo. 5 Provincial Board of Health. G 105 DEATH, 1917—Continued. a 9 © © ■ © a > © ■o o © to t~ rt qj © © © © oj c3 CJ © t**- P © © 5 CJ © CO P © oj ca CJ © © p © CO rg g p. -p ' p ci © © p CJ 'bo o B CJ bo < Total by Sexes. ci V bo p cj 03 ei CJ a p H M. F. M. F. M. F. M. F. M. 1 F. M. F. M. F. M. F. M. F. M. F. M. 1 F. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 1 1 1 2 2 1 4 3 7 2 4 2 1 1 22 9 1 1 1 1 1 1 1 1 1 9 1 1 4 1 2 1 4 1 1 2 1 1 1 1 1 1 1 "i' 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 G 112 British Columbia 1918 CAUSES OF 6 fe © a CJ CAUSE OF DEATH. 09 a 1 9 a 9 rt 5 (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) 9 73 CM O © CM © o IO GREENWOOD.—Concluded. M. F. M. F. M. F. M. F. XL—Diseases of Early Infancy. 152A 1 2 1 1 153a 153B XI11.—Affections produced by External Causes. 169 1 173 1 28 40 54A 61a 64 78b 79a 92 92a 92b 104 109 110a 117 151 151b 153a 165 171a GRAND FORKS. I.—General Diseases. Measles Tuberculosis of the lungs Cancer and other malignant tumours of the stomach, liver . Anaemia, pernicious Alcoholism, acute , II.—Diseases of the Nervous System. Meningitis, typhoidal Cerebral haemorrhage, apoplexy.. III.—Diseases of the Circulatory System. Cardiac dropsy Chronic valvular disease.. IV.—Diseases of the Respiratory Syste.m. Bronchopneumonia Pneumonia Pneumonia following measles Pneumonia-hypostatic Pulmonary congestion, pulmonary apoplexy . -Diseases of the Digestive System. Diarrhoaa and enteritis (under 2 years). Hernias, intestinal obstructions Enterocolitis Simple peritonitis (non-puerperal) VI. —Non-venereal Diseases of Genito-urinary System and Annexa. Nephritis following scarlet fever XL—Diseases of Early Infancy. Congenital debility, icterus, and sclerema.. Non-assimilation of food Still-born ." XIIL—Affections produced by External Causes. Other acute poisonings Traumatism by falling tree. 8 Geo. 5 Provincial Board of Health. G 113 DEATH, 1917—Continued. 10 to 20 years. 20 to 30 years. CJ © >* p s 40 to 50 years. oj ol CJ © © p © ice 3 s © JJ- p © © 70 to 80 years. CJ © p. p © CO 90 and upwards. 'be p CJ bo i 9 5 a QJ (M O 9 lO O (M 50 rt 9 © O lO 157 KAMLOOPS.—Concluded. XIII.—Affections produced by External Causes. M. F. M. F. M. F. M. F. 159 166 1 1 1 1 1 167 169 173 175 175a 186 186a 1 189 XIV.—Ill-defined Diseases. 7 5 4 3 2 2 1 30 56 77a 79 81a 91 92a 170 172 173a 175 NICOLA. I.—General Diseases. Typhoid fever Tubercular meningitis.. Alcoholism, acute IL—Diseases of Nervous System and Organs of Special Sense. Tumour of brain III.—Diseases of the Circulatory System, Myocarditis Acute endocarditis Organic diseases of the heart. Aneurism Embolism and thrombosis.... IV.—Diseases of the Respiratory System. Bronchopneumonia . Lobar pneumonia... VI.— NON-VENEREAL DISEASES OF GENITO-URINARY SYSTEM AND ANNEXA Acute nephritis XIIL—Affections produced by External Causes. Traumatism by firearms Traumatism by fall Traumatism by railway construction Traumatism by other crushing (railroad, landslides, vehicles, etc.). 20 41 PRINCETON. II.—Diseases of Nervous System and Organs of Special Sense. Measles. Purulent infection and septicemia Cancer and other malignant tumours of the peritoneum, intestines, rectum . IV.—Diseases of the Respiratory System. Lobar pneumonia V.—Diseases of the Digestive System. Diarrhoea and enteritis (2 years and over) XL—Diseases of Early Infancy. Non-assimilation of food 8 Geo. 5 Provincial Board of Health. G 117 DEATH, 1917—Continued. CJ >l o p © oj ca CJ © p © ci © *H P © CO CJ © ica p © Htl ci © © p © in ei © p s E ca CJ © CO p © ca CJ © © p © CO -P ci Tj ci © © p* CJ 'be HH P P be < Total by Sexes.*! B CJ 'bo HH P a •A CO £ ei CJ a ■Jd p Eh M. F. M. F. M. F. M. F. 1 M. 1 F. M. F. M. F. M. F. M. F. M. F. M. 1 3 1 1 2 3 1 1 1 F. 1 1 1 1 2 5 1 1 2 1 1 3 1 2 1 1 1 1 4 1 1 1 1 4 1 1 3 9 13 18 13 12 ' 16 3 9 4 14 7 2 1 1 100 55 155 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 1 2 1 1 1 1 1 I 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 1 2 3 1 2 3 1 1 1 11 6 17 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 G 118 British Columbia 1918 CAUSES OF d fe o ei ep 6 CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, i909.) CJ -p ei CJ CM P 2 to 5 years. 5 to 10 years. 154 BEATON GROUP—REVELSTOKE—Concluded. XII.—Old Age. M. F. M. F. M. F. M. F. 169 XIII.—Affections produced by External Causes. 1 1 VERNON. I.—General Diseases. 1 10 20 28 Tubercularnieningitis 30 34a 37 40 44a "i 46 47 60 50a 53 54a 61 II.—Diseases of Nervous System and Organs of Special Sense. 1 6lA 63 6SA 1 64 71 1 1 76 1 77a III.—Diseases of the Circulatory System. 78 78a 79 79a 88 IV.—Diseases of the Respiratory System. 1 1 92 1 1 92a 102 V.—Diseases of the Digestive System. l 1 103 1 108 1 1 117 120 VI.—Non-venereal Diseases of Genito-urinary System and Annexa. 134 VII.—The Puerperal State. 137 8 Geo. Provincial BOh^rd of Health. G 119 DEATH, 1911—Continued. ■vj el 9 © CM © © a 9 © CG o o CM to a © o © CO a 9 © c Q CO a 9 >> O © c « o Q O © rt 0) o CO © © 9 © © © © ■TJ a & © -©* q rt © © d 0) '5) o 0J En 9 X Q) CO s 'ci O H ® o A 9 J rt Q o H M. F. M. F. M. F. M. F. M. F. M. F. M. F. 1 M. 1 F. M. F. M. F. M. 1 F. 1 2 2 1 2 1 1 3 2 1 1 1 1 1 5 7 12 2 6 1 2 1 1 1 1 1 1 "i i i i i i 2 3 1 13 1 1 1 1 1 2 1 1 1 1 3 G 120 British Columbia 1918 CAUSES OF d fe a .2 rt o S Jj Q CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) J-. ei CJ CJ -p B ei V P HH oj ci CJ ira P ca IH ca CJ © p 150 VERNON.—Concluded. X.—Malformations. M. F. 1 1 M. F. M. F. M. F. 151 XL—Diseases of Early Infancy. 1 1 1 251B 153a 154 XII.—Old Age. 159 XIII.— Affections produced by External Causes. 170 172 Traumatism by fall 173 176 178a 6 6 2 1 3 3 1 VANCOUVER CITY. I.—General Diseases. 5 6 1 1 1 1 7 1 "i 2 8 1 1 2 1 9 1 10 14 1 1 20 2 Tuberculosis of the lung's (Asiatic) 2 28a 29 1 3 i 1 30 3 3 2 2 2 3 1 n Cancer and other malignant tumours of the stomach, liver 41 45 45B 46 47 1 50 51 52 i 1 54a 1 56 56a 8 Geo. 5 Provincial Board of Health. G 121 DEATH, 1911—Continued. a 9 © o © co" 9 O o © CM CO a 9 o o © CO* © o © CO i. a >i o © © o a © o © © 70 to 80 years. ro a 9 o © o -1-3 © 00 73 a a © c~. OJ 'So o IU be < Total hy Sexes. a > © X 9 w a 9 P H o H M. F. M. F.' M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 1 i 1 1 1 1 1 7 1 3 2 2 3 4 4 3 3 3 7 3 5 6 7 1 1 1 3 54 31 85 1 1 1 1 2 1 3 1 1 i 1 i 1 1 3 5 9 i 3 1 1 1 1 9 33 "'3' 15 5 1 1 5 1 1-1 i 2 1 19 67 1 1 14 5 2 1 i 5 19 1 1 2 1 1 1 2 13 7 15 I 3 2 10 2 1 1 2 1 2 1 28 4 100 1 1 1 1 1 1 1 2 2 3 29 1 1 1 1 1 10 1 1 1 2 1 1 1 1 1 2 4 1 3 4 1 35 10 2 1 1 1 10 2 1 1 2 2 1 3 1 2 3 1 10 1 2 1 1 4 8 3 2 2 2 7 2 2 2 3 2 2 1 2 1 18 9 15 6 1 19 1 1 1 1 3 1 1 3 2 3 3 1 1 2 1 1 . 1 1 2 1 1 1 1 1 1 1 1 , 1 1 2 3 3 3 1 1 4 1 1 1 2 2 1 1 21 2 1 1 1 1 1 1 1 1 2 2 7 1 1 1 3 1 2 U 3 2 1 1 6 1 1 <} 12 British Columbia 1918 CAUSES OF 61 6lA 63A 63 b 63c 64 6Sb 69 71 77 77a 78 78a 78b 79 79a 79b 79c 79d 79e 79f 79g 80 81 SlA 81B 82 84A 84b 85 87 89 90 91 92 92a 92b 92c 92d 92e 93 97a 97b 97c 97d 102 103 103a 103b 104 105 108 109 110 110a 111 113 114 115 117 117b 118 118a CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) VANCOUVER CITY.—Continued. II.—Diseases of Nervous System and Organs of Special Sense. Meningitis (Asiatic) Cerebro-spinal meningitis Acute anterior poliomyelitis Oedema of brain Tumor of brain Cerebral hemorrhage, apoplexy... Paralysis without specified cause . Cerebral thrombosis Cerebral abscess Epilepsy Convulsions of infants Otitis media Ill,—Diseases of the Circulatory System. Pericarditis Myocarditis Acute endocarditis Endocarditis, following rheumatism.,.. Cardiac dropsy ., Organic diseases of the heart (Asiatic) . Cardiac paralysis Chronic valvular disease Aortic insufficiency Fatty degeneration of heart Mitral regurgitation Cardiac dilation Cardiac embolism , Angina pectoris Diseases of the arteries Aneurism Arterio sclerosis Embolism and thrombosis Lymphangitis Hodgkin's disease. Haemorrhage IV.—Diseases of the Respiratory System. Diseases of the larynx Acute bronchitis Chronic bronchitis Bronchopneumonia Pneumonia Lobar pneumonia Pneumonia hypostatic Capillary bronchitis Bronchopneumonia, following infected fracture of hip Pneumonia following measles. Pleurisy Pulmonary congestion, pulmonary apoplexy Asthma Pulmonary abscess Pulmonary hemorrhage Pulmonary embolus Septic pneumonia Other diseases of the respiratory system (tuberculosis excepted). OEdema of lungs V.—Diseases of the Digestive System. Ulcer of the stomach _. Other diseases of the stomach (cancer excepted) Hemorrhage from bowels Duodenal ulcer Diarrhoea and enteritis (under 2 years) Diarrhcea and enteritis (2 years and over) Appendicitis and typhlitis Hernias, intestinal obsti uctions Other diseases of the intestines Enterocolitis Acute yellow atrophy of the liver Cirrhosis of the liver Biliary calculi Other diseases of the liver. Simple peritonitis (non-puerperal) Peritonitis, gastric ulcer perforated Other diseases of the digestive system (cancer and tuberculosis excepted).. Septic peritonitis 8 Geo. 5 Provincial Board of Health. G 123 DEATH, 1911—Continued. ca CJ © CM P © 5 © CO p © CM ci © p 0 CO ci CJ © 10 p 0 ei OJ © © 0 © 60 to 70 years. ci © CO 0 © 1 © © P © OO oj ci P. c3 © © d CJ 'be P B CJ CJ} «! Total by Sexes. d be 0 CJ OS £ ei CJ O *ci p H M. F. M. F. M. F. M. F. M. 1 F. 1 M. 1 F. M. F. M. 1 F. M. F. M. F. M. 4 1 1 3 7 36 2 2 F. 2 6 1 1 1 i 1 1 2 1 a 5 3 1 1 2 2 7 1 1 1 8 1 17 3 2 1 2 2 2 32 5 5 2 8 2 3 i 3 1 8 1 1 6 2 1 1 3 3 53 5 1 4 1 1 2 9 1 1 53 13 6 6 5 2 11 3 1 9 2 1 "2 2 1 io' 1 1 6 14 4 5 7 1 1 6 3 1 "i i 4 3 2 4 2 1 6 3 3 85 2 18 1 11 1 4 1 1 "i 1 1 8 1 2 5 1 1 1 8 1 1 i 1 2 1 2 1 2 2 2 1 1 1 7 2 1 8 18 15 3 1 2 6 1 .... 1 1 8 1 2 1 1 4 1 1 2 1 2 1 2 1 6 1 1 9 1 24 1 1 i 3 1 5 2 1 6 5 6 2 2 1 3 2 1 1 2 1 1 1 2 2 1 8 2 1 1 7 1 1 1 1 1 1 1 19 44 10 4 1 1 1 1 1 1 "'3' ii 12 9 3 1 1 '"i" 3 1 "T '"a" 3 1 i 1 4 i 1 6 2 1 1 1 5 4 2 3 1 1 1 2 1 2 1 1 1 1 2 S3 2 2' 2 1 2 ... 5 1 1 2 2 11 3 1 1 2 56 25 7 1 1 2 1 1 1 1 1 2 3 1 1 1 3 1 1 1 2 11 8 2 1 1 11 1 7 9 1 1 1 5 2 1 1 3 1 1 1 1 1 2 1 1 4 1 2 1 1 2 1 2 1 1 1 1 1 1 1 3 1 1 3 2 17 11 2 1 1 1 4 1 15 1 2 1 1 1 i 2 3 2 1 2 3 2 7 3 1 14 2 1 1 12 1 2 1 1 1 3 "2' 1 5 2 1 2 2 1 i 1 3 1 4 2 2 1 1 1 i 1 1 1 5 1 1 2 G 124 British Columbia 1918 CAUSES OF fe 119 120 120a 122 124 126 130 181 133a 133b 135 137 137a 137b 138 139 140 141a 141b 141c 141d 141k 142 145 150 150a 151 151a 151B 152a 153a 153b 153c 153d 155 156 157 158 159 160 165 167 168 169 169a 170 172 174 175 182 VANCOUVER CITY.—Continued. VI.—NON-VENEREAL DISEASES OF GENITO-URINARY SYSTEM AND ANNEXA. Acute nephritis (Asiatic) Bright's disease Uremia Other diseases of the kidne}fs and annexa Diseases of the bladder Diseases of the prostate Diseases of the uterus Cysts and other tumours of the ovary Parenchymatous nephritis Cholecystitis CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) VII.—The Puerperal State. Puerperal hemorrhage ;... Puerperal septicaemia Puerperal infection following miscarriage Eclampsia Puerperal albuminuria and convulsions , Puerperal phlegmasia alba dolens, embolus, sudden death.. Following childbirth (not otherwise defined) Pneumonia following childbirth Incomplete abortion Following Cesarotomy Ectopic pregnancy Puerperal fever VIII.—Diseases of the Skin and of the Cellular Tissue. Gangrene Other diseases of the skin and anne.xa.. IX.—-Diseases of the Bones and Organs of Locomotion. Diseases of the joints (tuberculosis and rheumatism excepted) X.—Malformations. Congenital malformation (still-births not included) Hemorrhage neonatorum XL—Diseases of Early Infancy. Congenital debility, icterus, and sclerema. Accident of labour Non-assimilation of food Atelectasis Still-born Premature Umbilical hemorrhage Melena neonatorum XII.—Old Age. Senility , XIII.—Affections produced by External Causes. Suicide by poison Suicide by asphyxia Suicide hy hanging or strangulation Suicide by drowning Suicide by firearms . Suicide by cutting or piercing instruments Other acute poisonings Burns (conflagration excepted) Absorption of deleterious gases (conflagration excepted) Accidental drowning Traumatism in logging camp and sawmill Traumatism by firearms Traumatism by fall Traumatism by machines Traumatism by other crushing (railroad, landslides, vehicles, etc.)., Homicide by firearms 8 Geo. 5 Provincial Board of Health. G 12c DEATH, 1911—Continued. CJ © p © oi ei © CO p HH © CM u ei CJ © **l p © 40 to 50 years. oj ei © © P © ire 60 to 70 years. oj ei CJ © CO P © ci CJ © © p 0 CO V ea a -p © © B CJ *s> p B CJ be ■*-** Total by Sexes. c CJ "be p B cj in oj -P ci CJ ft li p M. F. M. 2 1 1 F. 1 1 1 M. 1 1 F. i 1 M. 1 i F. 1 "3' M. 6 1 5 F. "i' M. 4 1 5 F. "i 3 M. i 5 F. M. F. M. 1 F. M. F. M. 16 5 21 F. 5 3 8 3 1 21 8 2 29 3 l 1 1 i 1 2 2 3 2 1 1 1 1 1 1 1 1 1 1 1 1 1 3 5 1 3 1 1 2 2 2 2 2 1 4 1 2 1 4 2 1 1 1 3 5 1 1 3 1 1 1 1 1 2 1 2 2 1 2 2 1 2 2 1 1 1 2 1 1 1 2 1 1 5 6 9 6 2 4 2 4 1 43 19 ...... 11 2 12 1 5 5 41 22 1 16 9 84 1 6 1 1 1 3 1 4 2 5 2 1 3 1 3 2 2 2 1 6 6 6 8 2 18 1 1 1 1 1 2 1 1 1 1 i l '"2 1 1 e> 2 1 i l 1 4 3 1 1 1 1 3 i 1 1 7 6 3 1 2 1 1 i 1 1 1 2 1 4 9 12 1 1 3 1 3 1 1 2 1 1 1 20 1 G 12G British Columbia 1918 CAUSES OF p *HH a _p ci CJ eg ci Q CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) Under 1 year. ca CJ CM P 3 >. ire P CM ei CJ © p 182a VANCOUVER CITY.—Concluded. XIII.—Affections produced by External Causes—Concluded. M. F. M. F. M. F. M. K. 182b 186 1 1 1 186a Shock 186b 1 187a XIV.—Ill-defined Diseases. 15 189 15 9 14 1 14 152 121 13 30 30a 32a 40 42 54A 62 63a 64 77 77a 78 79a 79b 79c 81 90 91 92 92A 92b 103 110a 120 120a 126 137 150 SOUTH VANCOUVER. I.—General Diseases. Typhoid fever Scarlet fever Tuberculosis of the lungs Acute miliary tuberculosis Tubercular meningitis Tubercular peritonitis Tuberculosis of spine Cancer and other malignant tumours of the stomach, liver Cancer and other malignant tumours of the female genital organs , Anemia, pernicious IL—Diseases of Nervous System and Organs of Special Sense. Locomotor ataxia Acute anterior poliomyelitis Cerebral hemorrhage, apoplexy .. Paralysis without specified cause . Epilepsy. Convulsions of infanta III.—Diseases of the Circulatory System. Pericarditis .... Myocarditis Acute endocarditis Chronic valvular disease Cardiac dilation Oardiao sclerosis with rupture. Diseases of the arteries IV.—Diseases of the Respiratory System. Acute bronchitis Chronic bronchitis Bronchopneumonia Pneumonia Lobar pneumonia Hypostatic pneumonia. V.—Diseases of the Digestive System. Other diseases of the stomach (cancer excepted)., Enterocolitis VI.—NON-VENEREAL DISEASES OF GENITO-URINARY SYSTEM AND ANNEXA. Bright's disease Uremia. Diseases of the prostate VII.—The Puerperal State. Puerperal septicemia X.—Malformations. Congenital malformation (still-births not included) 8 Geo. 5 Provincial Board of Health. G 12 DEATH, 1911—Continued. v 'be o c X a 9 © CM O © a 9 © CO © © Ol a OJ © o © CO a 9 © © © a 9 © © O i5 a 9 O o © © rt 9 © 00 o © a & © © o +j a F a rt o © d 0) 'be o CU «3 Total hy Sexes. rt OJ ft o H M. F. M. F. 1 M. 2 F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. 2 1 5 F. 1 3 1 1 1 1 1 1 2 1 1 2 2 7 1 1 1 1 1 1 3 1 112 1 45 3 16 49 51 105 72 109 44 109 51 68 35 26 23 3 2 1 33 810 497 1307 1 i 2 1 1 1 1 1 1 1 1 1 1 1 2 1 1 "T i i 2 1 1 1 1 i 2 1 3 5 1 1 7 1 i 1 1 1 1 1 2 1 1 1 1 i 1 2 1 1 1 4 1 1 1 1 9 i i 1 2 1 3 1 1 1 1 2 1 1 1 1 1 1 1 1 1 2 3 1 1 1 I . 1 1 1 1 2 1 1 1 2 1 1 2 1 3 1 i 1 1 G 128 British Columbia 1918 CAUSES OF p to B _p ei CJ CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) 3 — -p D ei CJ CM P ci CJ IO p CM CJ © o 152a SOUTH VANCOUVER— Concluded. i XI.—Diseases of Early Infancy. M. "» 3 1 F. 1 3 2 M. F. M. F. M. F. 153a 163b 153c 154 XII.—Old Age. 159 XIII.—Affections produced by External Causes. 169 1 175 186 1 4 IS 9 1 1 1 2 2 40 41 42 63a 66 77A 79a 81 91 92 92a 92b 151 152a 153 a 153b 158 169 175 VANCOUVER DIVISION—POINT GREY. L— General Diseases. Cancer and other malignant tumours of the stomich, liver Cancer and other malignant tumours of the peritoneum, intestines, rectum. Cancer and other malignant tumours of the female genital organs II.—Diseases of Nervous System and Organs of Special Sense. Primary lateral sclerosis of spinal cord. Paralysis without specified cause III.—Diseases of the Circulatory System. Myocarditis Cardiac rupture following ulceration.. Diseases of the arteries IV. —Diseases of the Respiratory System. Acute bronchitis Bronchopneumonia Pneumonia Lobar pneumonia Hypostatic pneumonia. -CEdema of lungs VI.—NON-VENEREAL DISEASES OF GENITO-URINARY SYSTEM AND ANNEXA. Uremia. X.—Malformations. Congenital malformation (still-births not included) XL—Diseases of Early Infancy. Congenital debility, icterus, and sclerema.. Atelectasis Still-born Premature XIIL—Affections produced by External Causes. Suicide by drowning Accidental drowning Traumatism by other crushing (railroad, landslides, vehicles, etc.).. 8 Geo. 5 Provincial Board of Health. G 129 DEATH, 1917—Continued. a -OJ © o © 9 © C © 55 ii a 9 © o © CO 40 to 50 years. CJ © cp p © ■ca a 9 © o © to a 09 © o © to rt 9 £ o © 00 a Is p a © © d QJ "So © 'a o B X CJ m oj H= rt CJ ft Is p IH M. F. M. 1 F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. 1 1 1 3 F. 1 1 2 3 1 3 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 1 1 1 2 2 1 1 1 3 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 2 i l 1 1 1 1 1 1 1 1 1 1 1 2 1 1 1 1 1 1 2 2 2 1 1 1 1 1 1 1 2 1 1 1 i l 1 1 1 1 1 1 1 i l ■j' l L 1 1 5 2 7 2 1 1 1 1 5 1 1 1 4 2 1 1 8 1 4 4 2 4 1 5 1 1 28 so 58 G 132 British Columbia 1918 CAUSES OF 6 a o 'a o 5 CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) a 9 m a 9 "5b p bo < Total by Sexes. ej 'a p B X CJ in ei CJ Q "ei P E-* M. 1 F. ' M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. p M. 1 F. i 1 1 1 i 1 1 1 1 1 l l i 1 1 1 1 1 ' 1 1 1 1 1 1 1 1 - 1 1 2 1 1 1 1 1 1 1 2 l 1 1 8 4 12 1 1 1 1 - 1 1 1 1 1 1 1 1 1 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 G 134 British Columbia 1918 CAUSES OF 6 ft a .2 « 9 s a 6 CAUSE OF DEATH. (After the Bertillon Classification Causes of Death, Second International Decennial Revision, Paris, 1909.) B a 9 o a ■o © u a >> © o to 137a Eclampsia Atelectasi Still-born Burns (co Accidenta Traumati Traumati Traumati Injuries b Other ext VANCOUVER—OUTSIDE.— Concluded. VIL—The Puerperal State. M. F. M. F. M. F. M. F. 152a XL—Diseases of Early Infancy. 1 153a 1 y 167 XIII.—Affections produced by External Causes. 169 169a 170 173 176 186 1 o 1 8 Whooping Influenza Tuberculc Tubercula II Meningiti RICHMOND. L—General Diseases. 1 1 28 20 1 1 61 .—Diseases of Nervous System and Organs of Special Sense. 1 64 77a Myocardi' Endocard Chronic v Pne union Hemorrha Other diss Simple pe VI.- Bright's d III.—Diseases of the Circulatory System. 78a 92 IV.—Diseases of the Respiratory System. V.—Diseases of the Digestive System, 1 1 117 120 -Non-venereal Diseases of Genito-urinary System and Annexa. 1 XL—Diseases of Early Infancy. 1 157 Suicide b Accidenta Other ext Cause of c XIII.—Affections produced by External Causes, 186 XIV.—Ill-defined Diseases. 1 2 1 3 1 1 8 Geo. 5 Provincial Board of Health. G 135 DEATH, 1917. CO S- ei CJ © P © 20 to 30 years. ci © p © CO CJ © p © CJ © ID O © oj rt CJ © P © © rt © :o p © tH « © © P © CO 90 and upwards. a CJ '5j o rp *CJj CJ X CJ Ul i>, XI ■rf ~p H e CJ 'Sa p X CJ m oj HS ci CJ ft HH P H M. F. M. F. 1 j\l. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. 1 1 1 1 1 1 1 1 2 2 1 3 1 1 1 1 1 1 1 1 3 1 1 2 1 1 1 1 1 1 4 3 1 1 2 1 4 1 3 !> 17 4 21 2 2 1 1 1 1 3 1 1 1 1 2 1 3 1 1 1 1 1 1 1 1 1 1 1 1 1 i 1 1 1 2 1 1 1 1 2 1 1 1 1 1 1 2 2 1 1 1 2 9 1 1 1 5 5 1 1 1 1 2 1 1 1 2 2 1 2 4 1 1 1 4 20 10 30 8 Geo. 5 Provincial Board of Health. G 137 SECOND MEETING OF MEDICAL HEALTH OFFICERS OF BRITISH COLUMBIA HELD at LABOUR TEMPLE, corner Homer and Dumsmuir Streets, Vancouver, B.C. SEPTEMBER 12th and 13th, 1917. Under the authority of Doctor the Hon. J. D. MacLean, Provincial Secretary. MEDICAL OFFICERS OF HEALTH. Present—■ Dr. J. E. H. Kelso Edgewood. Dr. Isabel Arthur Nelson. Dr. Mi Callanan Barkerville. Dr. H. W. Keith Enderby. Dr. J. P. Cade Prince Rupert. Dr. A. G. Price Victoria. Dr. F. Stainsby Field. Dr. H. C. Wrinch Hazelton. Dr. R. W. Large Port Simpson. Dr. J. H. Hamilton Revelstoke. Dr. S. Petersky Lucerne. Dr. G. H. Tutill Merritt. Dr. H. L. Turnbull South Vancouver. Dr. O. G. Ingham Nanaimo. Dr. W. F. Drysdale Nanaimo. Dr. G. deB. Watson Burnaby. Dr. F. T. Underbill Vancouver. Dr. S. O. McEwen New Westminster. Dr. W. E. Newcombe North Vancouver. F. F. WESBROOK, M.D, LL.D., President, of the University of British Columbia. Secretary to the Meeting : H. E. YOUNG, M.D., Secretary, Provincial Board of Health, Victoria, B.C. Wednesday, September 12th, 1917 Morning Session, The Convention was opened at 9.30 a.m., Dr. F. T. Underbill presiding. The Chairman: Ladies and Gentlemen,—I think we may call this meeting open and commence our programme. Personally, I would like to offer you all a very hearty welcome to Vancouver; and while I am very glad to see you, I should have been still more pleased had there been a fuller attendance. G 138 British Columbia 1918 There are one or two points which I would like to emphasize. The first is, that those who rise to speak will kindly give their name and place of residence, so that the stenographer can keep a proper record. Secondly, we desire to have a free and open discussion on all subjects and any amount of criticism—hit as hard as you like—we want to learn, and we can do so at a meeting of this kind. You will probably have noticed that no provision is made for any entertainment. It was thought that under the conditions in which we are now living such a proceeding might not be quite in place. However, the freedom of Vancouver, in so far as we can give it-—outside of the Police Court—is open to you. The hospitals will be glad to see you; also the Health Department ; for, while we are ashamed of our building, we have the material there if only we had proper space for it. Dr. Young has kindly organized this meeting, and I will therefore ask him to be good enough to open it officially. Dr. H. E. Young (Secretary, Provincial Board of Health) : Mr. Chairman, Ladies and Gentlemen,—As you know, some two or three years ago we undertook a programme of holding annual meetings of the Health Officers of the Province, and had, in 1914, a very successful meeting, and it looked as if we were launched on a programme that would be of very material benefit to the Medical Health Officers, and also to the public in general. The matters that we wished to discuss were those, of course, which loomed very large in the Province, and in many cases we had no precedents to guide tis. The conditions in the Province are such that these matters have to be met just as circumstances warrant. Unfortunately, following that meeting, war was declared, and, as a result, general disorganization of our staff in the Provincial Board of Health. Our men left—there have been some 200 members of the medical profession who have gone from British Columbia—and it was not thought advisable, under existing conditions, that we should continue the meetings at the time. However, war seems to be a fixed condition, and probably we might be pardoned now if we were to say, if there is anything in the expression, that business should go on as usual; and taking everything into consideration, and also the fact that in the near future, or we hope in the near future, there will be a cessation of the war and other problems will arise, such as immigration to the Province—we may be disappointed, but I feel that people in general are optimistic on this point, and in order that we may be able to meet these conditions, we thought it advisable to resume these meetings, and I have asked different members of the Medical Health Officers to give us papers. The programmes which you have before you show that I have made a very good selection in the choice of the men from whom we are to have papers. The intention of their papers is to register their views and the results of their experience in the practice of the profession, but the chief thing I wish to bring about is the promotion of a discussion of these papers; to get an expression from those of you who are here to-day, coming from widely scattered points in the Province and to whom at times important questions arise which you have to decide without the possibility of your being able to get advice. The Provincial Board of Health wishes the Medical Officers to feel that the Department is back of them in enforcing the requirements and regulations. When we come down to ultimate results, it is a matter of education—the people must be educated. It is difficult to enforce regulations when the enforcement interferes with the daily habits of the people or their personal liberty. They must be taught that they are individual members of a community, and that the health of the community depends entirely upon concerted action, and that the point of infection arising from one person neglecting to carry out regulations may result in serious epidemics and disorganization of business and death among the people of the community as a whole. I propose to continue to carry out as far as possible the distribution of literature along these lines, and we hope that those who are reading their papers during the sessions will consider they are contributing a great deal towards the publication of pamphlets which will go toward the education of the people; and great benefits will be derived from active co-operation, and from the knowledge of the individual that what we are asking them to do is for their own benefit. I look forward with a great deal of pleasure to listening to these papers and to the discussion of these questions. I wish to thank Dr. Underbill for the splendid co-operation he has given me in the arrangements for this meeting, and also for kindly taking the chair. 8 Geo. 5 Provincial Board of Health. G 139 The Chairman : As Dr. Young has said, I hope there will be a free discussion of all these papers. I would ask those who are reading to read as distinctly as possible, and also any one speaking to a paper to speak slowly and distinctly, and not to be disconcerted if any one asks them to speak up. The idea is for every one to hear what is being said. The first paper is on " Child-welfare," by Dr. Isabel Arthur, of Nelson, B.C. CHILD-WELFARE. By Isabel Arthur, M.D, Medical Health Officer, Nelson, B.C. Mr. Chairman, Ladies and Gentlemen,—It is a great pleasure for me to be here this morning. I was very much pleased to be asked to read a paper on this subject, but with the medical inspection of schools taken up by Dr. Brydone-Jack, and the infectious diseases by some one else, it left me another field entirely, not altogether medical, to go into, because I think " child-welfare " includes a great deal that is not medical. There is nothing else around which so much centres on or which so much depends as on tbe child. It is the possibility of the nation, the hope of the future. It comes into the world helpless, born in all kinds of places and in all kinds of conditions, without any choice as to what these conditions are. One is born in poverty, another in luxury; one in the palace, another in the slums; one in the home of luxury, refinement, and education, another in surroundings of vulgarity and ignorance. With life begun in such different circumstances it is hard to know just how far individual responsibility extends, but we must have individual responsibility, for without it we can have no law or order, and law and order are the essentials of civilization. In order to try and equalize conditions and put all children in as good a position as possible to begin life, much time has been spent, and never before has the welfare of the child been so much before the mind of the State. This is in the right direction, but we are a long way from having it before the mind of the State as it should be. The child is the asset of tbe State, and all conditions should be arranged as far as possible to get the best results from that child. It is a business transaction, and results are what we are looking for in all business transactions. We do not want inferior products turned out that may answer the purpose, but as perfect a thing as can be produced—something to be proud of; something with stability and quality, that can be used for the purposes of development and advancement and for the protection, if need be, of the State to which it belongs. Child-welfare is such a complex subject and has so many phases that it is difficult to know where to begin or where to end. The physical development of the child is so closely connected with its mental and moral development that one cannot be separated from the other, and so in discussing its welfare many things which do not seem to be physical must be taken into account. A child whose mental and moral development is taking place in unhappy or uncongenial circumstances has not the same choice to develop physically as one whose surroundings are pleasant and happy. Neither has a child who has a taste for certain lines of work and is forced into another line which he dislikes as good a chance of physical development, as the mental is in such close relationship to the physical that without harmony of the two the best results cannot be obtained. It would seem that there should be very close harmony between the education department and the medical, for the real welfare of the child can hardly be considered from the physician's point of view without taking into account its school-life, hours of study, hours of play, and many other things that come directly under tbe education department. Hence this paper is not all medical. We all realize that the physical well-being of. the child is of the utmost importance. We must have the healthy child, and how to get that is our first thought, and we must begin at the beginning. In order to have the healthy child we must have healthy parents, so that the care of the child is prenatal. Some one said, when asked the proper time to begin the education of her child, " One hundred years before its birth." That has a great significance. " Do men gather grapes from thorns or figs from thistles? " is a very pertinent question in this regard. Do we get the fit from the unfit? This is the thought that should be before the mind of every one interested in the welfare of the child. It does seem as if we begin at the wrong end in dealing with many problems. We allow things to occur and then try to treat results. Now is the time G 140 British Columbia 1918 to get at the cause, and unhealthy parentage is the cause of many conditions found in the child. We know that all kinds of tendencies are passed from parent to child, even unto the third and fourth generation—tendencies to wrong habits of thought as well as to right habits of thought and action. This is law—inexorable law; and although we may disregard it, it prevails just the same. When we want first-class wheat we plant first-class seed, and we get what we aim for. This is true all through nature, and in developing the resources of nature the fact is often taken Into account. Not so in the human family, though. I asked the Registrar the other day if there were any restrictions on marriage. He turned up the book, and all the restrictions I could find referred to age. Well, I find no fault with that—it is wise, perhaps; but is that all? What about the man of mature age that is a drunkard or a drug-fiend, or an idiot or a degenerate of any kind, or the man who has gone far into the country of tbe prodigal son, and who has wasted his substance and his health in riotous living, or who has acquired disease in any way and is devoured with it; can he get a marriage licence and no questions asked? Oh, yes! Why spoil the romance of life for him? He has been sowing his wild oats, and now he must settle down and become a respectable citizen. There is a lovely sweet girl with whom he is in love—why interfere? Let all the earth keep silent! and let this dreadful tragedy be enacted; and all through the years the tragedy, never ending, follows that innocent girl and her children. The shame and injustice is appalling. "Honour thy father and thy mother," says the good Book; but how can the child honour the parent who has bequeathed to it a heritage of ill-health or evil tendencies? Too much silence has been our fault; mock modesty and a foolish idea that certain things must not be spoken about have led to fearful results. The world has not always been fair to the child. It has allowed it to start out with a handicap, and in our cart-before- the-horse style we try to remedy the result. We will look after these children; we will see that the schools have medical and dental inspection; we will improve sanitation and have good water-supplies, and make everything tend towards health. What nonsense! Why ever allow them to happen? If we can't prevent people from acquiring disease, we can at least prevent them from passing it on to innocent children. My first thought, then, in child-welfare would be restriction of marriage licences. Any one contemplating entering into matrimony should be compelled to undergo a strict physical examiiia- tion by a capable and conscientious physician, and be required to have a certificate of good health from that physician before a licence could be issued. " Oh, yes! " some one says, " but money will buy anything; it won't work." Quite true, it will not work if doctors are going to stoop to a low enough plane to be bribed, but we like to think of doctors occupying a higher place; and, besides, they know the result of marriages of the unfit and unclean, and if they cannot be counted on to protect innocent women and children, God pity us all. Now, as perhaps never before, we need healthy children to take the place of those fallen in the war, and quality will count much more than numbers in this replacement, and careful attention must be given along every line tending to the conservation and elevation of human life. When the child comes into the world the problem of taking care of it begins, and was there ever such ignorance in regard to any other subject? The delusion that maternity brings with it the knowledge of how to do this is fast disappearing, and none too soon. The whole cry of to-day Is for skilled workers, people trained to do their work. All trades and professions call for training for and knowledge of the particular branch of work undertaken. But what about young motherhood? The young girl marries and in the course of time finds herself a mother without ever having had a word of instruction or how to perform the duties of motherhood, and to give that child the attention and training it should have in order to make it into the best class of citizen it is capable of being. All the girl has is her own intuition and love for her baby, and she has to depend on getting advice from very incapable people in many cases, and the result is that her whole care of the child is experimental. The pity of it is that it results in a terrible wastage of human life, often of the best type, that might have been saved through the knowledge of some of the ordinary rules for the care of the child. Not only must she know the way to take care of it physically, but she must understand that that child is not all physical. She must realize that it is not an absolutely new thing that she can train in any way she chooses; while it is true that training does a great deal in the forming of the child's habits and preparation for its life, it is also true that that child has a disposition and traits of character that no amount of training can entirely overcome. It has tendencies to good or bad habits, a predisposition to 8 Geo. 5 Provincial Board of Health. G 141 certain lines of conduct, tendencies to contract or resist disease, and a general make-up that is entirely bis own; and surely it requires a great deal of knowledge, tact, and ability to mould and form that little personality and direct it along right lines, with wisdom enough to know when to develop and when to suppress. Truly some training is necessary for this great undertaking, for great it certainly is. But she gets none. She learns as she goes on and the child is always there to practise on. How many young mothers know how to feed a baby properly if the natural food for some reason or other is lacking? The more the baby cries the more food it gets, and the more food it is given the more the baby cries. And so it goes on from bad to worse, until both mother and baby are physical wrecks. If by any good fortune the child survives, it often takes years to recover, and in many cases it never recovers altogether. This lack of knowledge of the proper way of feeding children does not end with babyhood. Indulgence is one of the crimes of our day. It begins in babyhood and goes all through life. The child must not be denied anything. It likes candy ; therefore it niust have candy, and plenty of it. Whatever the grown-up members of the family eat the baby must eat too, and the result is that tbe child is taking food quite unfitted for its digestion, and containing tbe wrong proportions of the different substances contained in food. For instance, many mothers do not know that meat and milk should not be given at the same time. Perhaps they have learned the fact, but if so they do not know the reason why, and so do not act on it. The child gets all the meat at once; it usually wants a good deal; and, of course, nearly all children have plenty of milk. There is also a great deal of irregularity in feeding the child. The pantry is open to it at all times of the day, and the result is that when the regular meal-hour comes it is not hungry. It should be taught that the time to eat is at the regular meal-hour, and that it must eat slowly and masticate its food thoroughly in order to get a proper amount of saliva mixed in with the food to help to digest the starch contained in that food. To do this it is necessary to have plenty of time for meals. I don't know how a child can do this if the time allowed is only one- hour; but of course it can't, and so we preach one thing and make conditions so that the child must do tbe opposite. One hour and a half is the very shortest time that should he given at the noon hour, for that is the principal meal of the large majority of children, and they should not have to " bolt" it and run. It would seem as if it would be a very wise thing to have a course for the " teen" age girl along lines that would train her for the duties and responsibilities of motherhood, a course that would give her an idea" of the amount of food to be given to a Raby and the proper length of time in between feedings, ahd the importance of regularity; tbe age when the child might be given solid 'food, and so on; also some instructions on clothing, so that they may know when a child has enough on and not too much. Too much clothing is a very frequent mistake, even more common than not enough. They should also be taught about tbe importance of sleep, fresh air, sunlight, and many more every-day facts. The home-work problem, too, comes in when dealing with the welfare of the child. Play is as necessary to its development as work, and if the hours after school are filled with work, when can it get its play? Either play or sleep must be sacrificed and both are absolutely essential. It seems as if for many years the child should be able to get all its instruction in schools, and that the rest of the time should be spent in other ways. We should try to make conditions so that this may be accomplished. Even in high schools it seems as if the amount of home-work boys and girls are required to do is enormous. It is not the fault of the teacher; it is our system that is at fault. I think we are trying to fit round pegs into square holes and square pegs into round holes, trying to make the child develop along lines where it has no- aptitude, instead of along the lines it likes. What we want to do is to fit the child for living, so that it may do well its life-work, whatever it may be, and to give it a sound mind and a healthy body, so that it can perform its tasks with ease and pleasure. Sleep is a very essential thing for the child, and its importance should be kept constantly before the minds of parents. Who has not seen little children from the ba'by-in-arms stage up dragged out at night to all sorts of things—picture-shows, concerts, and even dances being well patronized. There is no objection to these things in themselves, only the child should not be there. It should be asleep, but the idea that the child must have the same as the grown-ups is becoming far too prevalent. How can any one think that night is the proper time to take a three- or four-year-old child to anything? By that time the child is ready for bed; development goes on so fast in the little body and mind and so much waste material has been thrown off that G 142 British Columbia 1918 it is in no fit condition to have more heaped upon it; but the mother must be amused, the child must be amused, and so out they go. Of course, this does not amuse the child; it only tends to tire and weaken it, and helps to place it later amongst the physically unfit. The child is very easily amused in reality, and if left to itself it shows this at every turn. Give it space and a few simple toys that it can " do " things with, and then it will have real amusement and real benefit. But the fault lies with the parents. The child is the toy of the household. We think we are amusing it when we are gratifying our own selfish desires. We like to see the child dressed up; we like to see it doing smart things; and so with wrong ideas of tbe whole child- nature we bring it up with wrong ideas of living and of the world it lives in. A child whose whole idea of amusement and whose whole thought is of self, nothing but the material does it know anything about, and 'who is to blame? It has been brought up on excitement and amusement; it began when it was a baby; never a quiet moment did it have. When it was in its cradle it was rocked; when in its carriage it was shaken; if on any one's knee it was jumped up and down, then tossed into the air to land no one knew where, and thumped and patted, dandled till one became dizzy watching the performance. Tbe child is formed the same as any grown-up person, and I don't believe we would enjoy all this diversion. It may be pleasant to be tossed into the air, but none of us are anxious to try it. The child should be kept quiet with as little. handling as possible. It should have the use of its arms and legs and be allowed to use them freely, and should be allowed to develop itself. Gymnastic exercises for it given by some one else are not required. Nature takes care of all that, and all that is necessary is for it to be allowed to develop in nature's own way, but no such good luck! As it grows older our modern civilization seems to demand still more excitement for it. When Christinas or a birthday or any special occasion arrives, every one, father, mother, sisters, brothers, friends, and relatives, all conspire to give it a good time. The good time usually consists in working it up to the highest pitch of excitement; everything is piled on it; toys of every description, and never-ending, are there for a surprise, until it is so tired and worn out that there is no pleasure in anything for it. The day usually ends in its doing something very naughty, and the parents cannot understand how it can act so when every one was so good to it. One feels sorry for the child with too few toys and too little attention, but tbe child with too many toys and too much attention is more to be pitied. Too few people understand the simplicity and beauty of child-nature. The simplest thing amuses them; expense and costliness are quite outsjde its grasp, and we only flatter our own vanity when we heap costly things on it. All this is wrong, absolutely wrong. We must 'bri*ug up the child so it will develop into the capable man or woman, strong in body and in mind. With so many of our best men gone we must have healthy and capable men for the future, or what will be the result? The past we have nothing to do with now, but we must strive to be the guardians for the health and welfare of the future. The moving pictures figure so strongly now in the life of every child that it has become a real factor in its welfare. I have no objections to moving pictures for the child, provided the picture shown is of the proper kind and it is taken at the right time to see it. It is such a splendid opportunity to put such wonderful things before the child's mind, that there seems no reason why anything else should ever be allowed. I think all health authorities should take a great interest in the moving pictures, with the idea of getting things put on that are of an educative value, things that will not cause nerve-strain and mental exhaustion, and give the child a wrong idea of life. Not long ago I went to the moving-picture theatre to see Hall Caine's story " The Deemster " put on. It is a tragedy from beginning to end; the place was filled with children; all ages were there, from the baby in arms up. When a terrible quarrel occurred between two men, a small child near me said: "What are they doing?" The answer was: "They are trying to kill each other, dear." Yes, just tbe simple little thing of murder and tragedy. A most fitting subject for the child to see! Is that the right thing to put before the child's mind? I do not criticize the play, but I do criticize the fact that children were allowed to see such things. Not only does it see tragedy, but even worse. It often has phases of life put before it that cannot help putting into its mind ideas that lead later on to loose habits of thought and action, suggestive things, that surely lower the standard of living; and lower standards of living tend to lower the race in every way, physically, mentally, and morally. The child suffers a great handicap from the suppression of its natural curiosity to know things. All life and its problems are before it, and these problems are before the child-mind very 8 Geo. 5 Provincial Board of Health. G 143 early. It seems to be a prevailing idea that a child's questions should be ignored or answered wrongly. It is true that its questions cannot always be answered, but in cases like that the reason for not answering them should be fully explained, and whenever possible the proper answer should be given. What difference if it does take a little time; there is always time for anything you want to do, and you never can spend time in a better way. The child with the alert, active mind is the one we want to develop, and in order to get tbe best results we must satisfy its desire to know the reason why. The whole child-life is "Why?" And when it is brushed aside with a " Don't bother me," there is something suppressed in that child which is invaluable. Then, too, it will often do a wrong thing because it does not understand, and very often a good explanation of the reason why certain lines of conduct are wrong will do it more good than a whipping. Not that I think whipping should be done away with altogether, but one should be very sure who is to blame before it is given. The child never forgets an injustice, and I think most of us carry in our inmost minds the remembrance of some perhaps very small thing for which we were punished when we did not deserve it. It has left a scar and a feeling of resentment. We must be just to the child, first and, foremost. By that, I do not mean indulgent, for often the most unjust parents are the most indulgent. So much harm could be prevented by frankness between the parent and child. The parent should explain the dangers that may beset it and give it a chance to avoid them. The child does not know much about the dreadful diseases in the world, so we should be fair and square enough to warn it in time. Prevention is better than cure, even if a cure can be effected, which is not always the case. The child who goes out into the world unwarned and ignorant, and, not knowing, who is led astray, has the right to ask its parents " Why? " You have only to walk up and down the streets in any city at night to see things that appal you. Young girls unescorted and dressed in a style altogether beyond their years and means trying to make themselves look attractive. Their mothers have never warned them; they have gone their own way from childhood, and many a girl that might have been innocent and healthy, a credit to society, is lost to all good, simply because her mother was careless. If parents only recognized their responsibility to the children and were frank and just enough to warn them, society would have fewer outcasts and much less disease to deal with. Not only does the girl need a guiding hand, but the boy as well. Many people forget that the boy has a hard row to hoe, perhaps even harder than the girl. He is allowed liberty because he is a boy, simply because results can not occur the same as in a girl. They forget that there can be awful results, far-reaching and degrading, resulting in loss of health and things that make life worth living. We are allowing the children the liberty of the adult without the knowledge of adult life to protect it. It is often blase when it is sixteen, nothing left for it to know. Home-life is ceasing to be a factor in our civilization; too many attractions outside. The home must come into its own again; it is essential for the bringing-up of the child. For the welfare of the child I would suggest singing. It is good for it, mentally, morally, physically, and spiritually. I wonder if the statement that the Canadian child is lacking in musical taste is true. If so, it is largely because it has been ignored as a national asset. Singing should be national. Almost every one can sing if he or she gets the opportunity, and the opportunity should be given to every one. Not that every one should be trained especially to sing, but music should have a very prominent place in every school and in every home. Singing makes a better child. It develops its lungs and puts into that child a something that is indefinable, but which we have all felt and which we all know. " The man that hath not music in himself, nor is not moved with concord of sweet sound, is fit for treasons, stratagems, and spoils." Let us try to put into every child's mind the memory of sweet song; let us have music as a necessary part of tbe development and training. No crimes are committed with songs on the lips; song is tbe accompaniment of joy and happiness, brave deeds, and noble impulses, and to me seems a most necessary thing in the full development of the child nature, which we all know is very complex, and which must be considered on all its sides; and, while not forgetting the physical, we must remember that it depends to a very large extent on the development of its other nature, mental, moral, spiritual, and testhetic. We are not developing merely the animal, but something made in the image of God, and so this many-sided problem must be faced; and it is the study of a lifetime how to make the world a good place for the child to live in; how to fit the child to live as a child first, then as an adult capable of performing in the best way the various duties of life. We don't want the child just to be good; we want it to be good for something. Too much cannot be said in favour of our public schools, and every advance made is of incalculable value. Although children are born in all kinds of conditions, here at last they are on an equal footing; here there are neither rich nor poor, high nor low, no class distinction. They are all children together with the same instincts, tbe same love of play, the same everything. Here is where the child gets his chance, rich and poor alike, and so everything tending towards the betterment of the school is well worth while. It is coining about that the bodily development is considered as important as mental development. We are realizing that the mind must exist in a healthy body to give the best results. There is a great deal to be done yet, for we have not yet reached the point where all may get attention free of charge if necessary. Many a child still has to bear tbe hardships incident to defective teeth, enlarged tonsils, the existence of adenoids, and many more diseases that react upon its mental improvement. Probably the greatest problem that the Medical Inspectors of Schools in towns and outlying districts have to meet is the impossibility of getting the teeth attended to. Dentistry is very expensive, and it is simply impossible to have teeth attended to when there is a large family. It is not much use to send the notice to the parents, " This child 4s in need of dental attention," when you know quite well there is not money enough to buy food and clothing. It almost seems as if the old saying, " Where ignorance is bliss, 'tis folly to be wise," would fit here. We are all looking forward to the time when we will have dental inspection as a necessary part of our school-life. So many ills are put down now to diseased teeth that one has to keep very sane in order not to become quite panicky when yon see hundreds of children with diseased teeth, and you wonder if they really are all going to the bad. There is one thing in connection with teeth that I would like to say, and I will give an example of what I mean. A boy aged about eight years was found to have no teeth, either above or below, on either side, beyond the canine teeth. When asked what happened to bis teeth, he said that a doctor in a certain Prairie town had pulled them. " They were aching," he said, " and the doctor thought they might as well come out." " Was there not a dentist in the place? "' was asked the boy. " Oh, yes," was the reply, " but the doctor always pulled our teeth." Yes, he pulled them all right, six-year molars and everything else. He made a clean job of it, but if be had seen the misshapen jaw I am sure he would not be very proud of his work. That child did not get any teeth for years. It is true this was worse than is usually found, but too often the six-year molars are pulled, and not often by dentists either, so I feel like criticizing the medical profession on this point. The six-year molar is the most important tooth in the mouth; it is the key of the arch, and should be saved whenever possible. Goitre is one thing I see no hope for. It is very prevalent in Nelson; ISO cases were found in our schools last year, and there are probably as many more in children under school age and. adults. No bad results have occurred from it. It seems to be all of the simple kind, but it is very disfiguring, to say the least, and any theories or knowledge of its cause would be very welcome. In concluding, let me thank you for the privilege accorded me of reading this paper and for* your kind attention. Discussion on Dr. Arthur's Paper. Mr. Biker (Nelson) : I wish to congratulate Dr. Arthur on her very capable and very broad view-point expressed in her paper. While I am only here as a layman, practically, among* a crowd of doctors, I feel tempted to have nothing to say; but I can give you my view-point.. I might say, with regard to the curriculum in our schools, I think this subject might be included. Another salient point is that we have tbe future in our hands, and we ought to be- able to handle that. How many of us as parents warn our children of the conditions they have- to face? This is rather an important point. I would like to hear more with regard to the question of goitre. I believe we have an awful, lot in our town; this disease is very prevalent in the higher altitudes, and I believe about 90 per cent, is found in the altitude between 10,000 and 15,000 feet. I would like to hear more on that. Dr. Petersky: First I want to congratulate Dr. Arthur on that paper. I think it is the- most important paper on the programme. In my experience I have found that the ignorance* of the people in this Province is appalling. To illustrate that: I had a little child in my care,, the son of the Stipendiary Magistrate, who is supposed to be a man of judgment, and when food! 8 Geo. o Provincial Board of Health. G 145 was kept from this child for twenty-four hours, this man said he wasn't going to have that baby starved. After he saw the attack was cut short, he did have tbe grace to apologize. With regard to the inspection of schools, I have inspected schools in a country district principally around the Cariboo, and I find teachers as a rule—though some of them are polite to us—they think we are a blamed nuisance coming and interfering with their work. That is the way they look at it. The average teacher is just as ignorant as to why schools are inspected; they didn't read the pamphlet sent out by the Government, and not a teacher was conversant with it until I carried out the system adopted afterward, of giving them one week's notice, telling them it was their duty to read it as a teacher, and they had certain duties to perform for the School Inspectors, such as examining the youngsters' eyes, and they could find out certain things which would come under their notice, such as a limp, or curvature of the spine, and it was their duty to look after such things as well as the education of tbe child. They think they have only to teach that two and two make four, etc. I think the Health Department ought to take that up and make the teachers realize that this is a very important branch of their work, and they may treat the School Inspector with a better spirit. Then you take the average mother; that is a point to which I have given some thought, and although the general public limit their powers by making the laws of health, etc, I think the average mother should have a certificate that she has the education to fit her for her position. For instance, she should know enough about cooking not to poison her husband, and she should know enough about mixing various formula? of milk in case it is necessary, and also know what disturbances may be caused in tbe stomach. Personally, I haven't any children yet, but if I have I shall consider I have to put in my time to look after them; and as to entertainments, one of the parents—fortunately there are two—will have to stay home to look after the youngsters. I would not trust a child of mine to any nurse. In some cases children are left in the charge of women who drink, and what can be expected of the children if they have such a nurse for an example? It in all very well for us to get together here and read papers as to what we ought to do, but how are we going to get people to believe we are.not faddists and not carried away by our impulses ? Dr. Arthur suggested singing. I might carry that point a little further, and say any innocent amusements that will occupy their time; and for the parents, I think it should be made compulsory in the high schools and Normal Schools particularly that teachers should be obliged to take first aid and should be taught to respect the Medical School Inspector. Dr. Vrooman (Medical Superintendent, Tranquille Sanatorium) : I think Dr. Arthur's paper deserves much praise. I do not wish to take up much time on this question of " child-welfare," but there is one suggestion I should like to have taken into account—that is, the education of the parent. The parent cannot be educated by the physician, except partly. A great deal has been done in this city by the Child-welfare Committee, the Babies' Hospital, etc.; incalculable good is being done. Why not extend that beyond the City of Vancouver? Why not extend it into the rural districts by the appointment of nurses who will go to the rural districts and educate the mothers? We are not educating the mothers by making laws; it is a woman's influence with a woman that counts. A sympathetic nurse can do more than a medical man, and I think one suggestion arising out of Dr. Arthur's paper is that nurses be appointed for the rural districts in British Columbia. Mrs. Clark: May I ask a question as to the point about goitre? It is a prevalent idea that water has something to do with it. I had an examination made of Vancouver water, and a physician said it would be advisable to give my children a small quantity of lime-water each day, and I did so; but very few mothers know about that, and many have asked me if the lack of lime did not cause goitre. The Chairman: I was going to ask Dr. Young to give statistics on goitre later on. Dr. F. W. Brydone-Jack: I had great pleasure in listening to the paper this morning, particularly the non-medical side of " child-welfare " ; and then again the practical application with regard to dentistry, the prevalence of goitre, and the education of the parents. In connection with the education of teachers, I think that could be arranged in Normal Schools by having lectures given on " child-welfare " by some doctors at some time suitable to the principals of the colleges. 10 G 146 British Columbia 1918 In connection with the child-welfare movement, when down East this summer I saw the well-organized plan in Toronto. Whenever a child is born its birth is registered, and the Mayor sends a card of congratulation, telling of its value to the State. This contains a pamphlet of six pages describing methods of feeding, and illnesses, etc. It has twenty-eight child-welfare clinics, and a staff of nurses doing prenatal work in these child-welfare classes, and then the visiting of the school-children. In connection with births in -the public wards of tbe hospitals, it is almost compulsory that these matters be attended to. Dr. Brown has charge of this work for the City Health Department in Toronto, and also the present head of the work in the Children's Hospital there. When a mother leaves the public ward she has to take the child to the child-welfare clinic once a week for measurement, weighing, diet. etc. If the mother neglects to do this—at the present time they can almost compel her to do it—they take the matter up in the Courts as a mother being neglectful of the child. But the majority of women take the children to the clinics without any trouble. I think in New York there are about fifty-seven clinics, in Montreal twenty-eight, and they are spreading all over the country here. In Toronto they call them infant-welfare clinics, but they are child-welfare clinics because they look after children up to school age, and many defects which are found usually in children after entering school are in this way remedied before they come to school, because most of the defects found, as you know, in school-life should have been remedied two or three years before the child came to school. Dr. Stanier (Medical Inspector of Schools, Oak Bay) : I was much interested in Dr. Arthur's paper, and I hope she will let me have a copy of it, as I would like to take it home. Of course, by the very nature of that paper, it is sketchy. What I think would do a good deal of good would be something along the line of fiction, giving more intimate details of the bringing-up of children. There is no more popular book than " Helen's Babies " to show that a child should not bring up its parents. I think many of the clever writers to-day would be able to write something that would be humorous and well read by many mothers who are perfectly willing to know something about children, but do not like to be educated in the strict child-welfare way; but ranch that is informing could be introduced into a work of fiction, that perhaps would take up the first year of a child's life, or perhaps up to two or three years of age, and, later on, the school-life. Nine out of ten children born, I think, are born healthy, even if tbe parents are comparatively unsound; if properly fed and looked after the first year, they will grow up strong and healthy citizens and overcome tendencies to disease if properly handled during the first year or two. What the last speaker said about clinics is important, but I would like to see something written along the line of fiction, and I am sure it would be a book widely circulated and read. I haven't time this morning to criticize much, and there is very little to criticize. With regard to teeth, I have seen a number of young children with their milk-teeth practically gone. There is a theory that the sticky white flour is responsible for it, or eating sugar at night. About the only instructions I give to parents about these things is not to let a child eat sugar after supper, or to thoroughly clean the teeth after doing so. I know the use of sticky, fine white flour produces decay and tends to disease much more than we are aware. Dr. A. G. Price (Medical Health Officer, Victoria) : I think we ought to be congratulated on having the opportunity of listening to such a valuable paper on " child-welfare," so very full from beginning to end. It is only twenty-four hours ago that I was attending a meeting at Victoria, where we are starting late, but we are starting a child-welfare campaign. I only wish this meeting had taken place a few days before or our meeting a few days after, so that I might have had the advantage of this excellent paper. It is so very full that to touch on all the points would be impossible in the time given, but one point I am rather interested in and would like to touch on is the prenatal child. I do not think that enough importance is placed upon this point. Only the other day I had a letter from Dr. Plastings, of Toronto, asking for information about the child-welfare movement in Victoria. I gave bim the information, but finished up by saying, " You have got hold of the wrong end of the stick—you must get at the prenatal end." If you look through the statistics of the different cities—I know Victoria better than any other city— you will find an enormous death-rate among children under one year old, due to still-births, premature births, and malformations at birth. I can tell you, out of 101 or 105 of the infant deaths under one year old in Victoria last year, I think seventy-five were from prenatal causes— still-births, premature births, and malformations which we are in our present state of knowledge not able to account for. We know this; that maternal impressions are carried on to the offspring. 8 Geo. 5 Provincial Board of Health. G 147 For illustration: In one case where a baby was expected in about five months' time, the mother was in a crowd, and a man came up and drove his elbow in her chest and made a dent and a red mark. The baby was born with that dent and red mark. It is a deep dent which with a little excitement gets red. Another case, just for illustration, is this: An expecting mother came to me with a little boy who had been rolling a hoop and had fallen on the hoop and cut his lip. She was in dreadful distress lest her baby should have a split lip. I laughed at her, to prevent her having the impression, but when the child did arrive it had a split lip in the same place where the older child had been cut by this hoop. I know of another case, where a butcher was lifting a piece of meat from a hook, and the hook fell and tore his face in a horseshoe cut. His wife at one time had broken her finger at the top joint. Three of their children had no top joint to the finger, and two girls had a horseshoe mark on tbe face. Mental defects are carried down in the same way, and it is most important, I think, when infants are on the way, that expecting mothers should have some instructions. I would say that girls before leaving school should be given some instruction on how to live at that time, both mentally and physically. I come across many cases where the unfortunate mothers are out at work—husbands are ne'er-do-wells and the women are working for their daily bread. What can you expect to see in the offspring? I think this question should be brought up very fully. There is one book I advocate in Victoria; I got it from the Provincial Department; it is published by the Metropolitan Life Insurance Company, and given away free, called " The Child." It first gives the prenatal treatment; the mother, her treatment; and the treatment of the child from tbe first, its feeding, etc. It is a very small book, but I have advocated that it be placed in every public school in British Columbia, in Canada, and in the British Isles. It is a most useful book, and unless you give the mother something to read she will forget what you tell her. I wish to thank Dr. Arthur for her excellent paper. A delegate: I think we should congratulate ourselves on having Dr. Arthur here, opening up new phases of child-weifare. In our schools, if we were in touch with the boys and girls on the fundamental principles of life, when they get out to work, they would have this knowledge to guide them, and I think a great many of you will agree with me that if this were done a great many diseases and imperfections in our children would be eradicated. The State would not be called upon to keep these children and we would be a better nation. To my mind this is the fundamental principle that we should carry out. Mrs. Clark: I was convenor of the better-babies contest a few years ago, and we found a great lack of little pamphlets to distribute to the mothers. We were absolutely dependent on the Metropolitan Life for our literature, and we have thought since it would he an advantage to have the Provincial Government publish some little pamphlets to be distributed at such a time, when so many mothers and babies are congregated together. Dr. Young: Our intention is to distribute as much literature as possible. The baby contest in the Province was a new feature, and there is now a pamphlet pertaining particularly to these points under publication which will be distributed very widely, especially through Women's Institutes. Now, in reference to goitre, I found when I went into this some two or three years ago, in conversation with medical men, the question of goitre came up, and I took the matter up at the time, and called it to the attention of the Medical Inspectors, asking them to pay particular attention to it; and from their reports during the years 1915 and 1916—unfortunately our inspection was not carried out during the past term—but up to the beginning of the last school term there were 1,633 cases of goitre on the school reports. This is not by any means the number of cases in British Columbia, but a report simply of the children of school age; and it was very alarming. It was not confined to any one district in British Columbia ; I found it from the north to the south and from the coast to the east border. Through the Okanagan the percentage of cases was probably much higher than in the other districts of the Province. I took the matter up with the medical profession in general, and asked the Victoria Medical Association and also the Vancouver Medical Association to conduct some investigations along these lines; and the Vancouver n^ssociation kindly took the matter up at my suggestion aud appointed a committee; and I had an interim report from them, saying later in the season they expected to be able to give further data with reference to the matter. In the course of investigations I found not only humans affected, but animals, very much affected. I took it up with Dr. Haddon, of Agassiz, and he confirmed this; and Dr. Tolmie, G 148 British Columbia 1918 Dominion Veterinary, asked me about it. and I gave him some figures I had. and he agreed that it was very alarming. He informed me that the existence of goitre amongst animals was so serious that it meant a very great economic loss, and he was asking the Department at Ottawa for sufficient funds to conduct an investigation. The percentage of cases among the population of our Province is probably not greater than we should expect in a Province like British Columbia, where we have a shifting population. Following the knowledge I obtained in the reports, I wrote the Medical Inspectors and asked for their views, and they are agreed as to its prevalence; but unfortunately, owing to the carelessness of the profession, they did not pay any particular attention to the matter other than the fact that they regretted the condition, but I got what information I could from them with regard to their private practice. There does not seem to be any consensus of opinion as regards its source or origin. The theory of water-inspection was applied generally to the Province, as we are a mountainous country and the source of our water is glacial, snow-water. Whether it is microbic or not, I hope to be able to ascertain. It is a matter to which the profession should give particular attention. It is alarming. There seems to he after puberty a decrease in the number of cases. We are not peculiar in the existence of goitre here, but probably in its distribution. In other countries and in the East they have these epidemics of goitre from time to time, and I wish tbe medical profession would keep this in view and try to arrive at some solution and advise tbe Department. Mr. Biker: I believe we have localized within the District of Nelson over 400 cases in adults and children. Here, in my opinion, is a specially localized field, and I think, when an investigation is being made, we should have some investigation in.Nelson, as we have so many cases. Dr. Wrinch: I think we should be able to obtain some concrete results from this conference, which should be made as valuable as possible. With regard to disseminating information to the young, I have been pondering on that question for a moment after listening to this very full paper, and I wondered if it was sufficient to instruct the high-school pupils on questions of sex, maternity, etc.. also on diseases. Would it not be possible to use our present organization of school examiners to speak upon these all-important matters to both sexes during adolescence and early adult life? I fear it would not be sufficient to wait until the children are in high school, because a great number do not attend high school—a large proportion do not; we must reach them earlier. Could not some arrangement be made whereby children could be taken by the Health Inspectors in the Senior and Junior Fourth classes before they scatter, taking the boys and girls separately and lecturing to them as to the evils to which they are liable? It is very important that they should be taken separately and that the instruction should be given by medical teachers and not by school-teachers. In order that the information should be along the right lines and as carefully condensed as possible, perhaps the Department, by means of a little committee called together, could arrange a pamphlet of instructions to be given to Health Inspectors, outlining a course, so as to make the teaching uniform. These are just suggestions that have occurred to me as possible, whereby practical results along these lines could be obtained. Dr. Isabel Arthur (replies to discussion) : I think the greatest difficulty that I have found is to get the people to hear any papers or lectures on this subject. Several times I have advertised that I would give a talk on certain matters. When the time came I would look at my audience and I would not see a person there that I wanted to be there; that is, people who should be there were not there, and the people who were there already knew. I think it would be a very good idea if the Medical Health Officers were to publish in a weekly paper an article on " Child-welfare." It would not be a* very hard matter to write a small article each week, and in that way get a great deal of information before the public. As to the question of teeth, I have found in examining the schools that the Chinese boys and girls seem to have better teeth than our boys and girls, so I presume it has something to do with the food; whether it is sugar or not I do not know, because I do not know whether or not the Chinese are sugar-eaters. About the difficulty between Medical Inspectors and teachers: I have not found any difficulty along that line. I think one has to give tbe teachers credit for being very reasonable and rational S Geo. 5 Provincial Board of Health. G 149 in their treatment of the Medical Inspectors. I have not found the teachers in the schools I have had anything to do with anything but reasonable and rational, and they do everything I ask them to do. I think the suggestion that a pamphlet be prepared by the Government as to teaching in the schools, public and high, is a very good one, and I think it would be a very good way to get the knowledge before the children. The Chairman: Ladies and Gentlemen.—I have received a communication which I will read. (Reads communication from Dr. McKay Jordan.) Note.—It is moved and seconded that it be laid on the table. Tbe Chairman: It has been moved and seconded that this be laid on the table. All those in favour say " Aye." Contrary, " No." The motion is carried unanimously. The Chairman: I will now call on Dr. B. D. Gillies for his paper. Dr. Gillies's Paper. (The Provincial Board of Health regrets that they have been unable to get a copy of Dr. Gillies's paper at the time of going to press. They have, however, included in this report an account of the discussion on the subject-matter of "Mentally Defective Children.") Dr. Margaret Pitcairn Hogg (of Victoria) : I have listened with a great' deal of pleasure to Dr. Gillies's paper. This subject is of particular interest to me, and I think there is a crying necessity in British Columbia that some institution should be formed for these people. I was Resident Medical Officer in such an institution near London, which supplied the needs of all tbe schools of the London County Council and several counties. We took these children from the age of about four or five, before they reached the school age, and kept them until they were sixteen, segregating boys and girls in different houses. They all attended school and each child had individual training. I think some provision should be made to show that they should not be allowed to go into the world to swell the army of unemployable. We have 2,000 acres entirely run by the boys from our schools. In British Columbia, where there is so much waste land, i: would be a splendid thing for these children and adults to 'be put on a large farm and properly trained, as Dr. Gillies so aptly puts it, and keep them in proper associations as far as possible. Dr. Turnbull (South Vancouver) : I wish to speak in appreciation of the paper by Dr. Gillies, and to say that the points as uttered in his paper express my opinion very clearly in almost everyparticular. During the last year I think I have had seven cases come to me, most of them in families who have little of this world's goods, with some of the members of their family mentally deficient. Three of these cases could only be sent to Westminster Asylum, and that is not very satisfactory. Three were children; I scarcely think that is a proper environment for them. In two cases the mothers were dead and there were no friends to take them. We tried sending one to the Salvation Army for a time, but it didn't work out very well. The idea of a farm seems to me the proper idea. The Provincial Government, I believe, has had this under consideration for some time. I myself have written them, but they said they were unable to see their way now to do this, but I think they intend to take some steps in the near future regarding this matter. Dr. J. H. McDermot (Vancouver) : I just wanted to speak on one phase of the subject that Dr. Gillies did not bring in in his paper. We have enjoyed the paper very much, I am sure, and, as pointed out, there are a great many things we do not know; but there is one point that I think has not been touched upon very-much, and that is the border-line cases as they appear in our schools. Some little time ago there was some question as to establishing classes for mental defectives, and I tried to collect some data from tbe teachers, asking for the children in their classes. There were quite a number of names handed in, and I took each one of these pupils and examined them. We found there were more backward children than actually mentally defective children, and the trouble was due in many cases to defective tonsils and adenoids, and when these cases were properly treated a great many of these pupils came back to the class and kept up in the way they should be going. When these children were eliminated the number of mental defectives in our city was found to be too small to institute a special class for them. Of those children who are left, they are in some cases children of alcoholic parents and of people who should not be at large, as far as we can make out; at auy rate, they should not inflict such progeny on the community, and the G 150 British Columbia 1918 question is, how is this, thing to be controlled? I would like to hear from Dr. Gillies something along that line. Mr. Biker: I wonder if there is anything in the view-point of the number of children in a class in school? In some cases there are forty-five or fifty pupils in a class. How is it possible for a teacher to attend to that number if 20 per cent, are backward children? Dr. Stanier (Victoria) : Victoria City has a class supposed to take care of mentally defective children, but there is no compulsion to take them out of a regular class and put them into this class for instruction. No doubt the education is much better carried out along the kindergarten lines than along ordinary rules,, and I think it would be well to establish a farm colony. I find the trouble is the parents are often mentally defective also, and you have great difficulty in convincing them that their offspring are not right. It is, upsetting the class, having such children in it, and I think some compulsion should be brought about; it should not be optional with the parents whether the child be sent to school or to the class for mentally defectives, or the farm colony. Dr. Fetersky: I am very glad the last paper has taken up that point. I think it is a most important point. I think this is up to the Health Department. TTie teacher should be made to report children who stay more than two terms in one class. There should be an investigation by a medical man to find whether the child is mentally defective or not. If the child is mentally defective, it should be removed to a special school or institution where the others are in the same fix and the grades are standardized. In other words, it creates the environment Dr. Gillies spoke of. There are some boys and girls who have a tendency to be mischievous, and if put among thieves they become thieves. 1 think we should take this matter up; it seems to me the Provincial Government are neglecting the Health Officers' Department shamefully in a way. You cannot make the ordinary layman see that it is important. Dr. F. W. Brydone-Jack: It gave me great pleasure to listen to Dr. Gillies's paper. Personally, I want to see action on this sooner than on anything else that may be brought up here. In Vancouver we have twenty-four children attending the mentally defective classes. There are in addition about fifty in Vancouver who should be attending them. We cannot get enough teachers to handle them; the School Board has not seen its way to appointing a sufficient number to handle the whole feeble-minded proposition in Arancouver; but in regard to sending children to the class, the Municipal Inspector has the power of defining the school which any child shall attend, and if we report to him that a certain child in a certain school is mentally defective be can tell the parents that he assigns the child to this class, and the law supports him. We have only given that power in a few occasions, as we haven't enough teachers to look after the number we have here. I think the educational authorities can look after the education of the feeble-minded children up to the age of twelve or thirteen years. After that they become a harder problem to deal with. After girls get to that age, we from time to time have them in the Law Courts for having been taken unfair advantage of by men; we had two or three cases last year, and a case the other day, and it is up to us to look after these children. The only way to protect them is to put them into an institution such as Dr. Gillies has suggested. We can teach them manual training and domestic science and make them self-supporting, but they should have constant supervision. In the Old Country they find turning them loose in the world is wrong, because they do not attempt to remain employed and become criminals. We could keep them in a colony farm, where they could be self-supporting. At the present time they are turned loose on to the community at sixteen or seventeen and they become troublesome, and may later become criminals. A number of. parents have approached me and asked if it could not be arranged to have the Government take charge of their children; they know they cannot handle them, and want Government control, as that is the only way of looking after them properly. When in Toronto in July I had a talk with Dr. McMurchie, mentioned by Dr. Gillies, regarding the farm-colony control of these children, and she suggested that m British Columbia we should start in a small way, say in a good-sized house having eight or ten girls under a suitable matron, and then, as the fund increased, more buildings, and then have the farm-colony principle. Mrs. Clark: Speaking for the Local Council of Women in Vancouver, this question has been of vital interest to us for some years, particularly since the beginning of tbe war, and last June we had a very able paper, and a resolution went forward asking that such an institute 8 Geo. 5 Provincial Board of Health. G 151 as mentioned be established in British Columbia, not for the Dominion, but one for our own Province. Dr. B. D. Gillies (replies to discussion) : I do not think we should leave these children or throw them on the public at the age of sixteen. This is especially the time we want to have hold of them. They are ready then to go out and propagate and everything else, and just carry on what we are trying to control; and it is most essential that the Government should have permanent control of these people. We make them self-supporting; they are self-supporting in a proper environment, but they should be kept under control. There are a lot of things that one could have touched on, but it was utterly impossible for me to have prepared a paper of that character. I know it was deficient in many respects. I cannot deal with the method of organization of caring for these cases, but if we have a place where we can treat them, we will find out those deserving of such treatment. I wish to thank you for the way in which you have received the paper. Dr. Turnbull: I would like to make a resolution—that the Medical Health Officers and Medical Inspectors draft out and present a resolution that the Government should take steps to make some arrangement along this line. The resolution was seconded and carried unanimously. The Chairman: I will now call upon Dr. Stanier for his paper. VnVCCINATION. By F. T. Stanier, M.D, CM, Medical Inspector of Schools, Oak Bay, B.C. Mr. President and Gentlemen,—I believe I am called on to read a paper on that threadbare subject, " Vaccination," because as Inspector of Schools in Oak Bay Municipality I was fortunate enough to have a Board of School Trustees sufficiently enlightened to take my suggestion during the recent outbreak of smallpox, and under the " Health Act," section 7, subsection (11), compel every pupil attending either to be vaccinated or procure a certificate of exemption before they could be admitted to the school. The Victoria Medical Society had previously passed a resolution that the fee should be $1. The children were told to apply to their own medical men and were given three weeks. Toward the end of that time I attended at the schools and vaccinated a few who had no doctor who brought their dollar with them, and a few more who wished to be vaccinated but had no dollar. The conscientious objectors numbered more than I expected, noticeably among the poorer and more ignorant parents, many of whom were worked up by the usual extravagant letters to the papers by objectors who quoted horrible instances of infection; all of which occurred at remote times and places, and were past disproof, but not without influence. I found that the giving of certificates of successful vaccination was not being carried out, and not to make too much fuss I examined many who had been vaccinated and had not got certificates, and in doing so I was struck with the many different ways vaccination and the after-treatment of the sores is done, and this paper is a plea for uniformity in this little operation. One man makes four marks, another three, and another only one. One doctor puts on a shield, another a great thick dressing of cotton wool, and a third neither washes the arm nor puts on any covering. It is immaterial whether vaccination is done on the leg or the arm (one pretty little maid showed me her thigh—"We put it here in France," she said), but four, or at least three marks and an after-treatment that allows them to go unbroken through the vesicular and pustular stage are essentials of successful vaccination. To cut this paper short, I will tell you the method I employ and the reason. The subject is then open for discussion. The child is instructed to be clean and have clean underclothes. I wash the site chosen with plain water and a piece of absorbent cotton and dry it with absorbent. This, of course, is no more than burning a joss-stick to surgical cleanliness; but I ask you, if you took a thousand healthy, clean children and pricked the three marks without vaccine, how many would become infected? I next squeeze out the vaccine in three places, if the arm is fairly large, in a triangle, two above the insertion of the deltoid and one below. On a thin arm three vertically in that neighbourhood at least 1% inches apart. Then with a sharp-pointed needle that can be sterilized in a spirit lamp flame make about eight or ten very superficial stab punctures on each mark and lift the epidermis with each puncture. It is quite painless, much quicker than scarifying, G 152 British Columbia . 1918 much surer to take, as no blood is drawn and very much less danger of immediate secondary infection. There is no waiting until it dries. The clothes are pulled down and out goes tbe patient. I tell them it must he kept dry until the scab comes off. The only dressing allowable is a piece of soft linen sewn inside the sleeve of the undershirt. Almost any dressing more than this will cause the pustule to sweat, soften, and' break down into an open ulcer, with liability to secondary infection; and, worst of all, the protective serum that is grown under that hard scab with the intention that it should be absorbed into the system in sufficient quantity to give protection (for that reason at least three marks) is discharged in the dressing, and though the scars remain to show vaccination, that patient has very little more protection against smallpox than the unvaccinated, and if an epidemic occurs goes to swell the statistics against the value of vaccination. The method described has been used for some time in the military camps in Toronto with a more elaborate antiseptic preparation of the arm. I have no doubt many of you have tried it and can endorse my claim that it is easy, quick, sure, and painless; and if no dressing is permitted, the scabs allowed to harden, and the serum formed in the vesicles to be absorDed, the protection afforded will-be much greater than obtains with the present haphazard methods. This little operation and its results are seen by the public from start to finish, and when you are asked, " Why does Dr. S. only make one mark and put a thick dressing on it?" it is not going to add to the professional amenities or the public confidence to explain your theory. For that reason, if this meeting sees fit to endorse this, or any better, method of vaccination, I should like to move that a memorandum of some uniform procedure be seut to the medical societies for discussion and adoption. Discussion on De. Stanier's Paper. Dr. A. G. Price (Victoria) : In opening the discussion on this vast subject, I feel like one plunging into the ocean, rough on the surface and filled with submarines underneath, because it has been a subject which for years has been under discussion by the general public—the subject of vaccination. But I do not need to plunge into the ocean. I have to thank Dr. Stanier for throwing out two lines—as I am in the sea—to rescue me from getting into the deep. These are, first, the law in relation to compulsory vaccination; second, the methods of procedure in vaccination; and I will try to connect these two. The section referred to is section 7, subsection (11) ; that section states that all children attending public schools shall be vaccinated or shall give a certificate of exemption. This law, unfortunately, is not enforced. Why is it not enforced? Because of the second part, as to giving a certificate of exemption under the conscience clause, where the parent of a child may come and say that he objects to vaccination under conscientious scruples. A man told me: " I don't care a rap about my oath, but I am not going to have something injected into my child." Now, that man was both ignorant and immoral—immoral because he did not care about his oath, and ignorant because he did not take pains to find out just what it meant. About 80 per cent, of the parents are anti-vaccinationists. It is either a case of ignorance or prejudice because they are proud. They are ignorant in that they have not given any time to study the matter and have heard the tittle-tattle of other people, and are carried away with the rubbish you see issued by the anti-vaccinationists. They judge the case before they bear it. They have made up their minds that so-and-so didn't get smallpox and were not vaccinated, and what is the use? They are prejudiced and they are proud. Some people say: "We are Britons. We do not submit to our liberty being taken." The word " compulsion " is much against the feelings of a Briton. But in a case of this kind, if they can only be educated in this matter and can understand more about the uses and the protective properties, they would waive their idea of lost liberty and have their children vaccinated. With the conscience class that is in the Act we will never be able to compel children to be vaccinated. The law should be passed that they should be vaccinated or produce a certificate from the parents. We now come to the method which Dr. Stanier mentions. I, am afraid it is due to wrong methods that a great many anti-vaccinationists have some ground to stand on. I am afraid there are a host of medical men—I do not say so in this country, but I am speaking now of my own country, Ireland—I remember when we started vaccination as students a good many years ago, we were shown into a large room in the vaccination institution of the City of 8 Geo. 5 Provincial Board of Health. G 153 Dublin, and we would have perhaps fifty children down one side of the room and an equivalent number on the other. One lot of children had been vaccinated the week before; the others were the "new children to be vaccinated. As you probably know, Dublin is a very poor city, and the mothers would come out the same as though they were going to church to have their children vaccinated; they would put on their best clothes or borrowed clothes, and no idea of asepsis at all. All stood there together—children brought from anywhere. It is hardly an exaggeration to say that in some cases we had to look for their arms under the dirt. I am afraid in these cases it would not be simply a scratch on the arm without having some washing or some antiseptic used first, but the worst of the performance was we would take the serum from one arm, with no question as to health, and walk across the room and stick it into the arm of a child on the other side. They would come back in a week's time, some with bad arms, but we did not see them after a fortnight's time. This is an extremely bad method, and the anti-vaccinationists had some grounds to stand on, because they would say: " We are inoculated with impure vaccine and the children have bad arms." That is quite true, and the mothers were not told how to treat the arms. . In order to safeguard ourselves, I think we should be very very particular about the asepsis of the arm. We should be particular also in telling the parent how to treat them afterward. First of all, if you do not tell the parent how to treat it, and if you do not cover it with something, they will look upon it as a mere scratch and continually look at it, finger it with dirty fingers, and you have trouble before the week is up. As far as antiseptics go, I never used antiseptics that will remain on the skin, but I always swab the section with ether or alcohol. That completely evaporates and leaves no antiseptic behind which may destroy the activity of the vaccine virus; but it is better to always use thorough washing before scratching the skin. Then, as to the number of marks you put on, I think there, again, circumstances alter the cases. Efficient vaccination I think requires three marks, but you might come across a very small child, with an arm so small that there is not room for three marks on the arm, unless they are all in a line, and they would ta.ke up the whole length from the elbow to the shoulder —very emaciated arms. I think, in a case like that, efficient vaccination with one or two marks will continue for a year or two or three years, and after that they should be revaccinated when coining to school age. If you can put on three, that is the English number—four are required now—all the better; but I do not think it is wise to make four marks on a child whose arm is so small. As to the putting-on of cotton-wool, I always scorch a piece of cotton-wool, hold it to the bre until is charred, and put it on with three pieces of sticking-plaster. I do not,put it on thick. Sticking-plaster must not encircle the arm; but this impresses the mother that a surgical operation has been performed, and also keeps it clean; it also protects it from being scratched or knocked in any way while the child is about. You also tell the mother not to look at that mark under three or four days. You also tell her under no circumstances to get it wet, for if it is wet the wool, of course, turns to a poultice and softens the skin, and you have a much worse arm. The heating of the wool can be obviated by not getting too much wool on and telling the mother not to put heavy clothes on the child. If there could be some uniform method of conducting the little operation it would be a very advisable thing, because I am afraid there is a great deal of diversity in methods and other neglect, sometimes for the asepsis, and we have inflamed arms, and the parents object very much to vaccination, and they have a foundation to stand upon in that case, so that it helps to swell the crowd of anti-vaccinationists. Dr. Brydone-Jack: In our public schools not more than 10 per cent, have been vaccinated, and I think it is getting worse every year. If smallpox should come along we would have a bad time, the same as they did in Montreal, where they had many deaths when smallpox came upon them. I think it would be well to make them produce a certificate of successful vaccination or produce a certificate from a Magistrate under the protection clause. Dr. Large (Port Simpson) : We have to consider that a great many people say of the efficacy of vaccination as they say of the efficacy of many other things, " Well, we have been free from epidemics in the past and do not think we will have them now." I have been here for about twenty years in the medical profession and have vaccinated quite a number, but I bave vet to treat a case of smallpox. While we referred to the Montreal epidemic, there were G 154 British Columbia 1918 two things to be considered—lack of vaccination and proper precaution to isolate these cases. A great many people firmly believe in vaccination, but say there is so little risk of smallpox spreading under the stringent regulations at present that conditions have altered, and when it comes to a question of putting three or four scars on the arm, they object very strongly to that, under the present conditions. Dr. Isabel Arthur: I think the only way is to have an epidemic and every one will be vaccinated. In our town a few years ago we had an exndemie of chicken-pox, so it was reported, and at last some one conceived the idea of smallpox. Children were in the schools—I found it everywhere—they were not ill; but some symptoms appeared like smallpox in several cases— many did not. In the whole course of the epidemic there was no case in which there was secondary fever, aud there were no deaths. I vaccinated many children who had certificates of conscientious scruples against it, and I would rather in that case have had the disease than tbe vaccination and its attendant results. If that is smallpox it is changed materially, and we ought to destroy all the information we have in the text-books on smallpox, because that wasn't like anything I had heard of. Dr. Petersky: I didn't intend speaking on this paper at all, but a few remarks of Dr. Large brought me to my feet. Every one of us who believes in vaccination is, I take it, vaccinated. Personally, as a Medical Health Officer, I believe in the various health laws I am called upon to perform. I believe in the theory of vaccination; if I did not, I would not attempt to carry out the Vaccination nlct. I believe in it so thoroughly that I have a feeling, if I heard of any smallpox around in the community in which I am living, I would immediately be vaccinated myself, as it gives me a feeling of tranquillity, and these little scars are nothing; you might fall down and cut yourself aud have a scar for life, and look what the other scars do. Any medical man who has followed the theories of bacteria and vaccination in general cannot help but believe in the theory of immunity. I think this conscientious objection should be entirely eliminated from the Act. The Chairman: I would like to give you a warning. We are going to have an epidemic of smallpox with 30 to 40 per cent, of deaths some day. I was brought up amongst smallpox. We have had nine officially reported cases of Asiatic smallpox with three deaths this year in the City of Vancouver; some of the patients said they bad been vaccinated, but they had no scars or marks. The disease was brought in on a boat from the Orient. This is not the first time we have had this form of smallpox in Vancouver. Where you have an organized .Health Department you have some opportunity of dealing effectively with this or any other disease, but where the Health Department is small and inefficient it is not so easy. Some time we will have smallpox in this country if the people are not protected by vaccination. We tried several years ago to carry out the Vaccination Act in this city, but owing to the furor created by the anti-vaccinationists, and thanks to the conscience clause, the attempt came to nothing. To prove that the Act was worthless, I opened vaccination stations in ten public schools and only 200 children were vaccinated. I do believe, however, that if the provisions of the conscience clause were enforced and a statement properly sworn before a Notary required of the objectors, we should find very few conscientious objectors. Probably the real objection to vaccination is that the parents do not like the trouble involved by the sore arms consequent to the operation. I have never seen any of these certificates; the parents usually send word to the school that they object. I want to see the certificate required by the conscience clause insisted upon, and then we shall see almost universal vaccination. Dr. Stanier (replies to discussion) : I thank you for supporting me in my opinion regarding smallpox. I have not seen any, but I have only to read statistics of former epidemics. Sometimes you have a mild chicken-pox epidemic that doesn't mean much, but I am thoroughly convinced if smallpox gets loose in unvaccinated communities you will have a serious state of affairs. Reads clause 15 of the Vaccination Act as follows: " It is now deemed necessary, and is hereby ordered, that teachers in public schools and high schools or colleges shall require a certificate of successful vaccination from each child attending at such school or college, or a certificate that such child is at that present time insusceptible to vaccination. The certificates shall be presented on demand to the teacher or other proper authority." In enforcing that Act. or that clause, the school trustees or municipal authorities have discussed it, and in some places they have been ignorant and thrown it down, but in Oak Bay they 8 Geo. 5 Provincial Board of Health. G 155 had their own children vaccinated and brought that clause in. I do not know that we are so successful as we might have been. Dr. Price, I think, has missed my point of view—he wants to leave it optional. I maintain, without three marks, you will not have sufficient serum generated. If you can get it in one mark, it has to be the size of a 50-cent piece, aud then you have a great, big, ugly scar. I have not seen an arm so small that you could not put three marks on, 1% inches apart. That makes an arm about 4 inches long from the upper to the lower part. I am firmly convinced that at least three marks are necessary to manufacture that quantity of serum. These children I vaccinated were clean and not slum children. There is no objection to using an ordinary antiseptic to clean off the arm, but the point I wanted to make was that this method of vaccination, which just lifts the epidermis with the point of a needle, was quite effective, and while it might take a little longer to take, it has been found rapid and efficient by the military authorities in Toronto, and it is painless. The children do not mind this form of vaccination, as they do not realize about the af tertake. I do not know that there is any other point worth mentioning. I think I have answered all the questions that were asked. The Chairman: That brings us to the conclusion of our morning session. We meet again at 2.30 this afternoon. I have taken up the question of a committee on resolutions. You will remember we had one four years ago to draft out various resolutions that were suggested, and Dr. Young has asked that the following constitute such committee: Dr. Large, of Port Simpson; Mr. Biker, of Nelson ; and Dr. Stanier, of Victoria. The meeting then adjourned at 12.30 till 2.30 p.m. Afternoon Session. The Convention resumed at 2.30 p.m., Dr. AVrinch presiding. The Chairman: I shall have to ask your kind assistance in helping me to obtain order in this very large -assembly. I know you will kindly overlook any irregularities or such matters as might be expected in one who has been so long out of civilization as I have, and give me your kindest assistance in carrying on the meeting. I will now call upon Dr. Underbill—I do not suppose he would like me to call him the father of the health of the Province, but one of the senior health-men of the Province—who is to give us a paper on the " Control of Infectious Diseases." CONTROL OF INFECTIOUS DISEASES. By F. T. Underhill, F.R.C.S, M.R.S.I, D.P.H, Medical Health Officer, Vancouver, B.C. Mr. Chairman, Ladies and Gentlemen,—The subject upon which I have been asked to address you—namely, the " Control of Infectious Diseases "—is one which opens up a vast field of thought in which there are many diverse views and much room for controversy and speculation. It is not, however, my intention to approach this subject from the academic point of view, but rather as a Medical Health Officer who has to deal with it from the mere sordid and practical standpoint. I may, perhaps, be pardoned if I cite the difficulties of my own city by way of illustration. In the first place, there is the question of cases of an infectious nature in transients. These are always an unknown quantity, and as they are usually to be found in hotels and rooming-houses, their opportunities for spreading infection are greatly increased. Three or four years ago, when immigration was at its height, this problem was not by any means an easy one to handle, and frequently the accommodation at the Vancouver General Hospital was taxed to its limit. As many of these cases developed a day or so after arrival in the city, it suggests that the patient— if an immigrant—must have had the particular disease in its early stages at tbe time of his examination by the Quarantine Officer prior to bis entry into Canada, and I am of the opinion that the medical inspection of immigrants at the port of entry should be much more rigid and thorough. I feel very strongly that this inspection should be carried out during the voyage—not by the physician employed by the transportation company, but by a Dominion Medical Inspector— and that special attention should be paid to tuberculosis, mental deficiency, and specific diseases. This is especially true with regard to tuberculosis, and it is brought home to us forcibly when we are compelled to provide for persons who have been in the country possibly only a few months. G 156 British Columbia 1918 In preparing some data for Dr. Peter Bryce, who is giving a paper in Ottawa at tbe annual meeting of the Canadian Public Health Association, I found that of 468 cases of tuberculosis reported to my department during the years 1914 and 1915, forty-nine were immigrants, none of whom had been in Canada more than two years and many only a few months. Under the quarantine regulations these persons should have been returned to the country from whence they came, but owing partly to the war and partly to the fact that there is no properly organized system for handling these cases, nothing was done and they were allowed to remain—a menace to our citizens and many of them becoming a charge on the community. When the war is over this question of immigration will become a live one again, and it is time for us to prepare for it, making our laws more stringent and by enforcing those we already have, and not wait until we are compelled by pressure of circumstances to take action. We do not want disease-ridden people from other countries, for it is unfortunately true that we have more than sufficient of our own. It seems to me that, looking at the question from a national standpoint, the foregoing is the first essential in the control of infectious diseases, and granting it would be possible by these means to prevent the entry of disease into the country, the question would then become one of eradication rather than control. In this no real progress can be made until the problem is approached in a much broader manner. At the present time every city and municipality makes its own by-laws, and either does or does not enforce them, as the case may be. Of what avail is it to have effective control of diseases in any city when they are allowed to rage unchecked on its very borders? I feel very strongly that the only proper way to handle this problem, and indeed all public- health problems, is by centralizing tbe authority governing the question. I am of tbe opinion that there should be a Federal Minister, or Deputy Minister of Public Health, in order to properly govern immigration and inter-provincial relations. Each Province should also have a Minister, and public-health matters should be placed on a firmer basis and given the consideration which their importance warrants—free from politics and undue municipal influence. I have only touched very briefly upon this phase of the question, but would like very much to have it discussed freely. Having now given you my main idea regarding the broad principles of the control of infectious diseases, we come to the method to be adopted in the particular city of municipality, and again I must crave your indulgence if I describe to you the procedure in vogue in my own department. In the first place, there must be ready and willing co-operation between the medical men and the Health Department, and I am glad to be able to relate that this very gratifying condition obtains in Vancouver. The doctors show a commendable readiness to notify the Fumigation Officer directly their diagnosis is made in the more serious diseases—and in the minor ones also—when they are found out. Iii addition to the doctor, the parents and the schools are required to notify my department of any cases of which they may have knowledge, so that while we may get three notices of tbe same case, we are almost sure to get one. In almost every case of scarlet fever, diphtheria, and smallpox, the patient is removed to the hospital for treatment, and the bouse is placed under temporary quarantine and fumigated, tbe suspects or contacts being kept under observation until the Incubation period of the particular disease has'elapsed. When the patient remains at home the house is placarded with the name of the disease, and strict quarantine maintained until recovery, when thorough fumigation with formaldehyde is carried out and the clothing and bedding is disinfected by means of a steam sterilization. No quarantine is imposed in the minor diseases, such as measles, whooping-cough, chicken- pox, etc, but children suffering from any such disease or living in a house where disease is present are rigidly excluded from school until all danger of imparting infection is passed, when a certificate is issued from my department permitting the principal of the school to readmit them. Considerable attention is paid to the disinfection of school-rooms. The procedure I have adopted is the burning of all loose papers, etc, the washing of desks with some antiseptic solution, and the liberation of formaldehyde gas. There is, of course, considerable controversy as to the efficacy of this latter precaution. I am not prepared to go into tbe pros and cons of the matter from a prophylactic point of view, but we must remember that we are dealing with the public, who are never satisfied unless they can smell a disinfectant, and it is our duty to 8 Geo. 5 Provincial Board of Health. G 157 satisfy them that every reasonable precaution has been taken. Personally. I am of the opinion that the essential details in all fumigation are plenty of soap and hot water and elbow-grease, the burning of all papers, rags, etc, and tbe use of limewash. This is the method upon which we place the most reliance. To return for a moment to the subject of placarding houses: About two years ago the Provincial Board of Health instituted a system of placarding houses for the minor diseases, the placard bearing the name of the disease and warning all persons to keep away. I found that the effect of this was not what was intended, for people objected to having their houses labelled for measles or mhmps, and the result was that the cases were not reported. A great step forward in handling infectious diseases has just .been effected by the setting- aside of observation wards at the Vancouver General Hospital. There is a large number of people in Vancouver living in hotels and rooming-houses, and a great influx on boats and trains, and frequently a case of sickness occurs amongst these people in which it is impossible to make a definite diagnosis offhand. This difficulty has had to be met in the past either by using private wards or by placing a whole ward under quarantine, which for obvious reasons was inconvenient and undesirable. To overcome this difficulty a number of small cubicles have been erected at tbe hospital in which doubtful cases may be segregated for observation until a diagnosis can be made, when they are removed to their proper ward and the cubicle disinfected. With regard to diphtheria, we have now got the situation well in hand, and there is no valid reason why there should be a single death from the disease, provided the doctor is called in time. Free antitoxin is supplied by the city without any restriction whatever. The attending physician may, by giving a receipt to the City Druggist, obtain all he requires, and usually gives an injection as a precautionary measure, however doubtful the case, while awaiting the result of the bacteriological examination of the swab. Sterile swabs are also provided free of charge, and all the doctor has to do is to send the swab to the laboratory at the Vancouver General Hospital, where it is examined free. Everything is made as easy as possible, and the result is to be noticed in the very gratifying reduction in the number of cases and the percentage of deaths. The Vancouver General Hospital has now established as a routine measure the taking of swabs from all children admitted, for whatever cause, and by this means eleven carriers of diphtheria were discovered during 1916. ivltogether twenty carriers were found in the city during that year, and isolated until recovery—none of them showing the usual clinical symptoms of the disease. I regret that we have not been as successful in the handling of measles and whooping-cough as with diphtheria. It is an unfortunate fact that few parents realize the seriousness of these diseases and their complications in young children. During the year 1916 there were thirty- seven deaths from broncho-pneumonia amongst children under the age of one year in Vancouver, and there is little doubt that many of them were the result of insufficient care during measles or whooping-cough. These two diseases, which are so lightly regarded among the laity, are responsible for SO per cent, of the deaths from acute infectious diseases in this city, and yet people wilfully and criminally expose their babies to measles, though possibly not whooping- cough, in order to save themselves a little trouble later on. Typhoid fever, of course, depends very largely upon the water-supply and sanitary arrangements in vogue in the particular community. In Vancouver we have a water-supply which is the equal of if not superior to that of any other city in the world, and since 1910, when the problem of sewering the entire city was undertaken in a systematic manner, the number of cases of typhoid has shown a steady reduction year by year. In 1910 there were 265 cases reported and twenty-seven deaths; in 1916 there were thirty cases reported and three deaths, and as all but six of these were traced to outside sources, it may be said the typhoid-fever is non-existent in this city; and it may be safe to deduce that this happy state of affairs is due to the vast improvement effected in general sanitary conditions. On the subject of tuberculosis I hope to say a few words at the conclusion of Dr. Vrooman's paper. The eradication of this disease is one of the greatest tasks that has yet been faced by public-health authorities, and it is one which is becoming more and more important every year. In Vancouver/ in 1914 the death-rate from this disease was 1.1 per 1,000 of population; in 1915 it was 1.35; while in 1916 it rose to 1.57, an increase of over 50 per cent, in three years. .Something must be done soon. More drastic legislation, if necessary, must be passed by the Govern- G 158 British Columbia 1918 ment. We must be prepared to spend money, and in addition there must be a greater awakening on the part of the public to the dangers of the situation. I have not touched on poliomyelitis, as that is the subject of a separate paper by Dr. Carder, who has had exceptional opportunities for studying the disease; neither have I dealt with venereal diseases, deeming that it would not properly come within the scope of a paper of this nature, being too large and important a matter to be dismissed with a few sentences. In conclusion, I have tried to bring forward in a concise manner the salient points in the control of infectious diseases, not so much as one who speaks with authority, but rather in the hope that my remarks may induce some helpful discussion, for I am of the opinion that the resultant good would be far more lasting and beneficial to all than the reading of a purely academic paper, however learned or profound; and I venture to say that all of us who hold public office are glad of an opportunity to have a good grumble at things as they are and air our views as to bow they should be. There are times when the problems which confront a Medical Health Officer loom strangely large, and he feels that be is standing alone and is frequently unable to get the support even of bis committee, which he feels he has a right to, and an occasion like this is an opportunity not to be missed. There are many other matters of great importance in connection with public-health work that I would be glad to speak upon, but as they do not come within the scope of this paper I will bring my remarks to a. close. Discussion on Dr. Underhill's Paper. Dr. A. G. Price (Victoria) : Coming from the smaller city, the Capital City on the Island, I take the liberty of opening this discussion ou infectious diseases, following the paper by my friend Dr. Underbill. I would like to have heard Dr. Underbill for another half-hour, because he has had vast experience in Vancouver in the suppression of epidemic diseases. I am only a short time iii office in Victoria, but I happen to have come in at a time when there was a severe epidemic of measles, which took all of my exertions to suppress—I leave it to you with what success. Dr. Underbill mentioned they did not quarantine for measles or chicken-pox. Well, in cases of very prevalent epidemic, I thought it better to step in and quarantine, as measles is not a case you can treat in isolation hospitals when it comes to 2,000 or 3,000 cases such as we had in Victoria, and we have to have it attended to, of course, in the houses. I have had some experience in England in an epidemic of measles. One municipality would have them quarantined and another would not. Where they were quarantined there were no deaths, and where they did not quarantine there were six deaths. I found that where they were not quarantined the mothers allowed their children to, go out on the street at the end of one week or so, and the result was bronchial pneumonia. We keep them in sixteen days in Victoria from the commencement of the rash. The result was that out of about 2,500 cases we went through almost without a death until at the very end two very small children under one year of age died of pneumonia. The weather was very severe at the time, and I put down the non-fatality ■of the epidemic to the harshness of our quarantine, because we kept the children in and the Inspectors went down to see that the parents complied with the order. While the disease is a minor one, the sequel is severe in the case of chicken-pox. I think it ought to be notified, because there is such a danger among parents of mistaking a case of smallpox for chicken-pox. I tell you a case in point. We had a case of smallpox last March in Victoria. The lady who developed it was at a hotel in Victoria. We traced it from Tacoma within the period of incubation; we communicated with Tacoma and found a great deal of ■chicken-pox prevalent, but no smallpox. I have since seen the Health Officer in Tacoma, and found that there was a considerable amount of smallpox there since then. Were some of these -cases smallpox? A very mild case of smallpox may be mistaken for chickenpox, and for that reason I would advocate that it be notified. There was a case only a month ago in Victoria. I watched the patient in the Isolation Hospital and it turned out to be chicken-pox. Then I had the history of that. We had the case stopped in the Quarantine Station, but they allowed, against my protest, seventy-five steerage passengers to land at Victoria off that boat. I did all I could to prevent it, but it was left in the hands of the Dominion authorities. This happened to be a very severe case of chicken-pox; but I think measles and chicken-pox should be notifiable. 8 Geo. 5 Provincial Board of Health. G 159 I was glad to hear Dr. Underhill mention diphtheria as being a disease of less severity than it used to be. I remember a friend of mine lost three children in one week from this disease. We have bad a good many cases of diphtheria this year in Victoria, but no deaths in the hospital, with the exception of one Chinese who was found in Chinese quarters in an advanced stage and who died a few minutes after being brought to tbe hospital. In that case we always take the house and quarantine and thoroughly disinfect it; have the walls whitewashed or limewashed down to prevent the spread. I am glad to say now we have no infectious diseases of any kind in Victoria. Of course, we have some cases of tuberculosis, but no acute infectious diseases at present; and I hope and trust, to come back to the vaccination question, that we will have vaccination and will not have this terrible epidemic of smallpox which, according to Dr. Underhill, we are in danger of having. Dr. Vrooman (Tranquille Sanatorium) : I think Dr. Underbill's paper calls for congratulation to him on the report he gives on the health situation in the City of Vancouver, and the fact that such a disease as typhoid has been reduced to a minimum, and other diseases to such a small number that they can be controlled so well. There are one or two points that I would like to touch upon in Dr. Underbill's paper. Dr. Underhill stated that about 10 per cent, of the arrivals in Canada were sufferers from tuberculosis. My own figures show a little higher proportion. I find 10 per cent, of the admissions to the sanatorium are people who have been in Canada one year or less; 15 or 18 per cent, two years or less. These people bad come to Canada for their health, most of them giving a history of tuberculosis in England or the Old Country. The only way that can be controlled is by following out a scheme such as Dr. Underhill outlined that these immigrants should be examined on shipboard or before leaving England. Dr. Montezambert several years ago advocated that immigrants to this country should be examined before leaving the Old Country by appointees of the Immigration Department to see that they are not suffering from chronic infectious diseases, such as tuberculosis in particular. After the war there will be an influx of people to take care of, and practically all such cases will come to British Columbia because of the climate. Another important point has reference to notification of tuberculosis. It is not notified. The reason for that is partly apathy on the part of the medical profession and sympathy for tbe patients. Dr. Underhill will agree with me that he is notified about a number of deaths in Vancouver in a year. I notify him of any patients arriving, any advanced cases at the sanatorium, but there are many cases not notified by any medical practitioner. That applies also to Victoria. This point should be considered and provision should be made to notify open cases of tuberculosis. From a health point of view it is the open cases we are concerned in—not from a treatment point of view, but from a health point of view. It is quite true we have not adequate accommodation to look after them, but you cannot even keep track of them unless you know, and I have followed the history of some of these cases and learned how they moved around unknown to the Health Department, and it should be strongly emphasized that to control tuberculosis it must be notified to the Health Officer, because the medical profession in this regard are careless. Mr. Biker: I am very much interested in this question. I have been in a great measure in touch with the medical faculty in England and they have a great idea of the climate of British Columbia. The medical men in England are exploiting it against us, and if the percentage is 10 per cent, of the cases that arise we are just treating that number here at our own expense. Another point struck me; that is in regard to smallpox and chicken-pox. It is a matter of opinion regarding whether it is smallpox or chicken-pox. The Medical Health Officer of the district should be supported and not ridiculed. The patient should be protected, but we have to protect the public health, and to this end the Health Officer should be supported. Dr. Hepworth: There is one point I was interested in—that is, if one child in a family takes measles, should the rest of the family, or the children who have already bad measles, be kept at home? Supposing there is a family of six children, five have had measles, and one has them, are we to keep the rest out of school? I have had a fair amount of experience in these epidemics, and I find the disease spreads before they know they have got it. Measles will spread before the rash is developed. I have taken the stand that if there are four or five children, three of whom have had it and two have not, I have kept at home those who have not had it and allowed the others to go to G 160 British Columbia 1918 school. Am I right or wrong? There is one thing about measles; I don't pay much attention to them; they are not reported, anyway. About tuberculosis: I want to hear Dr. Vrooman's paper to-morrow. I have had dozens of people who do not feel well, and if I take their temperature and find it 99% for three days, that is all I want. If he has closed tuberculosis you let him out, but it may open up in a week after he gets into the country. You have to watch four or five days; no doctor living can make a diagnosis of closed tuberculosis in one day. I had a case the other day where one fellow said he could hear something and another did not; we found enlarged glands. He has tuberculosis that may open up at any time. This tuberculosis is rather a big question, I think. We had two cases of tubercular meningitis this spring; they died; and we had three or four other cases of tuberculosis. The trouble is most patients will not allow you to do what you want to do. If you want to take their temperature every three or four hours for three days, they say " No " ; and if you do not diagnose the case right away they go to some one else. Then there is the question of infectious diarrhoea. I did not hear tbe question brought up, but I would like to give a slight history of it. I have been eight years in Steveston as Health Officer, and I think I lost five cases of whatever you like to call it; I call it acute intestinal infection. This year three deaths; sick in the morning and dead at night—lasted about six hours, or perhaps a little longer. There ought to be some method of dealing with this. Who is going to control it? Suppose your municipality will not help you, who is going to do it? I can get no help where I have been. This is the first year they have not cleaned out a ditch, and there were three deaths from this disease, and only three deaths in eight years before. A. boy took sick one morning in one house, and I was sent for at 9 o'clock at night and he died at 11. Another boy in the same house got sick and lived. A baby got sick with it a short distance away; two others got sick and one died; two others got sick and got well. How are you going to control it? It seems to me a pretty hard thing to control and there ought to be some method of doing it. To me it has been one of the worst bugbears I have had. Dr. Petersky: Dr. Hepworth has brought up a certain question that I have had in mind, but didn't know where I was going to get it in, and I think it comes under infectious diseases; that is the difficulty of carrying out the control of infectious diseases in the country. You who are in the city have the people trained and the teachers trained, but it is different in the country. You go in there and attempt to interfere with what they have been doing for forty years. The Health Officers are unfortunately dependent on the police of the Attorney-General's Department, who act as sanitary officials. If the doctors cannot do anything the police never do anything. They seldom do anything, even if the doctor wants them to. Now, the district I am in at present, the police officials are paid $75 a month, and it is usually given to a returned soldier. If he finds out he can get $150 as a brakesman he resigns, and we don't try to check them up much for fear they will resign. I think measles should be quarantined. I think anything should be quarantined that is infectious, and if it were in my power even scabies would be quarantined. The last place I was in I got the people trained, but in this place there is no training done yet. I think the cities are very fortunate; they have Health Inspectors of their own; and all they have to do is tell the Inspector and he can call a man up. If I do that, why I am in quite a practice there. I think the Health Officer should be a civil servant, independent of any private income. I think that is a weak point in this Province. He should be given a living wage so that he would not have to practise, and be could look after a larger territory and things could be done properly. When I left the last place I was in I registered a solemn vow that I would never be a Health Officer again. Unfortunately, or fortunately—I don't know which—Dr. Young prevailed upon me to take it again, and now I suppose I will get into a jackpot; but I agree with Dr. Hepworth that in these country places where the people do not back you up it is pretty difficult. I think it is an educational campaign in sanitation as well. People are more concerned with commercial life, and we have to depend on the commercial part of it, and that is where the whole trouble lies. The Chairman: The discussion is taking a little bit of a side-track; will you kindly, as far as possible, keep the discussion to the lines of the papers? Dr. Hepworth : I want to make one point: Our police officials are ex-offlcio Sanitary Inspectors ; they are more interested in collecting a road-tax or a poll-tax to make their department pay. I think the Health Department and the Police Department should be segregated, 8 Geo. 5 Provincial Boarb of Health. G 101 because they will not see a dead cow in a ditch 5 yards away, but they can see anything half a mile away if they are going to collect a fine. I cannot get any sanitary work done in my department. Dr. Young: No doubt in the matter of infectious diseases the Medical Plealth Officers have been handicapped from the fact that there is no adequate machinery in the different municipalities in the Province. We have endeavoured to overcome this as far as possible. The millennium may come some day, and we will then have in each district a Medical Health Officer enjoying a generous salary ; but with tbe population of 400,000, which is a very large estimate, spread over 400,000 square miles, the Government cannot be expected to reach as yet the millennium in medical-health matters. We are doing the best we can, and regarding Dr. Petersky's complaint and Dr. Iiepworth's complaint about the police, they have a very large territory to cover; but 1 have made arrangements this year with the Attorney-General's Department for a very definite co-operation in health matters by the Provincial constables. The sanitary regulations have been consolidated and printed, and copies are being furnished to the Provincial -police, who are requested to act as sauitary officers and take an active part in the work, and not force the Medical Health Officer to be prosecutor as well as Medical Officer. Forms will be provided for them to fill out, and the policemen can make reports to the Provincial Board of Health Office in Victoria, and we can have co-operation through the headquarters of the Health Department with the Medical Health Officers. We hope to relieve the resident Medical Health Officer of the onus and responsibility attached to a man in private practice where the duty conflicts with his personal interests. The Chairman: I am glad that relief is going to be afforded; we will be glad to hate further discussion along the lines of the paper on the control of infectious diseases. Dr. Isabel Arthur: There is one question i would like to ask. In our neighbourhood there is a sanatorium and these patients come into Nelson from time to time and sleep in the hotels, and there are a great many complaints about this. I would like to know whether this is tbe right thing for them to do. With regard to the other infectious diseases, such as measles, mumps, chicken-pox, and whooping-cough, I think only the patient should be quarantined. It is too hard to quarantine the whole family for these diseases, and it is not necessary, and the Provincial Board of Health has sent out notices that children from these families may be allowed to go to school. In many of these diseases we have used moving-picture slides, asking the people from the screen that children with these diseases should not be allowed in these shows, and this has been found very efficient. Dr. McEwen (Medical Health Officer, New Westminster) : With regard to the question of tuberculosis, where a death has been reported to the Health Department, what precautions are taken as to disinfection or what methods are taken to prevent the spread from that case? Dr. Stanier (Victoria) : There are two points Dr. Underhill raised: One is the case of infectious diseases in transit. The cases that come in here most generally are from the Old Country, landing at Halifax. There are not many cases coming through Williams Head. They continue at the different cities until they land in British Columbia, and as they cannot go any farther without jumping into the water they remain here. Unless these cases are stopped before they get to Halifax, and there is a more systematic inspection, we are going to have them here. We can look after our own local infectious diseases, except tuberculosis. In Victoria there is one place for tuberculosis, and that is Chinatown. There is nothing done there for closed tuberculosis. I think about 50 per cent, of the Chinese are tubercular, and I think 90 per cent, of the cases in Victoria originate in Chinatown. Unless we can get at the root of that field we cannot eradicate our local tuberculosis. Dr. Underhill (replies to discussion) : Dr. Flepworth asked me some questions. There are some of the points that I certainly am not going to answer. I think possibly Dr. Hepworth and Dr. Petersky have not realized the duties of Medical Health Officers at all. One thing is sure, when a medical man is in doubt or does not want to make a diagnosis he sends for the Medical Health Officer, and it is up to the Medical Health Officer to make a bluff; if he says it is smallpox, it is smallpox; it doesn't matter whether it is or not. You have to take this responsibility on yourself and decide what has to be done and to do the best you can. l] With regard to the outbreak of measles in Victoria, that is a unique situation. If you can control 1,000 cases of measles, you do mighty well, for these cases are not all reported—make no mistake about that. Regarding chicken-pox, this is quarautinable, but unless smallpox is prevalent we do not necessarily placard for it. Regarding tuberculosis, Dr. Vrooman is going to tell us how to diagnose tuberculosis to-morrow; I don't know anything about that myself, but he told me in confidence he was going to tell us how to do it. Regarding deaths from tuberculosis, I would sooner disinfect for tuberculosis than for almost any other disease, and every precaution is being taken regarding the house and everything sterilized if possible. Chinatown raises a big question. That is one black spot in Vancouver. We have a Chinese hospital where all the Chinese tuberculosis cases go that belongs to Chinatown. I think we have much more air and more windows in Chinatown here than in most places, but it needs daily inspection. MEDICAL INSPECTION OF SCHOOLS. By F. W. Brydone-Jack, M.D.J CM, Chief Medical Inspector of Schools, Vancouver, B.C The present terrible war brings. home to us with great clearness the necessity of the conservation of the life and the resources of our nation. A nation's place in the world is determined by the combination of virility, intelligence, and the numbers of its people. This combination can be attained in varying degrees, depending on the extent to which a nation is willing to adopt and enforce the principles of hygiene. The department of hygiene with which we are particularly interested is that dealing with the child. We recognize its outstanding importance, for we know the child is the source of the nation's man-power, and that upon a healthy childhood depends the health, vigour, and mental alertness of the adult. The following are a few figures bearing on health: In Vancouver in 1916, Gl babies in every 1,000 died before reaching the age of one year. Nine and one-tenth per cent, died from acute or chronic indigestion, due to improper feeding. In 1916, 2,680 children were born. Therefore Vancouver alone needlessly lost 243 babies during that one year. Germany, in 1915, recognizing the importance of babies, enforced a comprehensive system of infant-care. The mother received antenatal care. An adequate supply of milk was assured for the child from birth to six years of age. Germany estimates that she has saved sufficient babies that by 1921 there will be more babies in that country than there would have been without a war, and she has obtained that result in spite of the fact that in many parts of the country there has been a fall of 50 per cent, in the birth-rate. Medical inspection of schools was adopted in Great Britain in 1907, in consequence of public opinion following the alarming percentage of unfits among the men attempting to enlist at the time of the South African war. There has been considerable improvement since school medical inspection was inaugurated, as the following figures show:— Number of Recruits rejected for the British Army per 1,000. 1909 299.04 1910 295.42 1911 246.50 1912 223.77 The figures for this great war are as yet unobtainable, but the corresponding figures are stated to be much better. A scheme of child hygiene should be comprehensive. It should concern itself with the prenatal care of the mother and the care of the child from birth to adult life. The child-life may be divided into three periods:— (1.) From birth to two years of age—infancy. (2.) From two to five years of age—the pre-school age. (3.) From six to eighteen years of age—the school age. There is no hard-and-fast line between these ages, and it would seem foolish to have three separate organizations each dealing with but one period of the child's life, and yet this has been the case in many cities, resulting in much confusion and overlapping. 8 Geo. 5 Provincial Board of Health. G 163 Generally, throughout Great Britain, one authority—the education authority—has. entire control of child hygiene. In New York City the Bureau of Child Hygiene, a division of the Board of Health, exercises a similar control. The same control by the Board of Health is exercised in Montreal, and since July 1st of this year has been adopted in Toronto. Previously in Toronto the Board of Health did the prenatal work and the work among infants, while the Board of Education had charge of the medical inspection of school-children. Much has been written for and against the control of medical inspection of school-children by the education authorities. To me it seems that where there is a well-organized and a comprehensive organization for child hygiene one authority should have complete control, but where health organization is difficult or impossible to complete, as in small towns, then a separate control of the medical inspection of school-children by the education authority may be vastly superior in results. In British Columbia the control of medical inspection of schools is vested in the Provincial Board of Health, but it has been made the duty of the local education authority—the Board of School Trustees—to enforce the "Schools Health Inspection Act" and to provide funds, the staff, and the equipment. The School Board is therefore particularly interested in that phase of child hygiene which applies to the school-child. Usually this work has been called " school medical inspection." This title expresses very well the results so far obtained. From now on what is required is not school medical inspection, but school medical service. Such a service is concerned with the detection of physical defects and the more important work, that of obtaining treatment for the conditions found. The control of contagious and infectious disease, the hygiene of the home, the proper heating, lighting, ventilation, and sanitation of the school, adjustable seats, the curriculum, good blackboards, proper size reading-type, character of the writing materials, school lunches, regular exercises, etc, are factors which the medical service must have constantly in mind in order to prevent as far as possible the child's acquisition of disease or defects in the grind for an education. A thorough physical examination is of the utmost importance. A great deal of criticism and dissatisfaction has been caused by the extremely superficial manner in which children have been examined in many American and Canadian cities. For instance, in Toronto the law called for a thorough examination, including the heart and lungs, but insisted that no clothing could be loosened without first obtaining the consent of the parent. Such consent was very rarely asked, and as a result 95 per cent, of children were only examined in regard to eyesight, teeth, and tonsils. No wonder people could not understand why the Medical Inspector did not find the crooked back, the deformed arm or leg, the weak heart, or the lung-trouble. New York recognized this weakness and has for the last two years been inviting parents and attempting to thoroughly examine children. This thorough examination is not done every year, but only in the first, third, and sixth school-year. In the other years it is of vital importance to have a specially trained nurse test tbe eyesight, see the teeth and throats, and estimate the general health of every child, so that a child needing attention may be referred to the school doctor for examination without delay. In this the interest and co-operation of the teacher is essential, because it is the teacher's opportunity to be with the child day in and day out, being thereby enabled to detect immediately any child's departure from its normal average health. Toronto is to inaugurate such a system with the opening of the schools in September. There is no reason to fear the results, for this system has been working very satisfactorily in Great Britain since 1907. In Japan also the thorough physical examination is recognized as the most satisfactory. N.B.—In regard to the thoroughness of the physical examination, Vancouver was the pioneer in North America aud still holds first place. In making the physical examination the following procedure should be followed:— (1.) The parent should be invited at a definite time. (2.) The child should be stripped to the waist in privacy and stockings and shoes removed. With female children a towel should be draped over the shoulders and chest for the sake of modesty. (3.) A nurse should always be present—to prepare the child, assist in the examination, and to make notes. Under these circumstances when a defect is found its nature can be very easily demonstrated to the parent. It can be found at once what is possible in regard to treatment, and arrangements can be made for the medical service to obtain treatment for the child if the parents are poor. G 164 British Columbia 1918 If it is impossible for the parent to be present at the examination, then a sealed notice of the defects found should be sent. The nurse should visit the home within two weeks, and in any case it should be the aim of the nursing department to know within a month what steps the parents have taken in regard to treatment, though this time is often too short when a nursing staff is small as compared to the many duties it is expected to perform. nln alteration in the school curriculum will be the treatment required for children suffering from certain defects. These children will be grouped in special classes called auxiliary classes. Such a class as the open-air class is required for the thin, weak, sickly, and the pre-tuber- culous children. An ordinary class-room with all the windows open, with movable desks and folding cots, is all that is required. Sometimes the flat roofs of schools are utilized when the accommodation in the school is limited. Some of these rooms are heated, some are not. The children must wear special clothing and must have an adequate rest period. The children improve more rapidly in health and weight when a good lunch is served. For tuberculous children open-air classes should be formed in sanatoria. A child with open tuberculosis should not be permitted to attend the open-air class intended for ill-nourished and amende children. Auxiliary classes are also required for the deaf, the blind, the semi-blind, children with speech defect, and for crippled children. It is estimated that 2.8 per cent, of tbe children of St. Louis have speech defects. Boston is tackling this problem in a sensible way, having what are called speech-improvement classes. During the past year 333 children were collected from eighteen school districts and instruction was given by five teachers to nineteen different groups of children. The improvement in articulation is most pronounced. Another interesting class in Boston is that for semi-blind children. Twenty-two children having a vision of not less than one-tenth normal were gathered together and receive special instruction. The type of tbe books is large and most of the teaching is oral. Seven classes were formed from the twenty-two, though most of the instruction is necessarily individual. Another type of auxiliary class is that for mentally retarded children. At least one child in every hundred is so affected. The best results are obtained toy attempting to give an education to those only that may profit by it. Children up to the age of ten or twelve may be taught in mixed classes in local districts, but afterwards the boys and girls should go to separate classes where more time can be given to domestic science and manual training. Mixed classes of the older mentally retarded children are not as easily disciplined nor do they progress as rapidly as the separate classes. Boston has fifty-five classes with an enrolment of 815; the older girls are sent to a six-room centre which forms a higher school; the older boys are treated similarly. Transportation is provided by the city. In regard to treatment of physical defects, there are at the present time three methods usually employed—by private physician, when the parent can afford it, and when not, by school clinics, and hospitals. Let us examine first the method followed in England to obtain treatment for school-children. The following extracts from the 1914 Report of the Medical Officer of the Board of Education for that country will give a clear idea of what is being accomplished:— " There is no more hopeful feature of the work of the school medical service than the fact that many of the most fruitful activities are of the nature of voluntary undertakings on the part of local education authorities. The Board's system of medical grants, graduated according to the efficiency of the arrangements made, has done much to reinforce local enterprise and lighten the burden of local expenditure. Under the ' Education (Administrative Provisions) Act, 1907,' the initiative in regard to treatment schemes remains with the local education authority, and a considerable proportion of the cost is borne by the local ratepayer. " In 1914. out of 317 education areas in England, 266 had some form of treatment in school clinics. Treatment was provided for:— (1.) Minor ailments in 204 clinics. (2.) Dental defects in 130 clinics. (3.) Defective vision in 195 1 (4.) Provision of spectacles in 165 j refraction-work clinics. (5.) Enlarged tonsils and adenoids in 83 clinics. (6.) Ringworn (X-ray) in 6S clinics. " In 1914 there were 179 school clinics. 8 Geo. 5 Provincial Board of Health. G 165 " The school clinic still maintains its position as the most generally suitable institution for dealing with children suffering from remedial defects, for the following reasons:— (1.) There are the advantages of complete control. (2.) Arrangements are easily made to suit the convenience of doctors, teachers, and children. (3.) Complete supervision of the treatment in all branches is possible. (4.) Clinics can be held in positions easily accessible. (5.) Follow-up work is readily arranged and accomplished. "Clinics for Minor Ailments.—The treatment is simple; it can often be done by a nurse acting under medical direction. Cases do better as they can be treated in school more frequently than they are at home. In 1912 (Warrington), 1,490 children lost 57,793 attendances owing to minor ailments, an average loss of 38.8 attendances. In 1914, on account of daily treatment, the average loss was reduced to 27.2. "The treatment of these conditions is essentially the work of the school nurse. The unsuitability of hospitals for carrying out treatment of this nature is generally recognized; the staff have not the time to devote to the supervision that is required, nor to tbe daily routine of treatment. Neither can the parents of the class, for the benefit of which these institutions are supposed to exist, afford the time or the means entailed in paying repeated visits to the hospital. " Clinics for Defective Vision.—Ten per cent, of children require treatment for defective vision. One hundred and ninety-five authorities are having clinics, and in addition to the prescribing of spectacles, have entered into contracts for the provision of spectacles at cheap rates. Work done by part-time ophthalmic surgeons 9S Work done by whole-time ophthalmic surgeons 4 Work done by staff of school medical service 74 Work done by contributions to hospitals 37 Spectacles provided by authorities 165 "There is dental treatment in 130 education areas. There are 200 dentists, fifty-one being full time, sufficient to treat 375,000 children. " Clinics for Enlarged Tonsils and Adenoids.—Of all the remediable defects of school-life, enlarged tonsils and adenoids are the most neglected and show the lowest proportion to have received adequate treatment, in spite of their prevalence and their marked disabling effect on health. The number of authorities making provision for operative treatment is small, only eighty-three. The reason for this is that in many areas tbe work is undertaken by voluntary hospitals without charge. Number of authorities S3 Work done by doctors not on school staff 24 Work done by school medical staff 7 Work done by hospital staff 57 Work done at school clinics 30 " Care Committees.—The development of the scheme of treatment has involved a corresponding increase in the work of following up. Every large school or group of schools has a School Care Committee, and the work of those committees is co-ordinated by a staff of paid organizers employed by the London County Council. Care Committees are also concerned with the provision of meals and the after-care of children, with the work of juvenile employment, and with attendance at evening classes. Leavers are interviewed as far as possible and endeavours are made to find suitable employment. " Results of the Work of the London School Medical Service, 1914. " During the year 84,500 reinspections were made. Of all the children found defective, 50 per cent, were treated by the time the first reiuspection was held. Of those children suffering from G 166 British Columbia 1918 ailments for which tbe Council bad made special provision, 62 per cent, of the cases were dealt with under the Council's scheme. Treated and completely cured. Cured naturally oi* without Treatment. Treated but not completely cured. Not treated and requiring Treatment. Refraction Ear, nose, and throat Teeth All cases 56.1 53.3 48.9 51.3 6.8 17.7 10.2 15.3 12.2 4.4 5.9 8.6 24.9 24.8 35.0 24.8 " In 1912 only 39 per cent, were treated under the Council's scheme. "The following table shows the percentage of children obtaining treatment from (A) tbe family physician; (B) under the Council's scheme; (C) at other hospitals or institutions:— . (A.) Private Doctor. (B.) Under Council's Scheme. (C.) At other Hospitals and Institutions. 3.1 17.6 7.4 74.3 50.7 58.9 56.1 6.2 22.6 31.7 33.7 21.2 27.1 22.7 66.7 Totals 13.6 56.2 30.2 "The high percentage (74.3 of the whole) who get their refraction done under the Council's scheme shows what a need has been met by the facilities for treatment arranged by the Council; very few cases needing refraction (3.1 per cent.) or cases of operation for adenoids and tonsils (7.4 per cent.) are able to arrange for treatment privately. " The medical treatment scheme adopted by the London County Council combines the advantages of a hospital service and a school-clinic service. During 1914, 294,026 children were examined and 101,432 were found to require treatment. In March, 1915, the education authority contributed to 12 hospitals, providing for 26,184 children, and to 30 other forms of institution, providing for 72,012 children, the total number of centres being 42, providing for 9S,996 children. " Under these agreements the Council pays to tbe hospital or institution the sum of £50 a year for each doctor, surgeon, or anaesthetic working on one half-day a week, and pro rata for each half-day a week so worked. In addition, a capitation payment is made of 2s. for each major ailment treated in respect of eye, ear, nose, throat, and teeth, and for X-ray treatment of ringworm a capitation fee of 7s. is paid. A dentist working half-time on five sessions a week is paid £200 a year. " There are three types of centres:— "(1.) Hospitals.—The time of the clinics is arranged to suit the convenience of the hospital. Doctors and assistants are appointed by and are under the control of the Hospital Board and devote tbe whole of the time for which they are paid by the Council to the work of dealing with the children referred by the Council. "(2.) Centres provided by Medical Practitioners' Committees, who provide and maintain the centre. These centres are under the administrative control of the Council. The medical staff are selected by the Council from names supplied by the Medical Practitioners' Committee and are paid for the time given to the clinic. The Council sees to the supply of patients and to the following-up of those under treatment. It also equips the centre with the necessary apparatus. A nurse employed in the Public Health Department of the Council is provided to attend the clinic and to assist the doctors in the treatment of refraction cases, ringworm cases, and ear, nose, and throat cases requiring operation." 8 Geo. 5 Provincial Board of Health. G 167 Medical Treatment in New York. New York has had medical inspection since 1897. It was found that only 6 per cent, of physically defective children obtained treatment by tbe use of the postal-card notification system. By the appointment of school nurses for follow-up work in the homes in 1908 it was possible in 1909 to have 83 per cent, of the defects treated. It was felt by the Bureau of Child Hygiene that the test of the value of school medical inspection was the character and the results of tbe treatment obtained by the children. In order that the existing need for more facilities for treating the children might be met, and that the character of treatment given and the adequacy of results might be under control, the department obtained in its 1912 budget funds for the establishment of clinics under the Bureau of Child Hygiene, exclusively for the treatment of school-children. Nineteen clinics were formed for nose, eye, ear, and throat service, for refraction, for dental work, and for contagious eye-diseases. At five of these clinics operations for adenoids and tonsils are performed. Operative cases are kept for twenty-four hours and a list of doctors on call is kept handy in case any untoward symptoms are noted. The clinics are open daily from 1.30 to 5 p.m., except Saturdays, when they are open from 9 a.m. till noon. Nose and throat operations are performed in the morning from 10 a.m. to 1 p.m. Many of the defects from which the school-child suffers should have been prevented or detected and treated before entry to school. It is felt in England, in New York, and in Toronto that the best and the most logical way of reducing the number of school-children with physical defects is to examine them and treat them in the pre-sehool age. Toronto now has twenty-two child-welfare centres at which this examination for the pre-school child is done, in addition to the usual infant and milk depot work. New York maintains fifty-nine such centres and Montreal twenty-eight. It is estimated that one child-welfare centre is required for every 20,000 people. As a rule, a doctor attends a centre for a half-day once a week. The centres are conducted in police stations, Y.M.CA.'s, Y.W.CA.'s, and in settlement houses and in schools. Inasmuch as the public already own the school buildings, and as a school building is the centre of a district, it has been suggested that schools should be used for the child-welfare centres. This could easily be arranged on Saturday mornings. It seems that more and more responsibility is being given to education bodies. This is not surprising, for we now appreciate that education does not simply consist in teaching the school-child the three R's, but it includes the education of people of every age in everything which can improve our national well being—truly an enormous task. In the preceding pages I have endeavoured to give an idea of the important features of a school medical service. We in British Columbia are young in the work and there is much that we will have to develop. We have made a good start, however, and it is my earnest hope that British Columbia will maintain the lead she has set Canada. Discussion on Dr. Brydone-Jack's Paper. The Chairman : This is a very important phase of work, and in order to have it more fully discussed there were three asked to prepare discussions. I will ask Dr. Isabel Arthur, of Nelson, to open the discussion. Dr. Isabel Arthur: I was much pleased to know what Dr. Brydone-Jack said about treatment. The treatment is the main point of medical inspection. There is not much use in sending notes unless they can be followed up by treatment. That is the reason medical inspection does not work out the way we hoped it would. This is being done in the large centres in the States, and in small towns and rural districts of 6,000 and 7,000 people there is no equipment in the schools and no treatment given. It very often is not done at all, and medical inspection therefore does not get the desired results. The Medical Inspectors in the rural districts are usually physicians who have other work to do, and they do not give up their time especially to that work. They do not get enough remuneration and do not spend their time. They have no nurse to help them and the remuneration is so small they cannot take the time to do this thoroughly. That is where our medical inspection falls down, and I hope some time to See medical inspection under the Government and Medical Inspectors paid to give up their whole time to medical inspection of schools; then and only then we will have good results from this work. G 168 British Columbia 1918 Dr. E. H. McEwen (Medical Inspector of Schools, New Westminster) : Mr. Chairman, Ladies and Gentlemen,—I feel very much like the man who never made a public speech before, and when he was asked to make one he had a friend prepare it for him. Through some mischance he did not get time to memorize it and so he had some notes. When be started to deliver his speech, he said: " Ladies and Gentlemen,—Of course, this is entirely extemporaneous; of course, you will understand it is entirely an extemporaneous speech. Hang it, I don't know what to say next, because I can't find the place." So if I cannot find the place in my notes I know you will forgive me. I was asked by Dr. Young to take part iu this discussion, but being away from the city I did not receive it in time; I did not know until to-day what Dr. Brydone-Jack was going to say. Now, in the first place, I would like to express publicly my thanks to Dr. Brydone-Jack for the assistance he has given me personally in the school-work since I have been in New Westminster. Fie has always been most obliging and has done his utmost to give me assistance in the work. I have been in the schools in New Westminster for the past six years, and, outside of one year before that, when I was in a country district, I had no experience whatever as to how to handle these things, and his assistance has been invaluable, and I want to publicly express my appreciation of that fact. In the next place, with regard to country work, some have spoken of the difficulties in connection with that. One of the greatest blessings you can have in doing school-work is a good nurse; that is more than half the battle, and you haven't that blessing iu the country at all, and you cannot keep in touch with the various patients that you run across. I think there should be some provision made by municipalities in general to appoint a nurse to give her whole time to country districts, and also some arrangements regarding her transportation from school to school before they can expect to get results from the country. Now, in tbe city work, we find the nurse clinches all the suggestions made by the School Medical Inspector. In all cases where w7e send out notices they are followed up by our nurse, and she stays with them and persuades them, whether they wish to be persuaded or not. that it is best to have the case attended to. As a result, we have bad a great many treatments on these suggestions. With regard to the teachers, I have been greatly blessed, and have bad good support from the teachers. Of course, there are exceptions; you cannot always find all of the lady teachers especially who will meet you in exactly the right way and follow up your suggestions as you make them, but, ordinarily speaking, they do the second time, at any rate, and I must say I have had good support from the teachers. Now, with regard to this morning's paper, there was some mention made by Dr. Gillies that there were a number of cases sent to the asylums. Tbe trouble, I believe, we must get to the bottom of in school-life and before school-life. We cannot teach the present generation—those in tbe asylums and those who should be—we cannot control them; but these children growing up, we have a certain amount of control over them, and that control should begin before the ordinary days of school-life. I am in accord with Dr. Brydone-Jack that we do not begin early enough, and it should be under one authority, and school-work and the pre-school work in training the child. We see so many examples in school-work of those who should have been attended to before the child comes to school; it is pretty well on by the time we get them under our control. We should prepare that child for its future' life. They come to school to learn the three R's; sometimes they get to high school and learn algebra and trigonometry, etc.; but the average child has finished his education before he reaches high school, and they are going to settle down and become fathers and mothers of future families. How many of these children know the first thing about themselves and the proper care of themselves, the proper care of the wife, or the husband, and the proper care of the children? I guarantee that a great proportion of them learn through a very bitter school, and I think we ought to try to accomplish the better education of the child-life on the lines of practical living. I think it is neglected in our present school-life. Dr. Brydone-Jack has spoken about thorough examination in the schools. It is either that. or nothing; that is to say, I do not think it is much use giving a superficial examination of the chest and passing it up. I am sure Dr. Vrooman will bear me out in that, that there are few 8 Geo. 5 Provincial Board of Health. G 169 cases of tuberculosis found in a superficial examination of school-children. I remember one case sent to Tranquille; we discovered a small patch in the chest, and then we found two or three places in the lung, and 1 discovered that after repeated examinations, and I only discovered about one-third of the whole thing. How much less could it have been discovered in a hurried examination of children in a school? He has mentioned that it should not be " medical inspection," but " medical service." I think that is the crux of the whole question. We have started in a small way in New Westminster. The nurse occasionally gets stuck and asks me for help, but she practically handles the whole thing herself, and much practice is making perfect. She is doing a great deal of good in our city in a great many minor cases; ringworm, small cuts and bruises, and minor injuries are all handled in our school offices. We hope to have a dental clinic established next year. We probably would have had it this year, only the money was not provided in the estimates, and it was left till after Christmas. We hope for great things after Christmas in starting our dental clinic. Regarding tonsils and adenoids, it is all done by private physicians. We have followed up these cases particularly during the past few years. Parents have been visited, and the fact brought home to them that it was a necessary thing for the child that these cases should be attended to. In cases where they were absolutely destitute I have attended to several cases, and the result is we have quite a number of operating cases to the credit of the school-work. That brings us to the backward children. The class of backward children has been greatly decreased hy attention to that side. This is only one phase of the subject, but it is a very important one. There is another difficulty, as Dr. Arthur mentioned, regarding thorough examination of the child. Most certainly, where the medical man has no medical nurse to assist in the dressing and undressing of the children he has his hands full, and a good many of us cannot manage it. I think it is almost impossible to give them a thorough examination, although it is a most desirable thing. The Chairman : I hope we all appreciate the fact that we are here to learn and to educate. The Government has called together, or the Health Department, this Convention, and they wanted our experience, and our views—our difficulties as well as our successes—that they might better organize the work to improve the service. We have had a paper and discussion by those carrying on this work in the larger centres of our Province, but the work is going on in a lesser degree, as far as it is able to go on, in the smaller centres, and we would be glad to hear from any of those who are carrying on the work in the smaller centres. Dr. Petersky: As a man who has had .experience only in rural districts, I think the Convention has ail idea now that I have only had difficulty in my work. I have not found great difficulty; I have gotten out of difficulty. I think this Convention is a place to bring difficulties to. With regard to the schools, I mentioned the teachers were not quite what they should be. I have got through examinations and had the teachers act as nurses for me, and they were quite willing to do it, but you have to use a certain amount of tact. Once in a while you come across one you can't do anything with. I want to take issue with Dr. Arthur on one point; I think she has said the money expended in country schools is wasted, practically, because there is no treatment. I find in my experience, particularly in dental work, and the eye, ear, nose, and throat, a certain percentage were attended to—not as promptly as in the cities, but the parents usually make trips to Vancouver or Victoria for other purposes, and take the youngster along and have it attended to at the same time. Usually I tell them if there is one man who can do it better than another. I think it is in the country where they attend to those things. You people who think you have all the cancer cases in the city, I would like to tell you that it is the country that acts as a feeder to the city. We are like a big railway company providing the passengers along the railway for the main line. Cases we cannot handle ourselves we send to the cities. We know the people better than you do in the cities, and sometimes the parents will apologize to me for not having these things attended to more promptly; but I know when I examine the children next year I find these teeth attended to, and probably other ones fixed up. Of course, some are not attended to at all. In the city you can get things done better and the teachers understand these points better, but we do not get the best teachers in the country because the salaries are not so good. G 170 British Columbia 1918 Dr. Isabel Arthur: I did not intend to say that money was wasted in the country schools, but that medical inspection could not be so efficient without following it up by treatment in every case. It is quite true many many children are treated from notices sent home. I find a large percentage of the children have been treated in these cases, but there is always a certain percentage of children who cannot be treated, whose parents have not the money to pay for the treatment, and if they cannot be given medical attention, the medical inspection cannot be as efficient as if it were carried further. Dr. Brydone-Jack (replies to discussion) : In regard to a certain amount.of education on health matters in the schools, last year we had " little mother " classes conducted by the girls in Senior Fourth class. They received a course of instruction from about the first of April to the end of June. They were taught to look after babies and the general principles of feeding, and were given instructions such as would fit them to look after children to a certain extent when they grew up and became mothers. There is some difficulty in rural districts as to examinations. That is why I emphasized having tbe parents present, because they could assist you and you could talk to them direct. The Victorian Order of Nurses will also assist when called up in medical-inspection work. In regard to treatment, of course it is difficult here at the present time. In England they are- having travelling dental clinics, travelling refraction clinics, rural school nurses, etc, and I think the Provincial Board of Health has that under consideration; it is simply a matter of time when they get it here. The Chairman : Dr. E. B. Carder, of Vancouver, will now give his paper on " Poliomyelitis."' POLIOMYELITIS. By Dr. E. D. Carder, Vancouver, B.C. History. In 1840 the first description of poliomyelitis as a definite entity was given by Heine, an orthopedic surgeon, in a monograph on the surgical aspect of paralytic conditions of the lower extremities in children, but containing a clear-cut description of the onset and acute stage. In 1890 Medin published the first good clinical account of acute poliomyelitis based upon the extensive Swedish epidemic. Smaller epidemics were reported from year to year, but no important additions to the existing knowledge of the disease were made until 1905, when Wickman, also studying Swedish epidemics, developed the epidemiology of the disease and its pathology, and described for the first time the abortive type. His exhaustive studies demonstrated conclusively the contagious nature of the disease. There remained, then, the problem of finding the infective agent. In 1909 independent observers in Vienna, Paris, and New York succeeded in experimentally producing the disease in monkeys and in transferring it from one monkey to another. The infectious agent, according to Flexner, is a minute micro-organism which passes through the finest filter and can be demonstrated under the highest-powered microscope only, the difficulties attending its artificial cultivation and identification being such as to make useless the ordinary bacteriological tests for its detection. It resists freezing, is destroyed by temperature of 50 C, withstands glycerine and y2 Per cent, carbolic, but destroyed by H,02. On the other hand, Rosenow, of Rochester, recently investigating a series of cases there and in New York, isolated a polymorphous streptococcus from the throat, tonsil, and central nervous system of poliomyelitis cases. This organism appeared to grow large or small, according to the medium used, even after passing through a Berkefeld filter. Using the organism in its large form, paralysis was consistently produced by intracerebral injections in rabbits and in monkeys. He suggested that the small filterable organism which has been generally accepted as tbe cause of poliomyelitis may be the form which this streptococcus tends to take under ana?robic conditions in tbe central nervous system, while the larger and more typically streptococcic forms which other investigators have considered contaminations may be the identical organism grown large under suitable conditions. However, three other investigators, Geo. Mathers, Nuzum, and Herzog, of Chicago, made similar claims for a gram-positive micrococcus which they bad obtained from tissue of the central nervous system, tonsils, mesenteric glands, and from the cerebro-spinal flued by lumbar- puncture during life. These organisms injected into monkeys produced definite clinical and 8 Geo. 5 Provincial Board of Health. G 171 pathological poliomyelitis. This micrococcus, too, occurred in small and large forms, regarding which they point out the similarity to the virus of rabies which presents Itself in a large form, the negri bodies, and in the small punctiform granules which pass a filter. Whether this organism is a. secondary invader (perhaps analogous to the streptococcus in scarlet fever) which in culture may become more or less closely associated With the independent virus of poliomyelitis, or is Itself the cause of poliomyelitis and capable of existing in filterable and non-filterable forms, is a problem demanding still further experiment and study. Mode of Invasion. The virus exists constantly in the central nervous organs, on the throat, tonsils, and nasal mucosa, and intestinal secretions of persons suffering or convalescing from the disease. It occurs less frequently in other internal organs, but has not been detected in the general circulating blood of patients. It is found also in the mucous membrane of the nose and throat of healthy persons who have been in contact with cases of poliomyelitis, who thus may act as carriers and convey tbe disease to others. This distribution applies to abortive cases as well as to the frankly paralyzed ones. From experiment and observation it is accepted that the entry of the virus is through the upper respiratory mucous membrane, and likewise the exit is by the ordinary secretions of the ■ nose and throat, and, after swallowing these, by the intestinal discharges. The fact that the disease has a distinctly characteristic seasonal prevalence—constantly reaching its maximum during the late summer and early autumn—is in marked contrast to the more common diseases generally believed to be transmitted by direct contact and to find access to the body through the respiratory tract, e.g., scarlet fever, measles, diphtheria, etc, which usually are most prevalent in winter and spring. This summer prevalence has suggested the idea of transmission by insects, but the case against insects has failed up to the present. The house-fly or other insect, however, can conceivably become contaminated and mechanically convey the poison; therefore their exclusion from poliomyelitis patients should be religiously carried out. It is generally accepted, then, that poliomyelitis is a human-borne contagious affection, the portal of entry for the virus being the upper respiratory tract—tbe uaso-pharyngeal mucous membrane in particular. The infection can be carried by' active and by passive carriers, of whom abortive and unrecognized cases are probably most important. The virus is resistant and, being protected by mucous secretions, can become attached to clothing, bedding, etc, to domestic animals and insects, and can be ground into dust and conceivably disseminated by wind. It has been found on the mucous membrane of the throat in a patient five months after the onset of the disease. Pathology. The virus, as we have said, seems to enter the body via the naso-pharyiix—through the lymphatics of the upper nasal cavities which are in direct communication with the meninges. This view is strengthened by the anatomical findings. The earliest change in the nervous system is a hypei'Eemia and the collection of numbers of small mononuclear cells in the lymph spaces surrounding the meningeal blood-vessels. These lymph spaces are anatomically processes of the arachnoid spaces, and the lymph in them is in communication with the cerebro-spinal fluid. The blood-supply of the cord is derived from these meningeal vessels, and as the pathological process advances this perivascular infiltration follows along the vessels as they enter the cord from the meninges. A cellular exudate then surrounds the outer wall of the vessel, while it is also probable that there is some effect, either toxic or mechanical, on the intimal lining of the vessels, for haemorrhages, minute or extensive, are frequent findings, and one of tbe prominent features of most cases is the extensive oedema. These three factors, then, cellular exudate, haemorrhage, and oedema, all of them dependent on vascular change, may be regarded as the primary reaction of the nervous system to the virus of poliomyelitis. The importance of the vascular system in determining the nervous lesions explains the fact that the cervical and lumbar enlargements of the cord are most affected, and that the anterior horns of the grey matter are more involved than the posterior, for these are the regions of the cord to which the blood-supply is most abundant. It has been suggested that the process by which the vascular lesions affect the nerve-cells may be a mechanical one. Now, it is impossible to deny the fact that the virus may exert some directly toxic action on these cells; nevertheless, in many ways the clinical and anatomical G 172 British Columbia 1918 pictures are readily explained by the circulatory disturbance and the exudate. On such hypothesis the damaging effect can result in part from the direct pressure on the nerve-cells of haemorrhage, oedema, and exudate. There is also the additional factor of anaemia following the constriction of the blood-vessels by the same merchanism. On account of this pressure and ana;mia the nerve-cells degenerate. If the haemorrhages are absorbed soon enough the cells recover their function. If, on the other hand, the anosmia and pressure have been prolonged or excessive, tbe nerve-cells go on to complete necrosis. The same sequence of vascular changes and subsequent degeneration of nervous elements is found, though to a much less degree, in the brain, medulla, and pons. The same, too, in the posterior root ganglion—i.e., vessels entering the ganglia, with degeneration and necrosis of the nerve-cells. The suggestion has been made that these lesions in the sensory ganglia account for the pain which occurs so constantly in the acute stage of the disease. The changes found in other organs are less striking, but practically as constant—viz, changes in the lymphoid tissue throughout the body and in the liver. So that the disease must be regarded as a generalized process affecting parenchymatous organs, lymphoid tissue, and most particularly the nervous system. Classification. The study of any disease is simplified if the various clinical forms can be grouped together into a few definite types. In poliomyelitis, hi which we have a pathological process which may extend through brain, medulla, pons, spinal cord, and spinal ganglia, or which may be localized in any part of the system, the signs aud symptoms may be very diverse; hence the difficulty is readily appreciated. Passing over the various elaborate and detailed classifications, the simplest and best from the clinical point of view seems to me to be that of Peabody and Dochez, as follows:— (1.) Abortive cases—in which no paralysis occurs: (2.) Cerebral cases—those rare cases in which involvement of the upper motor neurone with resulting spastic paralysis is the chief characteristic: (3.) Bulbo-spinal cases—the great majority of cases, comprising all those with lesions in the lower motor neurone and flaccid paralysis. This classification is not absolute, of course, because many cases are not purely of one type, either anatomically or clinically. Susceptibility. Childhood is essentially the age which is most susceptible, though adults are not immune. In the New York epidemic of 1907, 89 per cent, of the cases were under five years. Both sexes are equally liable, and social status seems to be unimportant; moreover, those attacked are usually hitherto perfectly healthy children, though other diseases, measles, etc, are often mentioned as predisposing causes. Whether the greater immunity of adults is to a non-specific resistance which develops naturally with maturity without reference to previous exposure or Infection, or is specific and acquired, from previous unrecognized infection with virus of poliomyelitis, is a matter of speculation, though our admission to-day of abortive cases, until recently unrecognized, indicates a greater general susceptibility than .has been generally thought. Poliomyelitis is one of the infectious diseases in which immunity is conferred by one attack, whether of the abortive or paralytic type. The protective substances do not appear in the blood until about two weeks after the onset, and have been detected as long as thirty years after an attack. If 1 c.c. of such a serum be mixed with 1 c.c. of the active virus (which is merely a filtrate of a 5-per-eent. salt sol. suspension of the spinal cord of an infected and paralysed monkey)—if these be mixed in a test-tube, Incubated for two hours, refrigerated overnight, and then injected intracerebral!}* into a monkey, the animal is protected and does not develop poliomyelitis. ♦ Course and Symptoms. In most typical cases of poliomyelitis the course of the disease is fairly constant. The incubation period averages eight to ten days. Following the incubation period and preceding the onset of paralysis, there is in the vast majority of cases a period marked by prodromal symptoms. These are at times of such a mild and fleeting character that they may be entirely overlooked, and there is. too, a small number of cases in which the acute stage with paralysis 8 Geo. 5 Provincial Board of Health. G 173 seems really to be the first clinical manifestation. The duration of the prodromal symptoms is on the average one to three days. The severity is variable, and it is a generally accepted fact that the severity of these symptoms bears no relation to the extent or the course of the disease. The prodromal period has until recently received little attention from clinicians, but now, in the light of our present knowledge and our hopes for a therapeutic control of the disease, assumes an unexpected prominence. It is during this period that we must isolate and quarantine if such measures are to be efficacious, and it is only in the prodromal period before an extensive destruction of nerve-cells has taken place that we can ever hope to make treatment efficient.. This, therefore, is the most important stage in tbe course of the disease, for on its recognization depends the possibility of controlling the infection. The most constant symptoms of this period are : Fever ; drowsiness ; irritability ; hyperesthesia ; pain, both spontaneous and that produced by passive motion; weakness of a limb or group of muscles; gastric symptoms, e.g., nausea and vomiting (which rarely becomes persistent) ; constipation or diarrhoea seems to be immaterial. That is to say, the common history is that of a previously healthy child taken suddenly ill during the summer or early fall with fever, a moderate gastro-intestinal disturbance, pain in the head, back, or legs, and often becoming quickly drowsy. On physical examination there is stiffness of the neck with resistance to flexion; the Kernig manipulation of the legs and the passive motions are painful; the child is irritable and wants to be left alone. A clinical picture which is suggestive in the presence of an epidemic, but which otherwise shows very little of specific diagnostic value. What other methods of diagnosis can we call to our assistance? The blood examination. Peabody and Dochez, of the Rockefeller Institute, say:— " In the prodromal period, while the total leukocyte count varies within the normal, there is a tendency towards the upper limits, i.e., more cases showed counts well above the usual extremes than below. There is, too, a definite polymorph leukocytosis, while the lmyphocyte percentages are distinctly below the usual figure. After the onset of paralysis there is a constant and well-marked leukocytosis, 20 to 30,000. There is also a constant, increase of 10 to 15 per cent, in the polymorphs, and as constant a decrease of 10 to 15 in the lymphocytes. The other forms of leukocytes show no abnormalities." The Spinal Fluid. Without going into details, I will present the findings of the Rockefeller Institute in sixty- nine cases on this point, briefly and dogmatically :— Fluids : Clear, a few slightly opalescent. Pressure: Normal or slightly increased (unsatisfactory because patients were usually crying children). Cell-count: Increased at first 35 to 990 per cm, gradually decreasing as the case progresses. In some few instances there were polymorphs, but usually at all times were from SO to 100 per cent, mononuclears. Globulin: Low at first, but increases during second and third week, then gradually falls. Reduction of Fehling's is present and usually prompt. Because the blood picture and the spinal-fluid examination seem also to lack specific diagnostic features, it would be wrong to conclude that they are of no assistance, because, taken in conjunction with the history and the clinical symptoms, frequently the diagnosis can be made. Tbe acute stage is arbitrarily considered as the period between the onset of tbe paralysis and the disappearance of tenderness on spinal flexion. Fever is not a characteristic of this stage and has usually markedly subsided. Pain is a constant feature, and in general may be said to be spontaneous pain—pain caused by manipulations or tenderness to pressure of tbe muscles. There are some cases in which stupor is a marked early symptom. To these the term cerebral has often been loosely applied, but not accurately, because the paralysis accompanying has been of the lower neurone flaccid type, and they must be classified as bulbo-spinal. The paralysis is and has been the prominent feature. In the vast majority of cases (the bulbo-spinal type) it is a flaccid or lower neurone variety involving muscles or groups of muscles rather than limbs or areas; the distribution is quite unsystematic. As to the relative frequency of various muscle groups, statistics show that in the great majority of cases muscles of one or both legs are affected, and in nearly 50 per cent, of cases the paralysis is limited to ths legs. In the upper leg the quadriceps is most often paralysed. G 174 British Columbia 1918 In the lower leg the anterior group of muscles, i.e.. peroneals, flexors of foot, and extensors of toes. Extensive leg paralyses are frequent, but complete and permanent paralysis is not the rule. In the arm the shoulder-muscles, more especially the deltoid, are most often involved. It is the general observation that the proximal muscle groups are more apt to be paralysed than the distal, and that after paralysis the distal recover more quickly and certainly. Paralysis of the spincters is very rare. Many have bladder disturbances, requiring catheterization, but this is a transient condition and probably analogous to that seen in the febrile conditions. Practically all cases dying of poliomyelitis without complications die of respiratory failure, due to paralysis of the intercostals and diaphragm. Tbe phremic nerve arises from a large number of roots from the 3-, 4-, and 5-cervical segments, and possibly this accounts for the fact that the action of tbe diaphragm is so rarely interfered with. , Bulbar paralysis—most commonly the cranial nerve affections form part of a general process in which the cord is simultaneously affected, though occasionally bulbar paralyses may occur alone. The facial nerve is that most often found, though it is suggested that slight attacks of poliomyelitis may be a frequent unrecognized cause of strabismus. The greater number of fatal cases comes under the heading of rapidly progressive cases, showing the symptom complex known as Landry's paralysis, i.e., an ascending paralysis involving first the legs (or arms and legs), intercostals, arms, neck, and diaphragm. Cerebral Cases. Just a few words as to cerebral cases. In 1SS5 Strimpell first called attention to the analogy between certain forms of cerebral paralysis in children and poliomyelitis. He analysed twenty-four cases, nineteen of which were below the age of four years. The onset was sudden, and there was an initial stage with fever, vomiting, and convulsions; then followed a hemiplegia, or a monoplegia of arm or leg or an ataxia without paralysis. There was no atrophy of muscles, no reaction of degeneration, and reflexes were usually exaggerated. In 1S9S Medio during the Swedish epidemic noted three cases with fever, drowsiness, convulsions, spastic hemiplegia, and exaggerated reflexes. In two of these the sixth cranial nerve was also paralysed, thus forming a connecting-link between the spinal and cerebral forms. Thus there are some cases, rare it is true, in which the pathological lesion is in the brain itself, and in which the clinical manifestations suggest a disturbance of the upper motor neurone. On the other hand, there are some facts which, assuming such a classification, are not easily explained. (1.) In spite of the fact that monkeys are usually inoculated with serum intracerebrally, the paralyses are always spinal and not cerebral. (2.) With the tremendous increase in the incidence of poliomyelitis during tbe past few years and its more general recognition, it is remarkable there has not been a corresponding increase in the number of cerebral eases reported. Lastly, the abortive type of case. These are the cases of poliomyelitis which do not develop paralysis. They are believed to contribute at least 50 per cent, of the total. They are just as truly and dangerously poliomyelitis (from the contagious standpoint) as the frankly paralytic cases, except that the nervous system has been spared. The blood-serum of abortive cases neutralizes the virus in vitro just as does the serum of paralysed patients, and the spinal-fluid picture is similar. The symptoms, apart from the paralysis, are similar and need not be repeated here. Prognosis. Prognosis in poliomyelitis is a complicated problem. We are asked to foretell:— 1st. In the preparalytic stage, whether paralysis will occur. 2nd. When it does occur, will it advance? 3rd. How much residual paralysis. 4th. Question of life and death. As to the first, it is impossible to tell by any symptoms or signs whether paralysis will or will not occur, though twitchings and convulsive movements in the muscles have been cited as indicating the area affected. As to the second, will it advance? As a rule, the initial paralysis is maximum and final, but there are enough examples of delayed involvement to make anticipation of further paralysis justified up to the seventh or eighth day. . 8 Geo. o Provincial Board of Health. G 175 As to the question of life or death: In a general way we may say the mortality has varied in epidemics from 6 to 25 per cent. In younger children the outlook is better than in older ones and adults. But such statistics are of little help in the presence of a given case of poliomyelitis, for this reason: In poliomyelitis there is a peculiar element of chance not present in other infectious diseases—viz, the accident of the lesion destroying the phrenic and intercostal centres simultaneously, an accident which is always fatal. In most acute infections we regard death as due to a toxaemia which overwhelms the body and interferes with its functions until finally some organ, usually the heart, weakens and fails. But in poliomyelitis, while in some few instances death is due to a complication, usually bronchopneumonia, ordinarily tbe toxaemia is a negligible quantity and death is essentially a mechanical one due to paralysis of the muscles of respiration. It occurs most often on the fourth or fifth day of tbe paralysis. Treatment. Whatever the future may bring forth, we to-day have to admit that there is no specific therapy by which the onset of poliomyelitis may be warded off, the paralysis prevented, or the resolution of the inflammatory process and consequently return of function hastened. The problem of treatment is, then: First, to prevent the spread of the disease; second, to treat the symptoms; third, restore muscular efficiency; and, fourth, to prevent and correct deformities. First: Prophylaxis. The incubation period is probably about eight days. The infectivity is unknown, but has been arbitrarily fixed at less than six weeks. It is spread by personal contact, though there may be other contributing causes at present unknown. Admitting that owing to unrecognized abortive cases and carriers effective preventive measures are difficult, we can only at present demand the following:— (1.) All suspected and recognized cases must be reported: (2.) Patients are to be isolated for six weeks just as carefully as we do scarlet fever, for instance, with windows screened, animals excluded, etc.: (3.) All discharges, naso-pharyngeal and intestinal, to be destroyed: (4.) All contacts quarantined or at least under observation for two weeks after last exposure: (5.) Regulation or prohibition of intimate congregation of children. Second: During tbe acute stage absolute rest in bed is an essential; thus will the damaged cord have the best chance for repair. Cold sponging is inadvisable, tending to cause increased congestion of the central nervous system. The value of an ice-bagto the spine is also doubtful. These cold applications cause an increase of pain. Constipation should be avoided and the child must not be allowed to forget to urinate; catheterize if necessary, for there may be at first some loss of bladder irritability. Pain is the most prominent sypmtom demanding attention. This is most often due to passive motion, thus indicating the necessity for care and gentleness in handling the patient. Heat, dry beat, wrapping the limb in cotton, etc, is a simple method of alleviating. Immobilizing by splint or sand-bag is helpful. Opiates may be necessary and should not be withheld from children because, unlike adults, they cannot voice their demands. Contractures and deformities occur early from the pull of unaffected muscles and the overstretching of injured ones if great care is not taken. Dropped foot is perhaps the commonest, so a cradle should be used to support the bedclothes and the foot kept at right angles. Sandbags may be used or light apparatus. The danger of restraining apparatus is that the limb may be kept too quiet and prevent active efforts to use the muscles at a time when motion should he encouraged. A good rule is to apply the apparatus at night only and leave the limbs free to move during the day. The phase of convalescence begins with the disappearance of tenderness and lasts from one and a half to two years, after which the condition has become more or less stationary. The pathologic condition at this stage is that the haemorrhagic myelitis is subsiding, the perivascular infiltration is being absorbed, cells are resuming their function, and the clinical manifestations of these processes is expressed by what we term " spontaneous improvement." G 1.76 British Columbia 1918 This is the period when the problem arises as to when the case ceases to be a medical one and comes in the sphere of the orthopedist. A too early resort to surgery and mechanical methods may cause the patient to rely too much on these and cease developing his muscles to their utmost, while, on the other hand, it is unfair to postpone the assistance of the orthopedist until deformities have occurred. At this stage Lovett, of Boston, favours ambulatory treatment, i.e., the patient is permitted to be up and about, insisting strongly, however, on the avoidance of fatigue. His general rule as to apparatus at this time is that it is to be used if the patient cannot stand without It, or if in standing or walking a position of deformity is assumed, because deformity leads to stretching of soft parts, and, if persisted in, to permanent bony changes. The therapeutic measures to be used locally are massage, electricity, heat, and muscle- training. Massage is used only after all tenderness has disappeared, and then very gently and briefly. Its proper use retards muscular atrophy and promotes muscular tone; more than this must not be expected of it. Its overuse is responsible for much barm. Electricity has done more harm probably than good; he does not advocate it. Muscle-training, however, is the measure of greatest value at this stage. Muscle-training attempts to force an impulse from brain to muscle, to enable it, if possible, to open up new paths around affected centres in the cord. It is based on the fact that as a rule the entire nervous control of a given muscle is not wiped out as a whole, but only in part. It is universally agreed that one voluntary effort on the part of the patient is worth a dozen passive movements made for him. One should not forget that overstretched muscles are placed at a disadvantage, and that fatigue and overtreatment by massage and exercises are detrimental factors of the highest importance. The third stage is called the stationary stage, and begins about two years after the onset. The dominant requirements of this stage are operative, and are, first, the correction of deformity, and, second, operations to improve functions. Just a word now as to drugs and specific treatment:— (1.) Urotropin has been used more or less extensively as a therapeutic measure. However, when we stop to consider that in urinary conditions-it has no antiseptic effects except in an acid medium, we cannot expect it to show much germicidal activity in the cerebral-spinal fluid, which is alkaline. Its use, I think, has been discontinued. (2.) Adrenalin was advocated by Meltzer, of New York, though both the Rockefeller Institute and the Health Boards of New York discredited it. He injected % to 1 c.c. of a 1.000 sol. intraspinally every four hours for several doses. His reasoning, however, was interesting even if not convincing. Tie said: " Any inflammatory focus is surrounded by zones of hyperemlc exudation and oedema. Experimenting on rabbits' ears, he found that an injection of adrenalin caused the zones of exudation and oedema to disappear completely for some time and reduced the inflammatory swelling to a small focus in the centre. The pathological condition of the cord in poliomyelitis is a similar one; the procedure is harmless, at any rate; therefore, if the same effect can be produced even temporarily, it is worthy of trial." Ordinary blood-serum has been used injected intraspinally from parent to child. Horse- serum in the form of antitoxin likewise, but with no definite results. Lumbar-puncture is advocated, particularly in those cases showing signs of pressure or prolonged stupor, with apparent good effect symptomatic-ally. Serum from convalescent patients—even those recovered, twenty-five to thirty years—is used, and does seem the logical procedure. It contains protective bodies which, as we have noted, will neutralize the virus when mixed in vitro in certain proportions, and will effectually prevent the experimental production of the disease in monkeys. The difficulties are, of course, the limited quantity to be obtained from convalescent human patients. It is injected intraspinally after the withdrawal of a certain quantity of cerebral-spinal fluid, just as is done in meningitis, and repeated at intervals. A suggestion has been made by Wells, of Chicago, that the injections should be given intravenously, reasoning that the lesions in the cord are essentially perivascular infiltrations, and also that the lesions are not confined to the nervous system, but involve various other tissues and organs (lymph-glands, etc.). Moreover, .a much greater quantity of serum containing the necessary antibodies is thus introduced to the patient. Summing up, then, our knowledge of the disease, we must admit that our position in regard to poliomyelitis, its prevention, its diagnosis, and its treatment, is unsatisfactory to-day. Never- 8 Geo. 5 Provincial Board of Health. G 177 theless, with the study and investigation that is being devoted to it, we can with assurance expect in the near future a scientific solution of the problem; a solution which will include a practical and reliable diagnostic test for the detection of clinical cases and carriers; a rational scientific cure of the disease itself; and, thirdly, what in view of the character of the disease and the early disastrous effects is much more important, a means of conferring artificial immunity against it. Discussion on Dr. Carder's Paper. Dr. R. E. McKechnie (Vancouver) : I have listened with much pleasure to Dr. Carder's paper and must congratulate him on it. It is very comprehensive and he has brought the subject up to date. There is very little that can be added to what he has read to us. The , only unsatisfactory thing about it is, there are so many indefinite things as to the nature of treatment, etc, but the paper is a particularly good one and thoroughly up to date, and Dr. Carder is to be congratulated on his resume of the subject. My first acquaintance with it, the first case I ever saw occur in practice, was a relative of mine. 1 cannot say that I recognized it at that time, because I had known the youngster from the time I was a youngster myself; she is about my own age and still living. Dr. Carder gives three types—one cerebral type; this was the cerebral type. The second case was diagnosed in Montreal General Hospital by Dr. Stewart in 1890, the same year Dr. Carder quotes the authority giving the first thorough description of the disease. Of course, no one had any idea as to whether it was an infectious disease or not. The case was in one of the general wards, and subsequently I saw other cases in the general wards. In my own practice, in the ten years, or a little more, that I was in Nanaimo District I saw some five cases—no two cases in any one year—and that shows no infection occurred in those cases. Since I have been in Vancouver I have seen several cases, but as my work is largely- surgical I do not run into it so much, and I fancy our climate is a good climate or we would see it more often. In discussing the virus or germ that causes this disease, there is something which makes us think of goitre. We have heard of the transmission of goitre through drinking-wells, and in the District of Lillooet we find the sheep and dogs have goitre, so we find the production of goitre is, like the production of poliomyelitis, from a certain virus. There is a similarity between the two—the germ that produces the virus, which produces one, passes through a filter the same as goitre virus; both can be cured by heat; neither by cold, so there is a little similarity. I would like to see that one of the subjects for your next meeting for the study of goitre in British Columbia. There is one point in Dr. Carder's paper which he brought out very nicely; that is the partial theory of the cause and symptoms in these cases. It is the mechanical theory, and to my mind is the correct one. Many of these cases are recognized by symptoms of paralysis. In more than one case the child was found paralysed when first noticed. That brings me to a ease I have in the hospital at this moment. A man was being hoisted out of a mine in a bucket with several other men and there was a beam that had to be passed where men were supposed to duck their heads. This was the tallest man in the bucket and he could not bend, could not miss the beam. He was struck on the head and there was a sharp twist and fracture of four cerebral vertebrae. He was paralysed in both arms and both legs when he came to the hospital. The censory columns are not much injured because he has complete sensation. There is some little injury, the same as in poliomyelitis; but his anterior columns got the brunt of the damage, the same as occurs in poliomyelitis cases. Here is where the similarity comes in between poliomyelitis and a traumatic case. The result in each case will depend on the number of nerve-cells which are absolutely destroyed, the number of nerve-cells partially destroyed that later will die, the number that have been partially injured and will recover, and tbe number that have not been hurt at all; and that all happens in a traumatic case almost immediately, and in a poliomyelitis case almost immediately. You have to direct your treatment to the conditions which already exist. Medicines are not going to do any good. Your first duty will be to combat the present condition, treating symptomatlcally only, and later on you will come to the mechanical and mental treatment of the case. Dr. Carder has emphasized the fact that death in this case is mechanical, the same as in traumatic cases. 12 G 178 British Columbia 1918 t One of the most valuable assets in treating these cases is optimism. A doctor who is not optimistic ought to be put out of the profession. When you have a long-drawn-out case like poliomyelitis, it is going to take a great deal of optimism. The most valuable therapeutic agency is volition; that is, for the will to work to make the muscle work. One attempted move is worth a dozen passive movements. That is the most important part in the early stage of the case. In dealing with children two or three years old, you cannot impart much optimism to a youngster of that age, but you probably can to the mother or the nurse in attendance, and this will help to cure the condition. In older children and in adults you can impress the importance of this on them and so make them help to cure themselves. Another important point Dr. Carder emphasized was the danger of overdoing your exercises, the danger of fatigue. You can eat too much meat or too much bread; you can overdo almost anything, and you cau overdo exercises. Take the case of poliomyelitis, where you have some nerve-cells whose vitality is in the balance, you can overdo the exercises. You have to use your best judgment in working along those lines. Following that, if the case is left alone, you will have contractures; one set of muscles has been paralysed, but the opposing set is still active, and you will have contractures. If you go to the military annex hospital you will see them working with patients along these lines, not cases of poliomyelitis, but of injury to the nerves by military wounds, and such a line of treatment will be used here. I have not touched on the important discussion at all, but purely the Department of Health aspect of the doctor's paper; I leave that to the others. His paper covers much of what I have been enunciating here and much of what was in my mind. Dr. Stanier: I cannot add anything at all to Dr. Carder's most exhaustive paper on the scientific aspect, but I can speak from a personal point of view. I think it was in the fall of 1911 I had an epidemic of this in the Victoria District. It was a long, hot, dry summer, when we could expect something of that kind. Perhaps that obviates the growth of that particular disease, the same as we get spinal-meningitis cases after a cold, wet winter. It must have been about September 15th; I had been camping, and a case occurred that had not been diagnosed on the other side of the bay, about three miles away, a young chap about twelve, and he was dead by the time the doctor arrived. I did not see the case at the time and was not paying much attention to it, as I had been on my holidays. The next thing I heard was that a dog was paralysed in the hind quarters, and then my own setter came in completely paralysed in the hind quarters. Shortly after that I was out shooting and I was seized with a violent pain around the loins and lower spine, and I could not get back to town; I remember the agony of that day. The paralysis occurs, of course, much more frequently in youth, but I was not tbe only adult case. I cannot to this day stand any great strain, on account of weakness in the spine. Dr. Carder says about 50 per cent, are abortive cases. I was m Toronto about two years ago and I was told they considered ninety-eight cases of meningitis occurred for two that were recognized, because the symptoms were not definite enough. This is the case in poliomyelitis; only when it gets into the nervous system is it recognized. As regards treatment, my case was diagnosed, a doctor was in attendance. I realized I was seriously ill, terribly constipated, and wanting to lie down—very tender and not much use of my legs. Continued heat was the only thing that could be done to relieve it. I can understand that now, since bearing the description of the vascular changes. As regards the effects, a boy came into my office the other day; he was about six or seven years old; he had this when an infant, and he has now practically complete paralysis of the biceps and triceps of the forearm, and hand cannot be used. I took an X-ray, and have tried to restore the muscular condition, but he is liable to dislocation on account of the loose condition. I am putting his arm in a rectangular splint. I find that massage is decidedly a good thing, but should be only mild in the early stages. Dr. Carder (replies to discussion) : The hour is late, and I do not think there is anything I can add, except perhaps to draw attention again to what I tried to emphasize in the paper. There is a tendency to want to do something too early, probably against their own better judgment. That is one point that should be carefully considered. Absolute rest is essential, and, better still, immobilization; do not be afraid to put a cast on or a splint. I think in New York 100 children are practically encased in plaster. And immediately after the plaster cast is applied 8 Geo. 5 Provincial Board of Health. G 179 the pain eases and the children are quite happy. Absolute rest is therefore essential. In time passive movements should be encouraged, and you can encourage the child to move, because, as stated, it is better than passive movement, but to do this too soon only causes damage to the nerve-cells and increases the irritation. It has been suggested that even four or five months should elapse before massage is applied. The Chairman: That concludes the programme for to-day. To-morrow morning we have some exceedingly interesting matter and a discussion of the question of tuberculosis. The Convention adjourned at 5.30 to 9.30 to-morrow morning. Thursday, September 13th, 1917. Morning Session, Dr. F. T. Underhill in the chair. The Chairman: I will call this meeting to order. We have a long and very important programme before us to-day, and we have first this morning the question of tuberculosis, in which we are all interested in this Province. I am not going to take up time and I will simply ask Dr. Vrooman to read his paper. By the way, discussion will be opened by Dr. Wesbrook, and then we will ask Dr. Walker and Dr. Proctor to speak to this paper. Dr. Young: Dr. MacLean received a letter this morning from Mr. Harris, Secretary of the Vancouver Association for Promoting Speech of the Deaf. (Reads letter.) If occasion will warrant during the day I will phone the office aud we may be able to have some talk on this very interesting subject. Dr. Vrooman then read his paper on tuberculosis. TUBERCULOSIS: HOW SHALL IT BE HANDLED IN BRITISH COLUMBIA? By C H. Vrooman, M.D, CM, Medical Superintendent, King Edward Sanatorium, Tranquille, B.C. In 400 b.c. Hippocrates wrote concerning tuberculosis: " The greatest and most dangerous disease and the one that proved fatal to the greatest number was the consumption." So that the problem we are considering is one which has afflicted the human race for many thousands of years. Hippocrates' description of the long-drawn-out illness of an advanced case of consumption is wonderfully accurate. In other medical writings of this time there is distinct evidence that the medical men of ancient Greece believed in the contagiousness of consumption. Yet it was only in 1882, thirty-five years ago, that Robert Koch discovered the tubercle bacillus, and we have since that time been able to make great progress in the study of the pathology of tuberculosis. As our present methods, both of treatment and prevention, rest on tbe essential pathology of tuberculosis, it is necessary before considering those subjects to briefly review our present-day knowledge of the pathology. To quote again from the father of medicine: " I look upon it as being a great part of the art to be able to judge properly of that which has been written. For he that knows and makes a proper use of these things would appear to me not likely to commit any great mistake in the art." Out of the volumes that have been written on tuberculosis certain conclusions now appear to have been reached, based upon accurate scientific observation and experiment. With Hippocrates' admonition in mind, let us examine briefly some of these conclusions and apply them to our present needs. The tubercle bacillus is the most ubiquitous parasite the human race has to contend with. It is so widespread, both in man and animals, that there is no doubt that we all, before reaching adult years, become its unwilling host, and the most of us without doubt remain the host of living tubercle bacillus during the rest of our days. It is then only because of the high immunity we have developed as a race to this parasite that only about 10 to 15 per cent, of us become clinically ill with tuberculosis. The rest of us accommodate the invader like the Allies did the German spies in the pre-war days—without knowledge, care, or suspicion; but to carry our analogy still farther, these same spies may, when in sufficient numbers, and at a time when our defences are least prepared, lead an invasion that may as suddenly overwhelm our organism as the Germans did Belgium in 1914. It will be readily seen that being infected with the tubercle bacillus does not necessarily mean that one is ill with tuberculosis and requires treatment. If G 180 British Columbia 1918 that were so, 90 per cent, of the.white race would require treatment. It is only when the infection is sufficiently massive to produce symptoms that we speak of a person being ill with tuberculosis. Chronologically, the earliest tuberculosis encountered is the bronchial-gland tuberculosis of children. The researches of Shon* and others show that the most common mode of entrance is by inhalation, and tbe setting-up of a small focus of infection in the lungs. This primary focus generally heals, but the bronchial glands draining the area become infected, and if the infection is sufficiently massive we may have developed the well-defined clinical symptoms of bronchial-gland tuberculosis. There is no doubt, as shown by the experiments of Ravenalf and others, that the bronchial glands may be infected from the intestinal tract, and that the ingestion of infected food may cause glandular tuberculosis without lesion in the intestines. The balance of evidence seems to be in favour of the hypothesis that most infection is conveyed by inhalation of tubercle bacillus, either in dust or moist droplets, eliminated by open cases of consumption. The chief means, then, for the spread of tuberculosis is the advanced and open case. Bovine tuberculosis may be, undoubtedly, conveyed by milk, and is the cause of a great deal of bone, joint, skin, and intestinal tuberculosis in children, but it is rarely a cause of pulmonary tuberculosis. Not more than one-twelfth of all the tuberculosis that has to he dealt with is due to bovine origin. In a country like British Columbia, where cows are kept well tested, the bovine tuberculosis originating in this Province must be exceedingly small. Age of Infection.—About 15 per cent, of children are infected the first year of life, about 50 per cent, the first five years, and SO per cent, are infected the first fourteen. While the mortality is comparatively high during the first two years, after that, from two to fifteen years, the mortality from tuberculosis is comparatively low, and during this period it is tbe milder forms of tuberculosis that we have to deal with. The mortality starts to rise at fifteen and maintains a high level until about forty, when it drops again. Bronchial-gland Tuberculosis in Childhood.—Bronchial-gland tuberculosis in children may be divided into three classes:— First: Those in which the primary infection is small and the general resistance large. The body-tissues react well to the invader; all the defences are ou the alert; and there is a rapid formation of fibrous tissue around the infected gland, and the parasite is promptly walled off. These children probably never have any symptoms, and the effect of this small invasion is, on the whole, good for the organism, as there is developed a certain immunity to subsequent invasions. There is also developed the well-known hypersensitiveness to the various tuberculin reactions— Von Pirquet's, Moro's, etc. Though a person may never develop any clinical symptoms, this hypersensitiveness continues throughout life. It might be as well to emphasize this point, as there is a tendency sometimes to give undue weight to a positive skin reaction. A positive Von Pirquet always signifies infection at some time with the tubercle bacillus, but it is so delicate that it may be produced by an exceedingly small focus well healed and doing no harm to the organism. Second: Those in which there is a moderate invasion the tissues react fairly well, but a number of glands become involved. There are little, if any, clinical evidences of infection. There is for a time a " biochemical 'balance " established between the host and the parasite. At any time, though, that this biochemical balance is disturbed there is a multiplication and a renewed activity of the parasite until we have the third type. Third: By reason of a continuous or massive infection, or because the biochemical balance is disturbed by the disease, such as measles, whooping-cough, etc, or bad living conditions, we may have what is the most frequent type of early clinical tuberculosis in children from two to fourteen. Allow me to quote a description of these cases from a recent article:+ " Clinically, these children present histories which are fairly typical. In these histories one may or may not be able to trace the source of infection. If the parents are of average intelligence, however, one can trace the source of infection in a very much larger percentage of cases than is possible in older individuals. Quite naturally, of course, one would hunt this source of infection in the immediate family of the patient. Failing there, one is often able to find it in the close vicinity of the patient's home. * Shon A The Primary Lung Focus of Tuberculosis in Children. Trans. E. Barty King. 1016. f Rave'nal. M. P. Jour.* A.M.A, 1016, LNVI., 613. % Gekel. W. A. Arch. Int. Med, 1017, Vol. XX, 32. 8 Geo. 5 Provincial Board of Health. G 181 " Coming to the history of the case itself, we find that, on close questioning, the parents will often say that the child has stopped growing, or does not seem to gain in weight. Along with this the parents will notice that the child does not have the energy that other healthy children have, and does not have the same inclination to play. The child tires easily, is apt to be irritable and cross. The appetite is slightly below par and is often capricious. There may or may not be some digestive disturbance. Often, however, constipation is noted, possibly due to the lack of exercise on the part of the child. Sometimes these children will have night-sweats, and the mother on close questioning will recall that the child has been feverish in the afternoons. There may or may not be a slight cough, which is hacking and unproductive. If tbe child is going to school, the teacher will often complain that he is inattentive and does not seem to keep his mind on his school-work. Occasionally one will be able to obtain a history of a pleuritic pain. As will be noticed, most of these symptoms are constitutional symptoms which may be present in other conditions, such as chronically diseased tonsils, middle-ear disease, and other cryptic infections. Undoubtedly many of these little patients have had their tonsils removed in the belief that this was the cause of the constitutional condition. " On physical examination one finds a child that is slightly undernourished, apt to look pasty, slightly anaemic, and not seldom stunted in growth. If there are diseased tonsils or middle ears present, there may be a slight enlargement of the cervical glands, which, however, are not necessarily tubercular. If there are decayed teeth, one is apt to find a similar enlargement of the submaxillary glands. Inspection very often reveals a slight or sometimes marked enlargement of the superficial veins of the chest, both anteriorly and posteriorly. The mobility of the chest-wall on respiration is seldom retarded, and is usually equal on both sides. There are very rarely evidences of any retraction. A careful percussion of the interscapular region will occasionally reveal a slight change in the note. Often after tbe fifth or sixth year one notices a slight diminution of resonance over the right apex, anteriorly and posteriorly, which does not necessarily indicate any underlying pulmonary disease. There are usually no evidences of pleuritic adhesions. Auscultation will give a positive D'Espine sign, very rarely any rales, occasionally friction-sounds at one base or the other. Along with the slight change of percussion to be found after the fifth or sixth year, one begins to notice a slight increase in the intensity of the breath-sounds over the right apex as compared with the left. This discrepancy between the apices is found from this age on, and may be considered normal. " On observing such a patient for another week or two, one will find that the Von Pirquet reaction is positive in a very large percentage of tbe cases. The pulse is unstable, even when the child is kept quiet, ranging in the evenings from 110 as high as 140. The temperature will also he unstable, sometimes showing marked amplitudes, at other times showing evening rises to 99.2, 99.4, and 100 Fahr, and even higher. On prolonged observation over a period of months one notices, further, a flat-weight curve. Even on a carefully selected diet the weight of such children often remains stationary as long as a year before there is any increase." This type of bronchial-gland tuberculosis in children is particularly amenable to treatment, and it is for these children that we should have our open-air schools and special sanatorium pavilions. By the early discovery and treatment of these cases many well-marked cases of pulmonary tuberculosis will be prevented from developing in later life. In other words, put these children under such conditions that their health is kept above par, and these infected and caseous glands will be enclosed in such a tough sheath of fibrous tissue that there will be little danger of them breaking down under the stress of early adult life. A man's immunity to pulmonary tuberculosis is to a large extent dependent on the strength of the fibrous capsule which walls off the infection received in childhood. Phthisis Pulmonalis.—As pointed out before, the most of our eases of pulmonary tuberculosis show themselves between the ages of fifteen and forty-five. The parasite gained its entrance in childhood, and it lived a secluded and quiet life in the bronchial glands until the opportunity arose for it to multiply and replenish itself at the expense of the tissue and often the life of the host. That the infection of tuberculosis may occur from without in adults is deemed impossible by some, and all investigators admit it is most difficult to infect adults from without, and then only by massive and continuous dosage. Phthisis pulmonalis in adults is, in most cases, caused by infection from within. The point that pulmonary tuberculosis develops from reinfection from within, and not by infection from without, has an important bearing upon preventive measures. G 182 British Columbia 1918 Whether a person develops pulmonary tuberculosis from these enlarged and infected bronchial glands is more or less due to the occurrence of what might be called the accidents of life. As Krause puts it:* "The development of tuberculosis disease from old benign tubercle depends largely on -whether the patient gets a cold, rows a race, or becomes pregnant at the wrong time." One man may carry through life a chain of enlarged solerosed glands that never give him any trouble. Another may only have a few, but situated close to a bronchus; its wall may become softened, due to inflammatory changes produced by an acute attack of influenza, and it may ulcerate .into the bronchus. The infectious caseous material is aspirated into the alveoli, and the practitioner is often surprised to find an attack of influenza developing into a tuberculous pneumonia. It is not within the scope of this paper to deal with the varied forms of pulmonary tuberculosis. Fortunately the great percentage of secondary infections are not so gross as to involve a whole lobe in a few days. The onset is generally insidious, only small areas being involved, and the patient at this time responds most readily to. the treatment. The absorption, though, of the products of the tubercle baccilli does cause definite symptoms, and the diagnosis, when made early, often means life to the patient, while delay in the diagnosis for six or twelve months without proper treatment often spells death. It would be straying from my subject to go into the details of early diagnosis, but I would like to emphasize that diagnosis in most cases can be made by symptoms alone. Physical signs merely tell the extent of the disease. Slight cough, fever without discoverable cause, slight, but continuous, loss of weight and strength, anorexia, and indigestion—with these symptoms tuberculosis should always be excluded by a careful examination of the lungs. A history of haemoptysis clinches the diagnosis without examination. An examination which shows a few moist rales after cough at either apex means in 95 per cent, of cases pulmonary tuberculosis and tbe patient should be treated as such. The occasional non-tuberculous case that would be treated is negligible in comparison with the number who would get treatment in the early stages if this simple rule were followed. It does not require exceptional skill to diagnose clinical tuberculosis, but it does require careful and prolonged examination. It is perfectly appalling the mistakes that some, otherwise good, practitioners make simply because of lack of care in regard for the essentials. There is scarcely a month passes in which I do not have a patient give me a history of a frank haemoptysis in which some practitioner has not told the patient it was due to a haemorrhage from the throat, or were assured afterwards that the lungs were all right. Haemoptysis, unless due to some readily diagnosed other cause, such as mitral stenosis, always means active tuberculosis, and should be so treated whether there are any physical signs in tbe lungs or not. Having traced our infection by the bronchial glands and shown how in early adult life this may under suitable conditions cause clinical pulmonary tuberculosis, it is not my purpose to further describe the many different forms that may develop. It will be readily seen, though, that a case is not always incipient because the onset of symptoms were of recent origin. Many cases are advanced when they first consult a physician. The terms incipient, moderately advanced, and far advanced have rather to do with extent of disease when symptoms are first Observed and have no significance as to the time of onset. The proper classification, though, has a great bearing upon the prognosis and time required for treatment. Cases that are incipient when discovered will sometimes, in spite of treatment, steadily progress and become far advanced and then become arrested. Advanced cases, with an apparently hopeless attack, will suddenly under proper treatment, and sometimes under most improper treatment, become quiescent, and the patient may be able to resume an almost normal working- life for a period of years. It is because of this that I hold no institution should be labelled a hospital for hopeless cases, and the proper function of all institutions caring for tuberculosis is to treat all cases who are ill. Such institutions should have wards arranged so that far- advanced and bed patients could be segregated from those who are not confined to bed. The prognosis and course of a case of pulmonary tuberculosis is varied so much by periods of quiescence and of exacerbation that in this more than any other disease we must exclaim with Hippocrates, " Experience is fallacious and judgment difficult." Having thus reviewed briefly some of the facts known in regard to infection and pathology of tuberculosis, it remains for us to consider that most important of our problem—viz, prevention. On paper the problem looks simple enough. * Krause, A. K. Am. Review of Tb, 1917, Vol. I, 65. 8 Geo. 5 Provincial Board of Health. G 183 First: To put all in healthy environment, with good housing and proper food, which are essential preliminaries to good habits. This is a basic economic question and its discussion would carry us somewhat far afield. It may, though, be stated that any agency which tends to remove poverty, bad living conditions, and drink is going to help to remove the curse of the white plague. Second: To recognize the disease early and put patients in the best possible circumstances to promote cure. Third: To guard the community against the dangers associated with the advanced cases. It is the two latter portions of the problem that we are more immediately concerned with in this discussion, and the paper simplicity of the problem somewhat disappears as the different activities involved in their complete solution are examined. To recognize the disease early means both education of general public and medical profession. And it means the provision of sufficient sanatorium accommodation where these patients may learn how to cure themselves. To guard the community against the open infectious cases means, first, that these open cases shall be known to the Health Officer, and, when known, that he shall be able to keep them under adequate supervision either in hospitals or under safe conditions at home. The Health Officer who reports his community free of tuberculosis merely because cases are not reported to him by the medical practitioners is burying his head, ostrich-like, in the sands of ignorance. The co-operation of the practitioner can and must be secured, and the surest way to gain this co-operation is the knowledge by physicians that by notifying their cases real help will be given in the care of the patient and that the community will be benefited. The general practitioner is the backbone of the medical profession, and he is always ready to co-operate in any movement to benefit the health of his patient or the welfare of the community. The headquarters of any campaign in any community against tuberculosis must- be the establishment of a tuberculosis dispensary in charge of a specially trained dispensary nurse. The dispensary nurse should be the accredited agent of the Health Department, and her duty would be to actively search for cases of tuberculosis. She would keep under supervision all known open cases. When an advanced case was discovered she would arrange for the examination of all contacts, particularly children. She would arrange for the proper institutional care of all diagnosed as requiring that care. Her duty would be multifarious, but, in short, she would be the adviser and friend of all those afflicted with tuberculosis. The dispensary would be the clearing-house, and while part of the activities of tbe Health Department, it would be necessary to have the medical part of the work under the supervision of a physician having special knowledge of tuberculosis. This means that supervising the various dispensaries in the Province there would be a Tuberculosis Officer. It may be objected that dispensaries are all right for the larger cities, but how about the rural communities? There is to my mind no reason why there should not he dispensaries in the rural communities, but in the rural communities the work would be widened to embrace all health matters. It would be useless to establish dispensaries unless there were hospital beds where patients discovered might be treated. It should then be laid down as a basic principle that all general hospitals should provide special wards for the advanced cases of tuberculosis in their community. It is quite true that in British Columbia all hospitals have to provide some beds for tuberculosis, but the number is ridiculously small. They are generally the poorest wards in the hospital, and in place of encouraging patients to be treated there the hospital authorities discourage them in every way possible. To provide anywhere near adequate accommodation for the tubercular cases requiring treatment there should be in British Columbia hospital and sanatorium beds equal at least to tbe annual death-rate from tuberculosis—viz, about 400. That would mean providing at Tranquille about 250 to 300 beds. The most of the beds at the sanatorium would be reserved for those likely to benefit by treatment, not necessarily all incipient cases, but moderately advanced and advanced cases, who have a chance to get well. There would necessarily have to be beds for advanced incurable cases, as not all are going to do well, and it is not possible to send every advanced dying case to their home hospital. It would mean seventy- five beds in Vancouver, thirty-five beds in Victoria, and forty beds divided among the other hospitals of tbe Province. In these hospital beds would be treated the open case awaiting admission to the sanatorium, and the advanced incurable case who wished to be near their friends during their last days. G 184 British Columbia 1918 In charge of the various dispensaries and acting as consultant to the various hospitals should be a Provincial Tuberculosis Officer. His work would be to supervise and co-ordinate the various anti-tuberculosis efforts, to act as consultant to the dispensaries and hospitals. His services should be available free to general practitioners in the diagnosis of suspicious cases. It must be recognized that very few practitioners have had the opportunity of obtaining special knowledge in regard to the diagnosis and treatment of pulmonary tuberculosis. It is only of recent years that medical students have been given the opportunity to study early cases of pulmonary tuberculosis in sanatoria or special hospital wards. This, then, would be the scheme:— First: To establish in the various centres of British Columbia tuberculosis dispensaries under charge of a specially trained nurse. This would be the central bureau. Cases would come here for diagnosis, advanced cases sent to suitable hospitals, cases who might be benefited sent to the sanatorium, predisposed children kept under supervision, patients discharged from the sanatorium would report here for re-examination, etc. Second: The provision at once in this Province of beds for the special care of pulmonary tuberculosis equal to the death-rate—viz, 400. Third : In charge of the dispensaries and acting as consultant specialist, a Chief Tuberculosis Officer. This scheme is no experiment; it was first originated by Sir Robert Philip, of Edinburgh, and has been adopted in the British Isles as the best scheme in both rural and urban districts for handling the tuberculosis problem. That it is effective is shown by the fall of the death- rate in the communities where it has been tried. In 1900 the death-rate in England was 19 per 10,000; in 1910 the death-rate from tuberculosis was reduced to 14.3 per 10,000. The most marked reduction has occurred in the communities where the most thorough methods have been adopted. Still more striking comment upon the success of these methods was made recently by Dr. Hermann M. Biggs,* of New York, after a recent visit both to England and France to investigate the effect of war upon the incidence of tuberculosis. Dr. Biggs says: " For many years in England an active anti-tuberculosis campaign has been carried on, and there has been a steadily and constantly decreasing death-rate from the disease. The death-rate from pulmonary tuberculosis there is now about 1 per 1,000 of the population, as compared with 1% in New York State and 3 in France. England has the lowest tuberculosis rate of any of the great countries of the world. In contrast to England, France has done practically nothing before the war for the prevention of tuberculosis. Such antituberculosis movements as had been taken were local and sporadic in character and were solely the result of private initiative. The sanitary authorities had never taken official cognizance of the disease, and notification of it is not required in France even now. There had been no provisions for institutional care either of early or advanced cases, and but few dispensaries. " At the beginning of the war there were only 1,000 sanatorium beds in the whole of France for tuberculosis, and these were in private institutions. There was no provision for the care of advanced cases, excepting as they were received in the general wards of the general hospitals. (You will recall that this method of care was prohibited more than twenty years ago in New York City.) " The death-rate from tuberculosis in France has been continuously high, and especially high in the cities, and has decreased slowly and but little. For the whole of France before the war it was nearly 3 per 1,000, and in many of the cities is was much higher. In some cities, as, for example, in Havre, the death-rate last year was more than three times that of New York City, and the tuberculosis death-rate alone of Havre was equal to 40 per cent, of the total death-rate from all causes in New York City. " The results, as I said, are exactly what one would have anticipated—the development of tens of thousands of cases of tuberculosis among the troops. By the end of December, 1915, 86,000 soldiers had been returned to their homes with active tuberculosis disease. In February of this year it was estimated that about 150,000 had thus been returned, and more are constantly being discharged for this cause. " The history in France has been repeated, I believe, from such data as are obtainable, in Austria, Hungary, and Russia, and to a less extent also in Germany. England alone has not . suffered to any great degree, and this is because, first, of the low prevalence of tbe disease in Biggs, H. M. Am. Review of Tb, 1917, Vol. I, 8 Geo. 5 Provincial Board of Health. G 185 the civil population of England previous to the war; second, because the army was mobilized deliberately, and careful physical examinations were made, and those applicants who had suspicious histories or signs were excluded; and, third, because the English troops live under distinctly better conditions at the front than do the French, because as a nation they are fond of fresh air and outdoor life. " The contrast between the present situation with reference to the tuberculosis problem as it exists in England and as it exists in France is most striking and instructive. France has suffered from the war infinitely more than England has thus far. Still Great Britain has raised an army of over 5,000,000 men, and no new or serious tuberculosis problem has been created. France, on the other hand, has a problem of such magnitude that it threatens even the future vitality and economic development of the French people. In England the tuberculosis problem has been efficiently met before the war; in France, on the other hand, practically nothing had been done. It is not, therefore, because measures for the prevention of tuberculosis are wanting or inefficient that tuberculosis has become such a serious problem in so many European countries, but it is simply because the well-tried measures have not been applied, both before and since the outbreak of war, in an efficient way." This surely is sufficient evidence that it is our patriotic duty to protect the health of the people by a properly organized anti-tuberculosis campaign. The results of inadequately handling the problem, or leaving the matter to private effort, is well illustrated by Dr. Biggs's report of the appalling conditions in France at the present time. As a result of his report legislation has been recently passed in New York State making it compulsory for every county having a population of 35,000 to provide hospitals or sanatorium beds for the treatment of tuberculosis equal in number to the death-rate in that county from tuberculosis. It is the imperative duty of this Province to adopt such well-tried measures as have proved effective in England and other countries. Let us cease trifling with this problem, and let not future generations reproach us that they knew but did not act. With our splendid climate, our uncrowded cities, and our young prosperous people, there is no reason why we should allow the matter to drift until we have the enormous problem upon us that they have in some of the older countries of the world. To carry on any effective campaign against tuberculosis in this Province means the expenditure of a large amount of money. It is'much more than can be done by private philanthropy. Private philanthropy has been the pioneer, but it is now time the Province should act upon the knowledge already gained. Public health is a purchasable commodity. Let the public understand that, once and for all time, and there will be no objection to the Province preserving for the people that which money cannot restore to them when lost. Discussion on Dr. Vrooman's Paper. The Chairman: I am sure we have all listened to this paper, this very valuable and ■ instructive paper, on the question of tuberculosis which Dr. Vrooman has so ably put before us, and we are particularly struck by the fact that for once we are running down some method of prevention; but I am not going to speak on this at the present time; I wish to call on President Wesbrook to open the discussion. I would also ask all those who take part to give their names and places of residence so that the stenographer may take it down, and also speak on one side of tbe room, or in front here, so that all can hear. Dr. Wesbrook: Mr. Chairman, Ladies and Gentlemen,—I wish first of all to congratulate myself and all of you upon having had the privilege of listening to Dr. Vrooman's paper. It is emphatic; it is clear; it does not advocate new and untried methods; it is a vindication of the practices which have been adopted, first, from a financial standpoint, and, secondly, backed up by Government in many countries of the world. Dr. Vrooman quoted Dr. Hermann Biggs a number of times. Dr. Biggs did more, I think, for municipal health, particularly in regard to tuberculosis, than any other one single individual in the world so far as I know. You may recall that in the early nineties, in order to get the people educated on tuberculosis and in order to stimulate an interest, sputum examinations were begun by the New York Health Department. They were made free. I remember at the time many people who had made themselves skilled in this kind of work used to protest against the city doing it for nothing, because it would interfere with the practice of medicine in that regard and interfere with fees. As a result of that, however, gradually the people and, still harder to do, the profession were educated as to G 186 British Columbia 1918 the economic and social importance of tuberculosis. We in the profession for many years had believed that every place in which medicine entered was holy ground, and that nobody was capable of understanding it unless he were a medical man. Gradually in New York they were able, through this publicity, to locate tuberculosis that otherwise would not have been located, and finally to make it a reportable disease, which completed the census of tuberculosis. That is the kind of thing that Dr. Vrooman is advocating for us here. Very aptly, I think, he pointed out the peculiar nature of tuberculosis, referring to its pathology and to its chronicity ; to the fact that the tubercle bacillus had a double effect, one of stimulating tissue-growth, the growth of ordinary tissue, and of connective tissue, and when in large quantities at present it has a capacity of breaking down tissue. Now, these two processes are going on all the time, and the treatment of tuberculosis is based upon that; that is, the building-up of the system and giving nature a chance to wall in the infection. However, the tubercle bacillus is a long-lived bacillus. It is extremely resistant; it has in its envelope a very resistant material, and it may remain alive, if not actively growing, for months and for years. Now, this proves a hardship—at least, makes the difficulties greater of dealing with tuberculosis ; but, ou the other hand, it gives a chance to save the individual, if not whole, at least to save him if we find out in time that he has tuberculosis. Dr. Vrooman pointed out very clearly to us that every one of us has at some time been struggling with tubercular bacilli in smaller or larger numbers. When the test first came out it was very discouraging to find that it was of value only in children, and we all reacted on this test after we got to a certain age. I was reminded, as he read his paper, of what I heard Osier say one day. Simon Flexner, before he went to Philadelphia and before he went to Rockefeller Institute, used to be at Johns Hopkins, and he was conducting an autopsy in order- to find out the cause of death where the patient had died of something else than the diagnosis.. At the time it was not thought it was tuberculosis; they didn't know what it was. It was a very interesting case. but. as Kipling says, that is another story; it was published later. I happened to see the first autopsy as the lungs were being examined, freely cut into, an old place—I forget whether it was calcified; I don't know; but while Flexner was conducting it Osier said: " Oh,, we all have them." Well, that was very startling at that time. There were very few people- who would have been as frank about it as Osier was; b*ut that was true; they had to struggle with the tubercle bacilli, and in hundreds of autopsies on adults you will find a very high percentage—perhaps you placed it too high. Dr. Vrooman—well, it is probably safe; and you will see evidences of a struggle with tubercular bacillus. Now, that gives us our chance, while it makes for us also a very difficult problem, because you never could know when the battle has been won. It makes it all the more important, however, that we should have early diagnosis; and in order that Dr. Vrooman's plans, which are admirable, should be successful, it means that early diagnosis must be made, and it means that those who are capable of making them should be available. Now, the physicians in this room are probably not very different from the physicians throughout the world, and in my experience probably not over 3 or 4 per cent, of the ordinary practising physicians, or physicians as they run, do make—I don't say they can't make, but they do not make diagnoses of incipient cases in many instances which come before them. Now, for Heaven's sake, we in the profession ought to be able to make a diagnosis long before the people on the street can. We don't want any curbstone diagnosis, across-the-street diagnosis. Temperatures, night-sweats, loss of flesh, cough, haemorrhage—some of these things, the laity can make a diagnosis under those circumstances. Now, we don't give ourselves or the patients a chance if we don't do it. 1 know that great pressure is brought to bear upon the physicians; when a patient suspects that he has tuberculosis and goes to a physician, he is afraid; but if somebody will just take a good look at him, possibly look at his tongue and pat him on the back and say, " You are all right," that patieut is very happy—used to be; but remember now that with this new axiom, that public health is a purchasable commodity, the people are taking a great interest in health and tbe principles which underlie it, and we are expected to be able to explain our problems in their language and to justify our decision. Now they are beginning to realize that when they go into a doctor's office to be examined for tuberculosis they may be stripped, and that an examination is to take some time; and many of them know about X-rays, some of them know about tuberculin, and they all know about the use of the stethoscope, percussion, and all that kind of thing. Now. it is no wonder that the people who are engaged in 8 Geo. 5 Provincial Board of Health. G 187 the practice of medicine, and who have to deal with all of these branches, in certain of them are not expert. Now, I have a reason for speaking on this. I believe very much in Dr. Vrooman's idea. I believe that we should have the best possible expert in the service of the Government at the head of this tuberculosis movement. I don't believe, however, that we need local ones; and this war has upset all of our calculations. Before the war, as Dr. Vrooman has pointed out, experts on tuberculosis were extremely scarce, and now with the lighting-tip of these cases, due to exposure and to bad physical conditions—because we have them in Canada as well as in France. We haven't any 400,000 or 500,000 as Biggs estimates for France, but we do have a good many cases which have escaped tbe attention of the examiner for overseas service, and have been lighted up since. We do not sleep so many people in an underground hut; we believe in fresh air, and have gone in for outdoor exercise, and so on, as Dr. Vrooman has pointed out; but we have an increase in tuberculosis, and it seems, as a war measure alone, any nation might well spend, and it would be real economy, a great many thousands, hundreds of thousands, millons of dollars, because every soldier, potential soldier, who is.kept fit in this way is a decided asset. That is equally true of these times. Now, to get back to the point to which I was referring to a minute ago: Why would it not be possible—I don't know whether Dr. Vrooman could do it if he had more assistants—and I am able to say that be needs more assistants. He didn't know I was going to say that, but I say- it now; I have been up there and he does need more assistants. That ought to be arranged so that all of us could avail ourselves of his special knowledge. Why wouldn't it be possible, say, to begin in Victoria, Vancouver, New Westminster, and some of these other places, and have Dr. Vrooman, or other experts if we have them, begin a little dispensary clinic. It would do two things—you would get a lot of cases if it were advertised, we could bring in a lot of cases we didn't know about; on the other hand, if the profession would co-operate, we would be getting a good many other people around us who are experts in this. I don't know whether Dr. Vrooman gets them or not; I suspect that he gets a good many cases sent up to him which might have been diagnosed as incipient cases a good many months and, in some cases, years before he gets them. Now, that is true in other dispensaries. It is true all over in every place that I know anything about; and I do think that we are going to save ourselves money; we are going to save the country many lives, we are going to save a great deal of suffering if we can get these diagnoses made earlier. I believe in the idea of the district nurse. I wish I could have had a chance yesterday of discussing the paper on " Medical School Inspection." I am a very great believer in it. Yon can't sit around, doctors can't, and wait for patients to come to them. The city has to go out and seek the sick, and there are many ways of doing this. The chief way perhaps is school inspection, and that will not be efficient unless it is seconded by visiting nurses. Very often the absence from school of a child will give you a clue to some illness that you would not otherwise have found, particularly if you are able to send your nurse out to the home and see about it. Now, that is a good thing in the city; it is a more necessary thing really in the country. Now, I would like to speak most enthusiastically and to speak at some length, but I think perhaps some of us in talking about these matters will suggest to Dr. Vrooman, or may directly ask him questions; and I think that Dr. Young, who got this meeting up. is to be congratulated that tuberculosis, always an important matter and during tbe war a very important matter, was so strongly featured on this programme, and I think it is a great privilege that I am allowed to be here and have an opportunity of getting back again into touch a little with the work of public health, which meant so much to me for such a long time. I thank you. (Applause.) The Chairman: Dr. R. E. Walker. Dr. Walker: Mr. Chairman, Ladies and Gentlemen,—I would just like to add a word in praise of the very excellent paper which Dr. Vrooman has communicated to us to-day. His wide experience on this subject always makes anything that he may say instructive, and it carried with it belief on the part of these who may have the privilege of hearing him. In his remarks Dr. Vrooman mentioned several points which to me, as a general practitioner, were particularly interesting. Firstly, with regard to bronchial-gland infection which Dr. Vrooman mentioned, I think that very few practitioners fully realize the frequenecy and the importance of bronchial- gland infection in children. So many children are brought to the practitioner complaining—the parents say they are not up to tbe standard, they are below par, they are run down; and very often, I think, the general practitioner is satisfied with this diagnosis; he does not investigate I G 188 , British Columbia 1918 the case thoroughly, and they are allowed to drift along by themselves with a drink of tonic or something of that kind; but a true diagnosis of the case is often not made. When I was in Eastern Canada not long ago I visited several of the tuberculosis clinics that were conducted by the various cities there, and I was much struck by the thoroughness with which these children are examined and a true diagnosis come to. All the children admitted to these clinics are given a tubercular test, and then they are X-rayed, and great reliance is placed on the taking of the X-ray. If the disease is active, in Toronto and Montreal both, they have very excellent sanatoriums close to the city where these children are placed. The Toronto one is quite an extensive institution, and they are kept there for varying periods; they are given suitable treatment, and open air classes are conducted, open-air schools are conducted with these children in attendance, and the result is very satisfactory in connection with that. I think, if the general practitioner were more alive to the fact that bronchial-gland infection is so frequently a case of sickness of an indefinite character in children, we would get much better results than we do. Then, again, Dr. Vrooman stated, with regard to pulmonary tuberculosis, that often the disease can be diagnosed from clinical symptoms alone. In this 'I quite concur. I think it is much easier for an inexperienced practitioner; that is, one inexperienced in making physical examination and diagnoses of incipient tuberculosis from clinical symptoms than it is from the physical examination; and in this connection I would like to draw attention to what I have found. We have heard Dr. Vrooman say that patients have frequently told them that their doctor said there was nothing wrong with them; that is, nothing wrong with their lungs. Well, I find that patients place an undue reliance on the physical examination. The stethoscope is a sort of mysterious instrument to them, and they come into your office and they consult you, and all they want is an examination. They come in and they don't want, very often—don't want to be questioned. The first thing they want to do is to strip off their clothing and have their chest examined; and no matter what you may say to them or what you may think, you may tell them that they are tubercular, but if, unfortunately, at the same time you tell them that you have not been able to get any physical signs, as perhaps an inexxierienced man—when I say inexperienced, a man who is not expert—he is not able to get physical signs, that Is about all they pay attention to ; and you may assure them that they are tubercular, but if you incautiously say at the same time that you have not been able to get any physical signs, anything wrong in their lungs, they go away quite happy and satisfied that they haven't got consumption, as they generally call it. So that I think more caution should be exercised in telling patients what the condition of their lung is; that is, if the doctor does not find physical signs, be should be very careful at the same time to impress upon them that, although the physical signs are not there, or that he cannot detect them, still they are tubercular. He should certainly impress upon them that they have tubercular trouble in the lungs, although it is not to his ear or under his examination discernible. With regard to the question of the immunity of England from tuberculosis, I happen to have read—I think it was an article by Dr. Biggs, whom Dr. Vrooman quoted, and he suggested in this article that the immunity of. England from tubercular trouble was purely the result of accident, in this: that many years back it bad been the custom for indigents to be placed in workhouses and poorhouses; long before the tuberculosis was recognized as an infectious disease, long before it was even diagnosed, these unfortunate persons soon became indigent and were placed in infirmaries. In this way segregation of advanced cases was made long before it was considered necessary to separate them they were separated, perhaps to the detriment of a good many of the other patients in the infirmaries, but it had a good effect on the community at large; and it is to this segregation, at first purely by accident, that England now is so immune from tubercular trouble. This, I think, has an important bearing on the whole question, for although this very segregation was extended, it shows, it teaches us a very important lesson, that we might learn the value of segregating advanced cases; and my own opinion is that all advanced cases should be treated in hospitals. I do not think that any advanced cases can be properly treated in their own homes, because when they become advanced they are more or less helpless, and no matter bow well they understand, how well they may be taught the necessity of taking care of their sputum, and that kind of thing, when they are very sick they become careless, and their friends become careless, aud I don't think that you can ever treat an advanced, open case of tubercular 8 Geo. 5 Provincial Board of Health. G 189 trouble anywhere but in hospitals. I think that that is a very important thing indeed, because it is through these advanced cases that the infection of tubercular trouble is being largely spread among the children and the non-infected persons in the community. With regard to the question of dispensaries, I think that is, of course, an excellent plan. It is a plan that is being adopted everywhere. There may be some difficulty in the country districts. The idea that suggested itself to me was that possibly, through the aid of the Victorian Order of Nurses, we might get some assistance. I know I have found these ladies connected with this organization of inestimable value in general work. They are well trained, they seem to have been selected very wisely, and are as a rule a very intelligent, able body of women; and in the country districts I think possibly their services might be enlisted in connection with visitation, home visitation of tubercular cases, as suggested by Dr. Vrooman. I thank you, Mr. Chairman. (Applause.) The Chairman: Major Proctor will now speak on this subject. Major Proctor: Mr. Chairman, Ladies and Gentlemen,—I will only occupy a very few moments. I want to add my testimony to the great pleasure with which I have listened to Dr. Vrooman's admirable address on this subject. Dr. Vrooman has given you in his paper the theory of this subject. I know something about Dr. Vrooman's work and practice. He is too modest a man, of course, to tell you what excellent results he is getting and the work he is doing, at Tranquille. I know I have thought that sometimes, as one who has been interested for a long time in this work, that part of the indifference of tbe general public—yes, and even of the medical profession—has arisen from the idea they have of the apparent hopelessness of doing very much with a tubercular patient, an idea which is absolutely erroneous, au idea that is almost cruel. I should like to tell you, along the lines that I have heard a moment ago, of the excellent work that is being done up there at Tranquille by Dr. Vrooman and his staff. I think that every Health Officer who has the interest of the general public at heart should know. Out of twenty-five cases that went there, and who were afterwards discharged as cured from that institution—a small institution, an institution that has been struggling along against great odds, the want of the necessary money—it cost, that batch of twenty-five patients, it cost about $6,000 to look after them and discharge them as cured; and from the date when these twenty-five patients were found, who were discharged as cured and whose cure cost $6,000, they had earned some $65,000 in wages since their discharge. That, I think, ladies and gentlemen, is a result worth talking about; it is a result worth knowing. (Applause.) This war has taught you and me a great many things. It has taught us, I think, perhaps above everything else, the value of physically fit people among those of us who have been talking about health problems for several years. We have been talking about tuberculosis, and we thought we might be accused of driving a bobby almost to death. I think, ladies and gentlemen, that this war has absolved us from that charge; and you know that is of supreme value to you and irie to-day as a nation to be a physically fit people, and no money that is spent in that way I think is money wasted. I find that since this war started, and since it has gone along and we have seen in the papers from time to time the huge amount of money that it is costing us to finance this war, although we have not been able to convince our Governments that they could spare the money to properly look after the indigent tubercular subject. Now, in our Dominion I think we now realize, ladies and gentlemen, how well spent that money would have been. Now, I am not going to keep you, because the hour is getting late, but Dr. Vrooman's paper, of course, points to a practical model of what is to be done. It resolved itself into two phases— treatment, which I do not intend to go into, he has gone into that so well; and the prevention which is the important thing. The care of advanced consumption, which, of course, is dangerous consumption, is of pre-eminent importance, as has been shown by Dr. Wesbrook, Dr. Vrooman, and Dr. Walker. We physicians see a good deal of advanced consumption. I see a good deal of it in this city; unfortunately, up to date there is no proper means of handling such a case. Suppose we have in this city, as we have, indigent consumption. We know their home; we have no means of taking bold of that man to handle him and put him into an institution and keep him there. I could give you instance after instance of what happened. Not so very long ago, about a year ago, an advanced consumptive was discharged because he wanted to go; he wouldn't remain any longer in our hospital up here, the Vancouver General. He spent the next succeeding five months in being a waiter in one of your restaurants in this city. Then when he got too sick G 190 British Columbia 1918 to carry on he returned again to the Vancouver General Hospital, ncvnd that, ladies and gentlemen, for that we have absolutely no means of handling it to-day, handling that problem. Another case that I saw this week has been in two sanatoria in this Province. He returned because he wouldn't stay there. We had no power to keep him. He refused absolutely to go to the Vancouver General Hospital. Now, that is the important thing. We want a place where we can keep subjects of that type, where they can keep them in a ward. The result is he is staying with many others in a rooming-house in this city, infecting others with the same trouble. That is a problem that confronts us, and it is one of the most serious kind. We had a clinic in this city, a clinic that -was established years ago by the enthusiasm and the interest of the women of our city, a clinic that I think has shown excellent work; and the problems that present themselves to those who attend that clinic are many and varied. I must not talk too much, but I just want to say this: Take, for instance, a case we sent up to Dr. Vrooman at Tranquille. the mother of a family. The mother goes there; perhaps she is an advanced case ; I have two families of that kind where the work of these households is being carried on in both these instances by girls, children of fourteen and fifteen. Those children are housekeepers; there is no money to do.any thing else. They are living in the same surroundings and under tbe same conditions as the mother who has been to the sanatorium, and perhaps died; and they have no present facilities for doing anything else; and yet those children will be the very ones who will develop this disease if they are not placed in proper surroundings, if they don't have to go to work, if they are not able to get the proper food that they require, and the amount of fresh air. I believe there is a movement on foot in this city, and I may be able to tell you it may—I don't know that it will be, but it is talked about being undertaken, under which in this city a children's institution for suspect and others who have tuberculosis, the kind of people who will develop tuberculosis if they are not particularly looked after. The trouble with meetings of this kind, the trouble with papers of this kind, ladies and gentlemen, is that too often a remarkable paper like Dr. Vrooman's is listened to with delight by everybody present, but nothing practical results. Now, what I should like, if possible, would be that you should authorize the Chairman of this meeting, say, to appoint a small committee to bring in recommendations to be sent to the proper legislative authorities, the recommendations being a result of what you have listened to here, with the hope that something practical may be the result of the delightful paper and the presentation of the subject such as you and I have listened to from Dr. Vrooman this morning. (Applause.) The Chairman : Ladies and Gentlemen.—We may congratulate ourselves on having with us to-day the Provincial Secretary and Minister of Education, Dr. J. D. Mac-Lean. I know he is with us in his interests as a medical man with regard to this subject, but I think he will go farther still and make the best endeavour to get the necessary money to carry on this warfare which is being carried on by Dr. Vrooman against the white plague. I will ask Dr. MacLean if be will kindly say something on this subject now. Dr. MacLean: Mr. Chairman, Ladies and Gentlemen,—I assure you that it indeed affords me a very great deal of pleasure to be present here to-day, and the pleasure is enhanced owing to the fact that you are discussing the problem in which I have always been very greatly interested, and that is the problem of tuberculosis and the prevention of this disease. Before taking up any discussion on the question, I wish on behalf of the Government to thank the men and the women who have come here at a sacrifice of time and energy to discuss a question of this kind. It speaks well for your loyalty to the Province, and it speaks well for your interest in the future welfare of the Province that you have come here in such numbers, many of you at considerable expense; and we all know, those of us who have been engaged in the practice of medicine, that time away from your office is absolutely money lost; so that 1 say that yon are to be congratulated for the sacrifice that you have made in this connection. Now, I do not appear before you to-day at all as an expert on the question of -tuberculosis. As probably some of you know, for the last ten years I have been engaged in the general practice of medicine in a rural community, or at least a community which was largely rural, and tbe question of turberculosis as it affects rural districts, of course, came largely before my mind and to my attention, and it seems to me that it is in the rural districts, in tbe outlying districts, that the problem is the greatest. Those of you who have practised medicine in the outlying districts realize the difficulties under which the general practitioner labours. For instance, you get a case of tuberculosis. You have a small hospital, probably anywhere from ten to twenty beds, and to 8 Geo. 5 Provincial Board of Health. G 191 begin with, the hospital authorities are not very anxious to take your patient in, for the simple reason that if the news gets spread abroad that there is a tubercular patient in your hospital, why the other patients in the neighbourhood, who would naturally go to that institution, do not want to go; consequently the hospital authorities—and this is not because they are not convinced of the seriousness of a case of tuberculosis, but from purely financial considerations. A hospital cannot be conducted without money, and if you have your patient in there, a tubercular patient, the majority of people are afraid to have a patient go into that hospital; consequently the problem is a very difficult one there. And in addition to that you have the fact that it is so difficult to convince the people that there is a case of tuberculosis in their family. Various considerations arise, most of which are uncalled for. They seem to think, the average individual, that there is some kind of disgrace attached to the fact that there is tuberculosis in the family. These are difficulties which have to be met in the outlying districts. I was particularly pleased with Dr. Vrooman's paper, and the particular feature that appealed to me in it was the entire practicability of the paper. Tbe suggestions that he made were not purely theoretical suggestions; they were suggestions that are absolutely carried out in private practice, in the practice of medicine in this Province. And I was particularly pleased with it for another reason, and that is that it went very much along the lines of the suggestion and the ideas of the Health Department in Victoria and myself, in discussing what could be done, and what should be done, or what might be done in the fight against this disease. I say it was very much along the lines that we happened at Victoria to consider wise. However, I do not wish at all to take any credit away from Dr. Vrooman for his very excellent paper, and while we have many of the ideas that he has, he has succeeded in systematizing and in placing them in a practical light which will be of very great assistance to us in our endeavours to have some solution toward the working-out of this very great problem. Now, I wish to assure the medical men and women who are in attendance here to-day, and the others of the audience who are interested in this work, that we in Victoria are deeply interested iu this question of public health, and, in particular, in the question of the preventiou and spread of tubercular disease. You know it is rather a large question, and you know that ■Governments are traditionally slow in moving, and you will have to take all that into consideration when you are looking for some results, or for results of this meeting, as suggested this morning; but I wish to assure you that we are seriously intending to grapple and are grappling with this question to-day, and laying out plans in order that we may be able to do something towards preventing the spread of this disease. It has always struck me as being rather remarkable that a disease like scarlet fever, say, or smallpox, how all the forces of Government, whether municipal or Provincial, when a case of scarlet fever appears in the community, all the forces of the Government are directed in one way, and that way is to segregate that case of scarlet fever, to prevent the spread of the disease; but in a case of tuberculosis in the community, which statistics show is many many times more deadly, very many more deaths from tuberculosis than there even begins to be from scarlet fever, the cases of tuberculosis walk around to spread the disease to and menace continually their associates, and yet nothing is done. So the great -question to my mind, the great problem to my mind, is the question of arousing the public to the very great danger of having those active cases of tuberculosis walking around pur streets. I do not wish to say any more, Mr. Chairman; I wish to thank you for the invitation to be present here this morning and to make a very few brief remarks. I do not wish to take up time which can be very much better occupied in listening to those who have a real practical knowledge and a working knowledge of the subject under discussion. I thank you. (Applause.) The Chairman: Ladies and Gentlemen,—This subject is open for discussion, for general discussion; but I warn you that the time is getting on, and we have two more important papers, and we have yet to have an address from Dr. MacLean to be delivered later on. He has just ■spoken a few words on the subject of tuberculosis. Now, I hope any one who wants to speak will get up and speak quickly on the point, and distinctly. Dr. MacLean: Mr. Chairman, I wish to correct your reference to the address that 1 was to give. Those of you who have been engaged in the practice of medicine realize how oftentimes the very best plans that you may make will go wrong; and, while I am not engaged in the practice of medicine now, I am engaged in work that is fully as jealous of one's time as the practice of medicine, so, as they say when they get in a hurry in some meetings, we will have G 192 British Columbia 1918 to take the paper that I was to have given to-day as read; so that if you were expecting any particular paper from me, I am very sorry that I have not been able to give the time and attention to the preparation of such a paper. The Chairman: Any further discussion on this subject? Any of you who wish to say something, do not delay. Dr. Wesbrook: I don't wish to speak twice, Mr. Chairman; but something has occurred tome, and that is that I failed in my talk before to express appreciation of the wonderful work that Dr. Vrooman is doing; and I wonder how many of tbe Health Officers and medical practitioners and others who are here to-day have visited that institution. I would like to suggest that that is one very good way of seeing modern tuberculosis work; and we have it, as you have gathered to-day from skiagraphs exhibited here, we have it in this Province in as up-to-date fashion as we could wish. I would like also to suggest that when Dr. Vrooman closes the discussion, if he will kindly do so, he will tell us a little something about the special tuberculosis school which is being run at Saranac, just a few words, because some of us may wish to avail ourselves of Dr. Vrooman's help, and I hope we all will do that; and some of us may wish to get a little further expert information, and he can tell us all these various particulars. W. J. E. Biker, CE. (District Engineer, Nelson) : I, like Dr. Wesbrook and others who have spoken previously, congratulate myself on hearing such a very explicit paper as we have had this morning. I would like to elicit from Dr. Vrooman a few practical points on the living conditions of the people. I am speaking as a layman and as an engineer, therefore I hope you will bear with me. I feel rather out of my atmosphere with so many doctors present, but the living conditions of the people must have something to do with tuberculous cases. I come from the Upper Country; I work up at Nelson, District Engineer for the Government, and my work takes me a great deal into the mining and logging camps. Now, particularly mining: I would like to ask Dr. Vrooman if be has any percentage of the cases that come under his control that come from mining camps in this Province, because in camps I have noticed buildings from 18 to 24 feet long and 6 feet high at the eaves, from thirty-two to thirty-six men sleeping in one room, and with very little ventilation at that. There was another point I would like to ask, and that is this : The immunity that England finds herself in from tuberculosis, is it entirely due to the methods that have been used in attacking this disease, or is it in some measure due to the improved sanitary conditions? Those are points that I would like to hear Vrooman on. (At. this point Dr. Wrinch substituted in the chair.) The Chairman: Is there any other discussion? There are some who wish to hear from Dr. Underhill. Dr. Underhill: I think, Mr. Chairman, as the time is getting on, I can add nothing more to what has already been said, but the only question I would like to ask Dr. Vrooman, in answering the remarks on his paper, is to deal with surgical tuberculosis, the methods and the means he would adopt for dealing with this question. I think that is something that is of great interest to all of us, especially at tbe present time. (Dr. Underhill resumes the chair.) The Chairman: If there is no further discussion I will ask Dr. Vrooman to reply. Dr. Vrooman: Mr. Chairman, Ladies and Gentlemen,—I wish to thank you for the very kindly way that my paper has been received. There is nothing in it but what you will find in the literature on tuberculosis for the last five years. I have tried to give you what are the well- established views, and my hope is that it may have some practical effect. In reference to a point raised by Dr. Walker, the patients are too ready, I quite admit, to say there is nothing wrong. I have had patients in and out of my office in the sanatorium, coming there and telling the other patients that I ea'id there was nothing wrong with their lungs, when I told them, though not definitely, that they had tuberculosis, but not much. This has happened more than once at the sanatorium, so I quite realize that it is going to happen many times in private practice, and it means that we have to be careful. I would like to hear mention the good work that has been done by the ladies of Vancouver in connection with the tuberculosis clinic. It has been a pioneer and it is leading tbe way. The only difficulty they have laboured under with regard to it is the lack of money. They have only had one tuberculosis nurse in Vancouver when they should have had three, and they haven't had any place to put the patients when they discovered them; but they have done good work, S Geo. 5 Provincial Board of Health. G 193 they have helped us in the sanatorium, they have helped to look after cases here, and I cannot pay too high a compliment to the ladies and the nurses who have been in charge of the clinic. Now, I only hope that the work will be extended much farther. Dr. Proctor referred to tbe incorrigible patient. We have to handle these in a special way, and New York handles them in a special way; they have a special place for them on one of the islands in the East River, a special hospital where the incorrigible patient who will not stay in the sanatorium, who will not obey the rules while in the sanatorium—there is a small percentage of these anywhere; and in New York City it is recognized, and they have established a separate institution for that purpose where they are committed by a Magistrate, those who are absolutely incorrigible, and most of them are drunkards and absolutely careless. They are committed, and they are allowed privileges only under conditions of good conduct. I think for that class something like that will have to be done, because there is a small percentage of what you might call indigent drunken, open cases of tuberculosis. The problem that Dr. MacLean has mentioned of the rural districts is a considerable one. The smaller hospital can hardly handle tuberculous cases, and that is the reason why I say that the sanatorium at Tranquille will still have to handle a certain number of advanced cases, because these rural hospitals cannot under many circumstances take them in. It is only in the larger centres like Vancouver and Victoria where they would have the separate hospital. I was very glad to hear also that the Government is now going to act. We hope to see that the action means the voting of a large sum of money to be devoted to this purpose. That quotation was from Dr. Biggs, that health was a purchasable commodity, and if the Government of British Columbia wishes to purchase immunity from tuberculosis, well, they can purchase it, and I hope to see that they will do so. I do not think that the public are fully aroused on this question. If I might be allowed to make an observation—because perhaps I come in contact with the public in some ways more than the medical practitioner, and they express their feelings—if I might decide my own profession, right in the family the public are even more aroused on this question than the medical profession or tbe Government. That is my own observation, but I believe that it is correct. There is a standing invitation for all practitioners of the Province to visit the institution. Too few have availed themselves of it. We will make yon welcome if you come and stay a day or a week; we will try and fix you up; and we will give you any opportunity you wish to study tuberculosis there, what we can do, show you what we are doing. The Saranac School has been recently established. It is called the Trudoff Outdoor School in memory of that great pioneer in America, Doctor Trudoff, who established the first sanatorium in America. In memory of him they have built that Trudoff School, which is under the direction of Dr. Baldwin, probably tbe leading man on tuberculosis in America, and they conduct tests in the schools for six weeks dealing with the tuberculosis problem, and my assistant, Dr. Gilchrist, had the privilege of attending that school this summer,, and I have greatly profited; he profited by it and I have profited a great deal through him in the teaching of the methods that he learned at that school; and if any of you can afford to do so, even if you cannot spend six weeks, if you will spend a week at Saranac in visiting their improvements, you will find them all royal fellows there. The tuberculosis specialists are only too ready to give you everything as accurately as possible, if you wish to learn. And even if you cannot go to the school, if you are in Eastern Canada and would visit Saranac and see some of the methods there, and visit the laboratories, you would see something that is being done and get a glimpse of some of the problems that come up there. They are doing a good deal of research-work that is being done. In reply to Mr. Biker, in reference to the effect of mining, we do get quite a proportion of miners. I haven't got any figures here—not so much among coal-miners, although we do get some coal-miners; but, of course, the dust of the quartz-mine is more irritating and more apt to set up tuberculosis. I think that living conditions in the camp may have something to do with those symptoms. In reference to Dr. Underbill's question as to surgical tuberculosis of children, I have a vision—I don't know whether it will ever be realized—of seeing an institution at Tranquille which will handle all forms of tuberculosis, surgical or otherwise; that we will have there an institution that we can both give the open-air treatment, and can give, if necessary, surgical treatment to children under practically what is the best kind of conditions, such as they have in Saranac. We haven't taken any of these, but they do, and they do exceedigly well under 13 G 194 . British Columbia 1918 sanatorium conditions after they have received the necessary surgical treatment. The doctor just gives you a glimpse of what you need, .and in thanking you for the way you have received my paper, I hope that it will give you that, and that something may come of a practical nature from it; that we will do something for these sufferers from tuberculosis. I could keep you all morning telling you of pathetic cases, but I am not going to, any further. I thank you, ladies and gentlemen. (Applause.) The Chairman: The next paper, " The Laboratory in Relation to Public Health," by Dr. Wesbrook, President of the University of British Columbia. Evidently some special privilege attaches to being the President of the University, as he is able to find a substitute. Many of us would desire the same thing when we are called upon to write a paper, but Dr. Wesbrook will kindly introduce the substitute for this paper. Dr. Wesbrook: I feel, Mr. Chairman, very much like a pretender. I have been very much embarrassed by the fact that my name should have appeared as the reader of this paper, but you have given me the privilege of explaining. At the time Dr. Young was getting up the programme he wanted a paper of this kind, and I volunteered; but just shortly after the arrangement was made a man who was very much better able to give it than I, a man who is in that work and has been in that work for a good many years, decided to come to this Province, and has assumed directorship of the pathological laboratories of the Vancouver General Hospital and is responsible for the teaching of bacteriology in the University this year. This is a composite arrangement which is, I hope, not cutting through the lines of co-operative work which in the University we will be free to undertake. If I might, in the opening of the discussion, speak to this, I will be glad to do it. This, you will observe, is also taking another privilege; that is, inviting myself to discuss Dr. Mullin's paper. Dr. Mullin returns to Canada ; he has made a place after a good many years in the States. Dr. Mullin is a graduate of Toronto University in Arts and Medicine, worked there in the public health as assistant to Dr. John Amyot, whom you know is another of those who are mixed up in the war. In parentheses I might say that Dr. Amyot and his three sons are all at the front at the present time. He had, too, I think, to misstate tbe ages of some of these sons in order that they might go. Dr. Mullin has practical experience in the Toronto General Hospital as a member of the hospital staff, was interne there—or house officer, as we call it—and also at Kingston, the Hospital for the Insane. Then he spent—well, a number of years in Minnesota in the University of Minnesota and in the State Board of Health. Dr. Mullin and I were associated together, I think, for nine or ten years, and he was my successor as director of the Minnesota State Board of Health laboratories. He has had a very wide experience in pathology and in bacteriology, and I regard it as very fortunate indeed that you are able to get his services in this Province. He will speak to you upon this problem of the laboratory in relation to public health, and if I may crave the privilege. I should like to discuss it and certain things which arise out of it, later. I shall ask, if I may, Mr. Chairman, Dr. Mullin now to give his paper. (Applause.) THE LABORATORY IN RELATION TO PUBLIC HEALTH. By R. H. Mullin, B.A, M.B, LjU*soratory Director, Vancouver General Hospital. Within the present generation medicine has become a highly specialized science, due to the rapid advances that have been made through scientific methods. No longer is it possible for a single individual who used to be called the family physician to be familiar with all methods which are employed in the various branches of medicine. This family physician has been supplemented by groups of individuals whose work is more or less restricted to one particular branch, and who are known as specialists in that branch, so there are surgeons, internists, gynecologists, etc. Not only has there been specialization in these various branches, but each branch has become further specialized into the clinical and laboratory science. During the process of this specialization a comparatively new science has developed—namely, the science of public health or public medicine. It is necessary to differentiate clearly between the practice of public health and the practice of private health if an adequate idea is to be obtained of public-health laboratories. Private health is what is more commonly known as practice of medicine, is essentially individualistic, and is an attempt to cure an individual of some disease for his own particular benefit, without regard to the bearing it may have upon the community as a whole. Public health, on the other hand, deals with community health and 8 Geo. 5 Provincial Board of Health. G 195 welfare, and seeks to promote this by the prevention of disease, and by devising methods for the promotion of the welfare of the community as a whole. In the one, individuality and cure are the predominating notes, while, in the other, community and prevention. It is not so very long ago that public-health workers were selected without regard to previous training from the ranks of practising physicians; now it is becoming realized that for the successful practice of this profession trained specialists are necessary. Just as in tbe development of the practice of medicine the necessity of trained laboratory workers soon became apparent, so, too, in the practice of public health this side of the science is becoming recognized. It is necessary to differentiate between a public-health laboratory and a clinical laboratory, and to appreciate that the two are essentially different, and that it is not necessary that a good clinical-laboratory man must be an equally good public-health laboratory man. The two services are just as different as are public and private medicines. The function of public-health laboratories may be briefly stated to be: (a) To assist in the prevention and control of disease; (6) to devise means for adding to the comforts of community life; (c) research; (d) education. The laboratory-work in the prevention and the control of disease falls naturally into three subdivisions—control of communicable diseases, supervision of public water and milk supply, and the investigation of foods and drugs. In some communicable diseases it is possible to demonstrate the infectivity of individuals by laboratory methods, and so determine that such individuals are a menace and danger while taking part in a community life. It is also possible in certain of these diseases to determine when individuals who have been infected cease to be a menace, and so accurate means are afforded for determining the time at which they may be permitted to resume their community activities. The laboratory may also provide certain biologic products which may be used to artificially immunize individuals in the community, so as to decrease the probability of their being infected; also to effect a cure when infection has occurred. This class of laboratory-work is accomplished in what is called a diagnostic laboratory. Of recent years it has become more generally appreciated that this diagnostic-laboratory work should be undertaken in close association with field investigation in communicable diseases, so that there is gradual development in different localities of what are called bureaus or departments of communicable disease, in which both field and laboratory investigations are made in order that all of the information related to a particular epidemic may be in one branch of the service. The scope of the work of a diagnostic laboratory may be broadly stated to be all laboratory- work that can be of any service in the control of communicable diseases. This is naturally limited to such of these diseases as have a known causative agent, but there should be no limitation as to the character of the examination that should be made where this agent has been identified, provided only that the examination will indicate the presence of infected individuals or assist in preventing the spread of the disease. From a legal point of view a communicable disease is one that is reportable, but in some instances it may be advisable for the laboratory to go beyond this limitation, especially where, as in the venereal diseases and cancer, the danger is great. It might well be said that the work of health laboratories should be limited only by the lack of money the public will provide through their governing bodies for maintenance. Usually the routine work consists in making examinations of exudates and tissue in cases of suspected tuberculosis; exudates from the nose-and throat in cases suspected of carrying diphtheria both for diagnosis and release from quarantine; the preparation of materials for the Shick test to determine susceptibility of individuals to diphtheria (especially children and inmates of institutions where epidemics of this disease are apt to spread) ; the blood, stools, and urine from suspected cases of typhoid fever or its allies and the preparation of typhoid prophylactic; spinal fluid from suspected cases of cerebro-spinal meningitis and poliomyelitis; exudates and tissue from suspected cases of anthrax, actinomycosis, blastomycosis, leprosy, etc.; brain of man or the lower animals in suspected cases of rabies, and giving the Pasteur treatment to people who have been exposed; necessary examinations for cholera, plague, and other diseases not at present frequent in this community. In the supervision of public water and milk supplies the laboratory-worker can be of the greatest service, since it is possible by constant supervision to illuminate the danger of conveying infection by either of these two routes. Here, too, there should be a close association between field and laboratory investigations if the greatest good is to be obtained. If safety is to be assured, frequent laboratory determinations and field investigations should be made, since at G 196 British Columbia 1918 any time accidents may happen which result in either water or milk becoming infected, aud thus affording a source from which a very great number of cases of certain of these communicable diseases may arise. The food and drug laboratory is concerned principally with the adulteration of foods and drugs. An extension of the use of such a department might be made, especially in the direction of infant-feeding, and the determinations usually undertaken in hospital laboratories in nutrition experiments. This side of the public-health laboratory has not as yet received the consideration and appreciation it deserves. In attempts to add to the comforts of community life, problems arise which require laboratory solution, especially from an engineering point of view. Most of these problems have to do with the disposal of wastes in a sanitary way. so that they will be neither offensive to the senses nor capable of acting as a source from which communicable diseases may arise. Enough has been said to indicate that a public-health laboratory is not a single entity, but is comprised of a number of units, all differentiated, but with points of contact between certain of the units. It should better be known as public-health laboratories. Many different problems are presented, with all of which it is impossible for one individual to be familiar. It must be appreciated, therefore, that just as in other sciences, and so in public-health laboratories, specialization has occurred to a very considerable extent. However, no matter how great the specialization, each has functions in addition to the public service which they fulfil. These other functions are research and education, although in most organizations the greatest amount of stress is laid on the public-service function of the laboratories. These other two functions should never be lost sight of, and their importance is difficult to overestimate. Unfortunately, it usually happens that most public-health laboratories are undermanned, so that all the time and energy of the workers is absorbed in the service function, leaving the other two sadly neglected. There are certain elements that are necessary for successful and efficient work in any of these various laboratory branches of public-health activities. As already indicated, the work is highly technical and specialized, and, as such, demands the service of well-trained, full-time workers if accuracy and reliability of results are to be assured. The idea that a recent graduate or an office-girl is, ipso facto, qualified to do laboratory-work in any branch is surely passing, and the importance of receiving dependable results from experienced workers is becoming appreciated and demanded. In the beginning of development the number of such workers need not be great, as it is possible to obtain men who are sufficiently qualified to oversee various branches until expansion demands an increase of the force. Adequate quarters should be specially designed and equipped with a view to carrying on the work so as to produce a maximum of results with a minimum expenditure of energy. Efficient clerical and laboratory assistants will always prove an economy. These laboratories should be so situated, geographically, that they are of easy access, so that the least possible delay will occur in making reports to physicians and health officials. Transportation facilities will have considerable bearing on the location of the laboratories, since the mails must be depended upon for delivering of specimens. Where the territory to be covered is of considerable extent and the population scattered, branch laboratories can be maintained in the larger centres of population. When emergencies demand quick action or the character of the work necessitates investigation on the spot, " travelling laboratories " may be sent out with au investigator to satisfy the immediate needs. All of these features point to the necessity of providing an adequate budget for the proper support of the needs of the laboratories. One health department has for its motto, " Public health is a purchasable commodity." This surely means two things: First, that it can be purchased; second, and equally important, it must be bought. The private individual who attempts to obtain something for nothing, or for very much less than its face value, is usually looked upon as a grafter or a crook. Should a community expect to obtain a valuable commodity gratis or at less than a fair price? It has truly been said that "The public health is public wealth." which should indicate these two are closely interrelated. The service rendered should be free to the individual, but supported by the community (and where possible to obtain philanthropic funds) and under governmental control at least in part, so that the results obtained can be legally applied to effect reform. No successful health-laboratory work can be carried out on a fee basis for each examination, collected either from the patient or the community, 8 Geo. 5 Provincial Board of Health. G 197 since such a practice places a natural reluctance, from a financial consideration, to taking full advantage of all the services that can be rendered in limiting an epidemic. . There are other essentials upon which the success of a public-health laboratory depends. Since public health is a group science dealing with groups of individuals by groups of workers, it is necessary that an active and hearty co-operation should occur among all concerned. In order to obtain such co-operation it is necessary for the laity and physician to understand what the objects and methods of public-health workers are. Since the science is comparatively new, there is a large amount of education necessary to this end. It must be appreciated that the funds for the support of health activities come more or less directly from the governmental bodies. It is usually only through pressure from their constituents that the individual members of such governing bodies can be made to see the necessity of adequately providing funds for the work. The education of the public is therefore necessary if satisfactory advance is to be made in public-health laboratory work, or, in fact, any other public-health activity. The public-health laboratory is closely related to a variety of people. In the first place, it should be intimately associated with the health department of the community, since it is the latter that is clothed with the police power necessary for the application of tbe results obtained in the laboratory for the control of some particular community disease. It is related to the units of the population, particularly the practising physician, and each individual family, since in many cases the duration of quarantine is dependent upon laboratory findings. Where groups of people are collected together in hospitals, charitable institutions, schools, etc, the laboratory is of particular use, since in such institutions communicable diseases find a greater opportunity to spread. On account of the education that is so necessary at present, a teaching function is added to the ordinary laboratory function, and in this way the laboratory is brought into close association with the teaching institutions, such as the public or high schools and universities. In determining the organization of a laboratory it must be recognized that it is impossible to lay down an absolute rule which can make all laboratories exactly the same. Each one has to meet the particular needs of the particular community in which it happens to be. If, however, recognition is taken of the relation of a laboratory to the health department, to the hospital, and to the university, it should be possible to develop a single institution which will adequately serve the needs of each, and so prevent the duplication of equipment and workers, which is sure to occur when each of these three different contributing parties attempt to establish laboratory-work restricted to their particular needs. Where such a co-operation exists and can be fostered, it is possible to avoid many of the petty jealousies and friction which invariably arise when different groups of workers approach each other at the border-line of their work. Discussion on Dr. Mullin's Paper. The Chairman: Now the discussion, and I think Dr. Wesbrook asked the privilege of opening the discussion, so I call upon him first. Dr. Wesbrook: Mr. Chairman, Ladies and Gentlemen,—I feel as if I had been doing a great deal more than my share of the talking this morning. Dr. Mullin's paper is clear and to the point, and he has shown the various lines of service which a public-health laboratory is able to give to the people. In his modesty he failed to tell you that he has been the bead of a laboratory that covers practically all these things, the State Board of Health Laboratory of Minnesota, of which he was chief; and he was a member also of the University of Kingston. This laboratory was inaugurated and was made an integral part of the University of Minnesota. It had a Pasteur Institute for the treatment of those who had been exposed to rabies. The first year of its operation it treated 212 people. I think it was the 242nd case in which fatal results occurred, and I think that they have had none since. They must have treated from 1,200 to 1,500 people by this time. That is not an important matter in British Columbia yet, but we never know when it will be. As bearing upon what the Provincial Secretary and Minister of Education said a few minutes ago, that it is the spectacular cases which appeal to the public; that is, speaking of scarlet fever and of tuberculosis, the stimulus that is given to public activity and, if necessary, public expense when a thing like scarlet fever appears. I can say the same thing about cholera. I was in Germany one time engaged in research-work at Marburg under Karl Bruncker, when they had a case of cholera in a little community about three or four miles outside of this town. The G 198 British Columbia 1918 manoeuvres of the troops for that year were to be held about three weeks later, and 12,000 troops were to be assembled there. I remember what I felt like at night when I discovered—we were notified at about 11 o'clock that we had cholera iu the community. I think I was the enly English-speaking person left in that community by noon the next day. It was part of my duty, because I had already worked for three years on cholera, and I acted as a volunteer assistant, and three of us carried out all the necessary measures for the prevention of the disease. We only had sixteen cases and four deaths, so I think we did very Well. We had sixteen pure cultures from these sixteen patients, though, in a very few hours, so that We can see what the stimulus of cholera did—in 1894 this was. In 1892 Hamburg had its particular lesson. Now, to give you an experience from rabies: We got $5,000 to run that institution for the first year. It was part of the public-health laboratories there. We were able to treat 212 cases. Everybody was afraid of rabies. The doctors and the people knew so little about it that we could have got any amount of money we wanted for that, but we couldn't get it for water; we couldn't get it for tuberculosis; we couldn't get it for measles and all those other diseases, although the deaths from measles at that time were greater than the deaths from smallpox, although smallpox was quite prevalent, but it was of the very mild type. The people apparently, many of them, would rather have smallpox than be vaccinated; but they had to change their mind shortly afterwards, as it was said yesterday. Now, there were other features of the work; they had engineers, chemists, bacteriologists, and a new trained specialist and epidemiologist. The work was here before, but the name was born just recently. We were speaking of field laboratories; we wouldn't examine specimens of water sent up by an analyst, somebody -who didn't know whether the water was to blame or not. If there were a question of that kind came up, in the public interest we would send a travelling-laboratory man, and a travelling specialist sometimes, and sometimes a chemist and a bacteriologist, and the engineer. Well, I won't go into this thing further, except to extend a little what Dr. Mullin was saying and give you the idea that he had this in charge. I will say this, and I think this is a public lesson we get out of it: It is particularly hard for us in the pioneering stages of our different communities, owing to the fact that this is a huge Province and the population is relatively small, and we are as yet scientifically in the pioneering stage; but we do not deny ourselves automobiles, and I think we shall have air-ships pretty soou. We have the best hotel in Canada, supposedly, in this town—the most expensive one, anyway. We haven't denied ourselves these things in our pioneer days; now, why shouldn't we have tbe things that are most essential, because in public health and public wealth, as Dr. Mullin has said, we would be conserving our cheapest asset. Now. in order to conserve this, there are a lot of people required for which our social, aud economic conditions as yet make no provision. A consulting engineer (several of them for competition) in waterworks in this Province—I mean the sanitary engineer—would starve to death if it were left for individuals to employ him. A chemist devoting himself in some way to a line of public-health work would be equally called upon to live at his own expense. The medical profession cannot—their patients are not yet trained to believe in it to a sufficient extent—the laboratory-man in medicine cannot make a living, so that from a number of public bodies it becomes necessary to define certain groups of people. Amongst them every city ought to have, as Victor Bond, of the University of Michigan, says, a forensic institute; you should have a medical man ; you should have chemists ; we should have physiological chemists; we should have other experts, and particularly so that when an autopsy is beld, if it is held by a man who is trained to do that work, just the same as we go to a trained surgeon; we should have them—there is one group of the forensic institute. I won't go into it further, but I think I have made my question plain. Then you have a group of public- health experts, of which Dr. Mullin has told us; then we have the group of diagnostic experts, not for the purpose of preventing disease, but for the purpose of suggesting a cure. Nowadays you can make sections of the tumours, and these are examined whilst the surgeon is working. You need blood-clots; you need analyses of stomach contents; you need people to study the metabolism of a particular patient to see on what dietetic treatment he shall be put, or to see what is wrong inside—see why he is not working right. You need all those, and we need sanitary engineers, as I have said. Now, how are we going to get them; how are we going to provide for them? The • Provincial Government needs public-health laboratory facilities; Vancouver needs public-health laboratory facilities; and in some places they separate the water branch from the public health, but it need not be done. It just depends on who is going to be 8 Geo. 5 Provincial Board of Health. G 199 boss of the job, whether it is the sanitation, whether it is to be sanitation from an engineering point of view or engineering from a public-health point of view. There are no difficulties in it. As Dr. Mullin said a little while ago. you are not going to have two organizations that are exactly alike. Personnel, after all, is what counts rather than system. Now, we can't get all of these things at once here; but the Vancouver Flospital is short of funds—and, by the way. the Vancouver Hospital Laboratory should not be ruu on the basis of fees to be collected at the time. (Applause.) It should not rest on that basis. Suppose a patient in the hospital, when he is ill, you make an examination of him; if you charge him for that examination you are practically precluded from making a whole lot of other examinations afterwards. He may prove to be a very difficult case, and he may prove to be a very instructive and educational case; aud suppose you want to examine him every fifteen minutes day after day, you can't charge him or some one else for each one of these examinations. I am getting off the track; that is just an aside. But ultimately a group of men should be brought together, consisting of bateriologists. chemists, physiologists, pathologists, engineers, and various other people, for the carrying-on of the public service. Now, if that cannot be paid out of the fees from patients, if it cannot be paid by municipalities employing experts when they need them—here is another aside—you know they usually get into all sorts of difficulties because it costs from $5,000 to $10,000 to have experts, and after they get into difficulties they spend $100,000 in getting out; and they do that under the stress of an epidemic of typhoid fever or cholera, or something of the kind. But these have to be provided. Now, you can get them one at a time until you have got your group. You can get them, for instance, in this Province by the Provincial Government, the Provincial University, the Municipality of Vancouver, and various other municipalities, all co-operating. You see, it is public money after all, and I do not believe, personally, that you ought to gather certain problems together and leave other problems absolutely untouched, because as soon as you get a little bunch of people together they all get interested in the same problem, they alUtackle it, and they leave everything else undone. The function of a university is to teach a course, to teach what is known now. It is just as much its function to add to that knowledge, because all knowledge would stop if everybody confined himself to teaching; in fact, that is the most important thing. It should be done within the university; it should be done without the university; it should be done in co-operation with every existing official organization in the Province. It is the people's money which is being spent and we should give the largest return to the people. In addition, it should have experts, and it must have experts, for if the Province is not going to get the best experts in its university it had better keep out of the business altogether. Those experts ought to be available also for the purpose of giving advice and suggestions, undertaking investigations and researches, the result of which could be available for the different departments of Government. It seems to me that that should be apparent to everybody. Now, I want to make one thing quite clear: The university has nothing to do with administration or legislation or politics, and the moment it oversteps that—the best State university in the United States, the University of Wisconsin, made that fatal mistake once. It was called upon to investigate the health of the city in every way, and it did make a magnificent job. Now, what happens? After you have made a diagnosis and a prognosis and suggested treatment, it is very easy to bold the patient's nose and make him swallow a pill. Now, that is a Government job; it is not the university's job, and the university only gets into trouble whenever it begins to connect principles and men, to connect men with principles. It must keep away from that. Now, I think we can make this start; I think we have got a start with this big movement. We have only one here now; that man is Dr. Mullin, and he has indicated to you that public health has four specialties. He has his own special duties and desires. Now, if we can get that group started, it seems to me that a Provincial university is the logical basis for the beginning of that; ultimately we will have a group which will not only take care of the work, but it will train other workers in that line. Now, we have been getting impatient in the university at the present time to start a medical school, but we have all seen that in public health we need special training. Vancouver is an important town ; there is no public-health laboratory nearer than Toronto or McGill, and as far as I know these are the only ones existing in Canada. We can only start that and, when the time comes, a medical school, and the private practice should be practically related to that, this question of public health, and we could have here built up in this community a medical G 200 British Columbia 1918 school out of the bigger foundation of a public-health organization. That lies in the future, bow far we do not know; but we ought to provide for immediate needs as best we can, and we ought to conserve our money so that every public body contributes its quota and co-operates instead of competes. That seems to me to be the practical outcome of this paper this morning, so far as we can directly apply it. I know that Dr. Young is quite in sympathy with such ideas. I know that the Hon. Provincial Secretary, Dr. MacLean, is in sympathy with such ideas. I know that Dr. Young has the matter in hand with the authorities of the Vancouver General Hospital here; but one man, aud he has to be very very efficient in the one line, cannot spread himself over all of these things for long and give satisfaction to himself and to the community. I believe that that is one of the things in which we might co-operate, and in which perhaps the university might be the focusing-point. The same kind of thing is being undertaken, I might say, although this does not bear on the subject, in a number of other lines. In agriculture, for instance, at the present time there is close co-operation between the Provincial Department, the Dominion Department, and the University; and we hope that that will be true of forestry and of mines and of fisheries, and that will make us really of some practical, as well as potentially practical, value to the community which has supported, and had the courage to support, a Provincial university during war-time. When we are getting impatient it is most comforting to know that the people of this Province had the courage, anyway, to start, a university during wartime ; and it seems to me that by this time it should be started, because it is the day of the expert, anyway, chronologically, and the war has made it doubly of the expert, and we cannot get along very much longer without training and using the expert in this Province more than we have, but we will so use it in industry, in social and other life, the way we have been using its products for pleasure and for comfort. Now, I apologize for having wandered from the subject, Mr. Chairman. It is always a pleasure to speak to people who are interested in the same subject which has interested me for so long; and I always find that whenever I speak of the university here, people are so interested and so kind that I am inclined to transgress, and I hope that I shall be forgiven; and I can assure you that every member of the staff and those on the executive and governing body of the university are almost anxious to be of the utmost possible service to the Province as a whole, and to do their share in national and Imperial problems which w e are now facing. (Applause.) The Chairman : We shall be glad to have discussion by any one else on the subject. I think we have always got some light from this kind of paper. I say some light, but I should say a great deal of light, a great deal of instruction. Speaking for myself, I certainly have; I can see great possibilities opening up as the result. Any further discussion? We will be glad to hear from any one. Dr. Hepworth: Mr. Chairman, Ladies and Gentlemen: I might say a few words from the standpoint of the general practitioner. This laboratory diagnosis is a thing that we cannot get along without, but I think the subject has been pretty well taken up. The question is, if you want to make a laboratory diagnosis, who is going to pay? Is it the municipality or is it the doctors? I have had so many cases where I have had to foot my own bill to make the diagnosis, where the people themselves cannot afford to pay; that is the trouble. That is one poiut that I found out about that. Many a time I have had certain cases where I wanted to do it and have had to pay $3 or $2. Lots of patients cannot afford to pay for that. When I send a patient to the Vancouver General Hospital I have to pay this $2. Well, if he pays me $2 he thinks he has paid me plenty, and all I can ever get out of him is about $3. It may cost me actually a lot more, and the question is, is there any method of getting the municipality to foot some of these bills? As far as laboratory diagnosis goes, why there is no question of the necessity of having one. Last year I wanted to get a Babcock milk-tester, and I went to Dr. Underhill to get some information from him about it; but I couldn't get any one to put up the $10 for it. I had no power to force them to give me a Babcock milk-tester. What is the good of Health Officers if you cannot get anything done. It is all very fine to have all this theory and all this talk and paper, but we want practice; we want the stuff while we are working; that is when we want it. I tell you it is right at home we need it; and when you cannot get anything done, what are you going to do? They haven't spent a 5-cent piece on sanitary measures in my town this summer, and I had no 8 Geo. 5 Provincial Board of Health. G 201 power to spend any money. As to this laboratory diagnosis, I had four or five cases that required laboratory diagnosis and they haven't any money to pay for it. The Council have no power to do it; so, if they are going to do anything, we want it for practice; we don't want it in theory; we want to get it done. I think the municipality in certain cases would pay some, possibly the Province would pay some, but here I have had all kinds of cases that required laboratory diagnosis and I cannot get it done; and I think Dr. Wesbrook took the proper point on that, that you cannot get the people to put up anything; you cannot get your municipality to do anything; but I think that some time the Province will begin to see that they should do these things. The Chairman: Any discussion on this paper? If there is no further discussion I will ask Dr. Mullin to reply. Dr. Mullin: I don't think I have anything to say. The Chairman: Nothing further; then that completes the programme for this morning. We will meet at half-past two and continue the work of the Convention. As you know, there is just as good work before us as we have had previously, so if you meet promptly at half-past 2 the Convention will resume. The Convention thereupon took a recess until 2.30 p.m. Afternoon Session. The Convention resumed at 2.30 p.m. pursuant to adjournment. The Chairman: Well, ladies and gentlemen, we will call this meeting to order and have the last session. The first paper is " Milk in Relation to Public Health," by Dr. A. G. Price, Medical Health Officer of Victoria. I call on Dr. Price for his paper. (Applause.) MILK IN RELATION TO rUBLIC HEALTH. By A. G. Price, M.B, B.Ch., Medical Health Officer, Arictoria, B.C. The use of cow's milk as a food, especially for the nourishment of infants, and the fact that the composition of milk furnishes so excellent a culture medium for bacteria, and is so fitted for the conveyance of germs "of infectious diseases, places milk in the forefront among matters of hygiene which must be considered and studied by Health Officers with a view to the maintenance of public health. In considering the milk-supply to cities and towns or rural districts, it is necessary to consider the milk in three stages—namely, milk with the producer, milk with the retailer, and milk with the consumer. In other words, milk in the farm, milk in the dairy, and milk in the home. Let us first consider milk in the farm. Ideal milk within the udder of the healthy cow should be sterile. It is found, however, that the milk-ducts and teats of a perfectly healthy cow always contain bacteria. No doubt these come there through infection of residual milk by bacteria from the exterior of the udder. The anatomical location of the udder pre-eminently lends itself to the collection of microorganisms from the cow's hoofs, from the skin, and from the ground on which the cow lies. Flies lighting on the teats, and the hands of the milker too, are means of contamination by micro-organisms. It is therefore impossible to collect milk free from bacteria; even collected under the very best circumstances, fresh milk is computed to contain about 500 micro-organisms per c.c, while the average number of micro-organisms in milk collected in the ordinary way and as sold to the public has been estimated at not less than 400,000 per c.c. Although it is practically impossible to procure fin absolutely sterile milk from the cow, yet it should be the aim of every producer to collect milk from his cows under the most favourable conditions for procuring the purest milk possible. It is with this object in view that legislation is made for the guidance and education of producers endeavouring to produce pure milk, and for the punishment of those who neglect precautions against contamination. The latest amended "Contagious Diseases (Animals) Act" ■of this Province is one which eminently strives for procuring of milk under the best conditions, G 202 British Columbia 1918 stress being laid upon sanitary conditions of stables, the care and health of the cows, the cleanliness of the dairies and utensils, and the health and cleanliness' of the milkers; the premises, stables, and cows being classified into three grades A, B, and C. Mark you, it is not the milk which is classified, but the premises and cows, with the assumption, and rightly so, that the better and cleaner the premises and cows, the better and purer the milk. Stress is laid upon the freedom of cows from disease, especially from tuberculosis. No milk is permitted to be sold from diseased cows, and such cows must be slaughtered. The subject of cattle-diseases directly communicable from the cow to man through milk is one which can only be briefly touched upon now. It is one which, if at all adequately treated, would occupy more time than is alloted to the reading of this paper. Foot-and-mouth disease, scarlet fever, vaccinia, and tuberculosis are among the diseases which affect cattle and which are communicable to man either in the same or in a modified form. The question of the conveyance of tuberculosis to man from the cow by means of milk is one of the greatest importance and one which has been extensively investigated by bacteriologists. Owing to the morphological and pathogenic difference between the bacillus of bovine tuberculosis in the cow and bacillus of tuberculosis in the lungs of man, discussions and differences of opinion arose as to the identity of the two types. The bovine type is shorter than that found in man and it grows less actively in artificial media. The difference in pathogenic qualities of the bacilli on certain animals is marked. Bovine bacilli injected into a rabbit was found to kill the rabbit in a few weeks, while the human type of bacilli injected caused but mild disease and did not kill the rabbit for six months, and occasionally failed to kill the rabbit at all. Attempts made to infect cattle with the human type of bacilli for the most part have failed; while infections of human beings with the bovine type have been proved beyond doubt. Koch, realizing these morphological and pathogenic differences, attributed such differences to the environment and nature of the infected subject rather than to the infecting agent. I quote the following conclusions of the Royal Commission on Tuberculosis given in their report: " There can be no doubt but that in a certain number of cases the tuberculosis occurring in the human subject, especially in children, is the direct result of the introduction into the human body of the bacillus of bovine tuberculosis, and there also can be no doubt that in the majority at least of these cases the bacillus is introduced through cow's milk." The following facts are conceded: Bovine tuberculosis is communicable to man; bovine tuberculosis affects especially young children, causing abdominal tuberculosis; pulmonary tuberculosis in adults is often traceable to abdominal bovine tuberculosis in childhood. Keeping the above facts in view, it is plain to see of what great importance as a factor in the suppression of human tuberculosis is the prevention of the consumption of milk from cows affected with tuberculosis. The "Contagious Diseases (Animals) Act" demands the periodic examination of all cows for tuberculosis and forbids the sale of milk from affected cows ; and thus, together with sanitary rules and regulations applicable to stables, legislates for the production of milk in as pure and wholesome condition as possible. So far we have considered the milk as secreted and extracted from the cow with a view to maintaining its purity at the source. Let us now consider the milk from the time it leaves the stable till it reaches the consumer. The protection of milk from contamination and its preservation during this period, whether it be long or short, is of equal importance from a hygienic aspect as the production of milk under sanitary conditions in the stable. The rapidity with which micro-organisms increase in milk is very great under favourable temperatures. Kept at freezing-point the bacterial increase is not appreciable, but kept at a temperature 86° Fahr.' for twenty-four hours it was found that a sample of milk at first containing 30,000 micro-organisms per c.c. at the end of this time gave a count of 14,000.000,000 of bacteria per c.c. It is evident, therefore, that in order to prevent the increase of bacteria in milk, the milk should be cooled as soon as possible after collecting and kept at a temperature near the freezing-point. Furthermore, in order to prevent the increase of bacteria, additional micro-organisms must be kept from entering the milk from the atmosphere, from dirty utensils, and from water used in washing same. Milk, therefore, after cooling should be placed in covered containers which have been efficiently washed and sterilized by means of steam or boiling water. It is best to place milk in glass bottles immediately after cooling. Keeping of milk in metal cans longer than 8 Geo. 5 Provincial Board of Health. G 203 is absolutely necessary is inadvisable, nor under any circumstances should milk be placed warm in a can in which it is to remain for any length of time. Milk is a fluid which readily absorbs a metallic taste from the can in which it is contained, and especially so if the milk is warm. Strict regulations are laid down'by the "Contagious Diseases (Animals) Act" as to the construction, the cleansing, and,the keeping clean of dairies and utensils where milk is kept for the guidance of tbe dairymen and the safeguarding of the health of the public. It is necessary that Health Officers should inspect dairies and inspect them frequently and efficiently. Many dairymen are uneducated as to what aseptic cleanliness means, and they do not realize the necessity of such cleanliness; they are apt to show gross ignorance or carelessness in matters of milk hygiene unless continually reminded or instructed, or even threatened with punishment for neglect. Let us now consider the milk in the home. The consumer may have procured milk from healthy cows under best conditions of stable and dairy, from a producer or vendor who fully conforms to milk regulations under frequent inspection of Health Officers; yet illness from milk-born germs, diphtheria, typhoid fever, scarlet fever, or diarrhoea may occur in the home. The illness is reported, the suffering family places the blame on the milk-vendor, the dairy or farm from which the milk has come. The dairy is visited, a sample of milk taken and examined and found to be good; then the cause of illness is put down as " undetermined." When diphtheria, typhoid, or diarrhoea occurs in a household, I make it my first duty to examine the larder or place where the food and milk are kept before making inquiries as to whence the milk has been procured or examining the dairy or store. In 00 per cent, of cases I find that the milk is kept in a place or in such a manner as to invite contamination and growth of germs. It is well known that the diphtheria bacilli, the bacilli of typhoid, and the various microorganisms which are the cause of infantile diarrhoea grow freely in milk; they are not indigenous to milk, but they are implanted in the milk from outside sources. Every precaution may be taken by Acts and regulations, by inspections of stables, and supervision of dairies to prevent contamination of milk, but all to no avail if the milk in the home is exposed to the access of germs of disease. Some years ago, while engaged in practice in Ireland in a town which at that time had no system of sewers other than cesspits, an epidemic of diphtheria occurred. In one house where four children had diphtheria the milk was kept in an open pan on a window-sill in close proximity to a dirty toilet to which flies had free access. In another house where there were three cases of diphtheria a broken drain ran under the floor of the larder where the milk was kept, the drain leading direct to the cess-pit. In another house nine children visitors were affected with diphtheria; all the children had partaken of milk from the same stock; on investigation it was found that a cesspit had been recently emptied in close proximity to the milk-house in which the milk had been exposed and beside which the cow had been milked. From past experience I have come to the conclusion that diphtheria is produced by infected milk more than by any other cause. Some time ago I had occasion to examine a dirty mixture of milk and water taken from pools on tbe concrete floor of a room where milk was kept; microscopical examination revealed bacteria identical in appearance with diphtheria bacilli. The germs of typhoid fever are supposed to he more frequently carried by water than by other means, but is it not possible or probable that in the majority of sporadic cases of typhoid the germs of the disease may have been carried by the house-fly or by other means to milk and have thus been transmitted to the patient? I recollect some years ago, in a neighbouring town to where I lived, a sudden epidemic of typhoid occurred; there were some fifty cases, all of which were traced to infection from one case occurring at an unsanitary dairy which supplied milk to the families affected. We know that the typhoid bacillus grows rapidly in milk, and it therefore behoves Health Officers to be extra careful in the supervision of milk-supply with a view to prevention of contamination when cases of typhoid fever exist in their district. The proper care of milk in the home is only to be accomplished through education of the public. Many householders.are ready to place the blame for illness occurring in the families upon outside, supposed, insanitary conditions, while they overlook their own negligence and carelessness, or in many cases ignorance. G 204 British Columbia 1918 The study of hygiene, and especially the subject of the transmission of diseases, should be taught in all public schools of the Province, and simply worded bulletins on the subject should be distributed. It is beyond the powers of Health Officers to personally attend to milk in the homes in a city. The Health Officer can only supervise the milk in the farms and in the dairies; further his influence cannot go to prevent milk-contamination except through education. The importance of the supply of purest milk, not only to the homes but to the mouths and stomachs of children, is a matter which cannot be overrated. Up to a few years ago the principal cause of deaths among infants in cities of Eastern Canada was summer diarrhoea, second to which was immaturity and still-births (a matter needing investigation, but one outside the scope of this paper). The death-rate of children in Eastern cities is considerably higher during the months of July, August, and September than other months, whilst the death-rate of adults is highest during winter months. Statistics show that in these cities the child deaths in summer were due principally to diarrhoea, and that since, during the last few years, more rigid milk regulations have been made and enforced with the object of supplying pure milk to children, the infant death-rate from diarrhoea has fallen, and we now find that prenatal causes, premature and still-births are the leading causes of infant mortality. There is still vast room for improvement. Diarrhoea should be one of the least frequent causes of infant deaths in these cities. In the City of Vancouver in the year 1916 the deaths from infantile diarrhoea numbered only seven, while in Victoria City there was only one death from this cause, or about one per thousand births. While in a more eastern city in 1912 seventy- nine deaths of infants from digestive trouble per thousand births occurred, and in 1915 in the same city twenty-eight infants per thousand births died from the same cause. These records show a satisfactory condition of milk-supplies in Vancouver and Victoria, if we judge the purity of the milk-supply according to the absence of diarrhoea. In New York the National Commission on Milk Standards, which met in February of this year, laid particular stress upon the grading of milk by bacterial counts, advocating that the control of milk-supply for the community should be based primarily on this system. The Commission stated that the fundamental objects of grading milk are:— (a.) To aid in making safe for human consumption all milk which can be legally sold for drinking purposes: (6.) To distinguish between classes of milk which, while all are safe, are of different degrees of excellence in respect to cleanliness: (c.) To provide means by which the consumer can make intelligent selection of the kind of milk he wishes to purchase: (d.) To encourage demand for clean milk, thereby rewarding efforts of clean-milk producers. The Commission proposed that milk be graded into A, B, and C classes. A grade milk must contain less than 10,000 bacteria per c.c.; B grade, less than 1,000,000 bacteria per c.c.; C grade, any number over 1,000,000 bacteria per c.c. A and B grades to be used for food raw, while C grade be used for food only after cooking. The Commission further stated that in establishing the bacterial standards for a city it is important to take into consideration the necessary age of the milk, the distance it is hauled, and the methods employed in hauling, in addition to the sanitary condition of the milk at its source. This latter finding of the Commission appears to me to be an acknowledgment of the faultiness of the bacterial-count standard previously advocated. If the bacterial standard were a system to be relied upon for the supply of pure milk, it would he unnecessary to consider the sources of milk-supply. On the other hand, if the source of the milk-supply be sanitary aud the storing and hauling be under best conditions, then the bacterial-count standard is unnecessary. It appears to me that bacterial count is useful in proving the age or impurity of milk, but that it is too lengthy a proceeding and too impracticable in making frequent and quick examinations to be satisfactory for regulating the milk-supply of cities. It takes several days to make cultures for bacterial count. A sample of milk taken from a dairy one day, and another sample taken from the same dairy another day, may vary considerably in bacterial counts. It would be impossible, owing to the time required, to grade milk every day by bacterial-count standard, and there would be no guarantee that a dairy which supplied grade A milk a week ago was supplying the same grade to-day. 8 Geo. 5 Provincial Board of Health. G 205 For the guaranteeing the purest milk-supply, it appears to me that the best method of procedure is that which is followed in this Province—namely, strict attention to the cleanliness of the source, the keeping and delivery of milk, and to the cleanliness and health of the cattle and milkers. Bacterial counts are unnecessary. In England, Scotland, and Ireland the "Contagious Diseases (Animals) Acts" are very similar to that of this Province. They order the registration of cow-keepers and dairymen, the inspection of cattle, cow-sheds, and dairies, and direct sanitation of same and cleanliness of milk-stores and utensils, hut they do not consider bacterial count. Thus far we have treated the subject of raw milk and bacteria and have considered the methods best adapted for the procuring a raw milk in as pure a condition as possible. We have seen that, in spite of all precautions taken, raw milk still contains bacteria. These bacteria, however, are not of pathogenic type, they are bacteria which cause acidification, curdling, and decomposition. We have seen that under suitable temperatures the process of decomposition is rapid. We must therefore consider the methods of preservation of milk. There are three methods—that dependent on low temperature, which inhibits the growth of bacteria; that dependent on high temperature, which kills the bacteria; and that which depends on the addition of antiseptics to the milk. Germs will not grow in milk held at freezing temperature; for this reason all milk in dairies and the homes should be kept at a temperature as near freezing as possible. This is not feasible in the homes of the poor, who have not refrigerators; we therefore must advocate for them pasteurization of milk. Pasteurization of milk is simply the heating of milk to a temperature of 150° Fahr. for half an hour and then rapidly cooling. This process kills pathogenic germs without appreciably affecting the nutritive qualities of the milk. Consumers of milk, especially mothers of children, should learn the methods of pasteurizing milk and carry them out in their own homes. The purchasing of pasteurized milk from dairies is not satisfactory unless the dairies are specially licensed and supervised daily. To completely sterilize milk it is necessary to raise the temperature to boiling-point and to repeat the boiling on several successive days. The process of boiling, though rendering milk absolutely safe, has its drawbacks; it alters the taste, destroys the fine emulsification of fat, coagulates the lactalbumin, and renders casein less easy of digestion. The lower temperature in pasteurization does not appreciably affect the digestibility or nutrient properties of milk. Preservation of milk by the addition of antiseptics, such as salicylic acid, boric acid, formalin, or peroxide of hydrogen, should be prohibited both in the dairy and in the home as an injurious adulteration. The nutrient value or richness of milk is usually determined by an estimation of the percentage of butter-fat and solids not fat. Boards of Health in most municipalities demand that all milk sold shall contain 3.25 per cent, butter-fat and 8.5 per cent, solids not fat. In setting such a standard of richness it appears that no account is taken of the breed of cattle supplying the milk. The milk of the Holstein cow will seldom give 3 per cent, butter-fat, while the Jersey cow usually gives as much as 5 per cent. Keepers of Holstein cows as a rule keep Jersey cows and mix the Jersey milk with the Holstein milk in order to make up the deficiency of butter-fat in the latter. This is a wrong policy, especially where the feeding of infants is concerned. The milk of the Holstein cow with its smaller fat-globules is more digestible with infants than Jersey milk, while the mixture of the two milks is found to be less digestible than Jersey milk alone. Far better would it be if the standard of butter-fat were designated to each breed of cow and permission granted to sell Holstein milk as Holstein milk although it contains only 3 or even 2.75 per cent, butter-fat. Holstein milk, though lacking in butter-fat, contains the necessary casein and solids and is more suitable for infants. Samples of milk from various dairies and milk-vendors in a city should be frequently tested for butter-fat and for solids not fat; a deficiency in the quantity of solids indicates the addition of water, while tbe quality of solids will show whether foreign substance has been added; there is no fraudulent adulteration of milk which cannot be discovered by careful examination. If central milk-distributing stations were instituted in all cities, all milk-vendors bringing their milk daily to one of these stations where the milk would he checked and samples taken for examination, such a scheme would go a long way towards a satisfactory settlement of the pure- milk question; it would prevent adulteration and would be the -means of bringing the best milk to the consumer; it would make the work of the Health Officer easier of accomplishment, but would probably raise the price of milk to the consumer. In the City of Victoria by-laws will shortly be in operation which will demand inspections, grading, and registration of all dairies and farms supplying milk and the licensing of all milk- vendors selling milk in the City; but no steps have yet been taken towards the institution of central milk-distributing stations. In conclusion, I may say that milk is the first, the most perfect, and perhaps the most universally used of all foods, and yet the most dangerous. It therefore behoves all Health Officers to untiringly endeavour to procure and maintain the purest possible milk-supply in their respective cities, municipalities, or rural districts by frequent inspection of all farms and dairies supplying milk, by education of farmers and dairymen along sanitary lines, not withholding prosecutions where there is persistent neglect of sanitary precautions. And, lastly, toy education of the public, the consumers of milk, as to how to keep milk to the best advantage in the interests of their own health and in the interest of the preservation of child-life. (At this stage Dr. Wrinch took the chair.) Discussion on Dp, Price's Paper. The Chairman: The paper will now be open for discussion by any one present. I would ask that in the interests of all who are in the hall, and especially on account of the disturbing noises of the street outside, which are inevitable, you will come forward to the front and then you can more readily face those that are here and be heard by them in the discussion. The discussion is to be opened by Dr. Proctor, also by Mr. McDonald. Live Stock Commissioner. Dr. Proctor: Mr. Chairman, Ladies and Gentlemen,—I did not know that I was to be the first to discuss this excellent paper which we have just listened to ; but we have had a very fine resume of the whole subject, from the dairy to the consumer, and dealing with the question of bovine tuberculosis. It is now known that bovine tuberculosis is not the proper name at all; it is definitely transmittable to man, and the Government of this Province deserve all sorts of credit for the powerful and efficient way in which they have insisted on the examination. It means the outlay of a great deal of money for the systematic testing of our cattle for tuberculosis, but as a result to-day I think there is very little milk reaching our people from non-tuberculin-tested cattle. It would be interesting for us to know just how much bovine tuberculosis is existing among our children ; but I am satisfied, if this work is continued, as I think it will be, that that will be very much eliminated, as it has been eliminated already. I had the privilege some year ago of being on a Milk Commission in this Province. I had the privilege of working with Dr. Paton, and I hope that we accomplished some good for the Province, but we certainly learned a great deal ourselves—I learned a great deal myself. We found that the problem of the milk-supply of our people was not as simple as it appeared. It is somewhat in the nature of a chain from the dairy right to the consumer, aud there are several important elements in that chain. First of all,, there is the system in this Province under which these dairies are grouped and the cleanliness of the supply safeguarded. We found in the Province in those days dairies of different types. Some dairies' were a credit to the Province, some were not; and we usually found that where they were not it was the result of absolute ignorance on the part of the dairymen as to what was necessary to ensure a good milk-supply. They were all willing enough to do it if they only knew how, but they didn't, seem to have any conception of the danger from the fly and from having the manure-heap close to the dairy. At any rate, they seemed to be quite glad to do it when they were told; but there were certain dairies, as I said, that were—and I am sure they are different since—very much in want of cleaning out. Then the question of transportation of that milk—that is, of our milk-supply in this city; I am not sure that it is true of Victoria or any other city—has not grown right into the facilities of the city, and the transportation is a simple matter; but in this city, at any rate, it comes from a long distance. I dare say you know that a very large proportion of your milk-supply comes from south of the boundary, from Washington; and I know one of the grievances of the dairymen iu this Province was. in the line of milk-supply here, that while the dairymen in this Province were subject to all sorts of inspection which it was hard for them to live up to, hard to live up to all the rules and regulations, we had no right to go into the State of Washington and inspect their dairies and penalize them if they were not up to the scratch. That was a grievance. 8 Geo. 5 Provincial Board of Health. G 207 It is a comparatively simple matter, of course, in the winter-time to keep milk that has been properly cooled at the proper temperature; but it is a very different thing in the hot months of the summer. I dare say maiiy of you have been up here in Chilliwack on the main line of the Canadian Pacific Railway and the railways to the south of us, and you have seen milk-cans on the platform which have stood out after being cooled; perhaps there is something the matter with the time-card, tbe train has been late, and that can is standing out in the sunshine and getting thoroughly well heated, and then jogged along, and there is no attempt made at cooling until it reaches the city. These I tell you are some of the difficulties we found out when I was on that Commission. Then the milk reaches the city. One of our recommendations—I am glad to see it is one of Dr. Price's, because it is one I am thoroughly in favour of In regard to having an efficient milk-supply—is that this city and every city ought to have a central milk depot. Now, under our present system, inspectors of milk, and that statement is true to-day, get samples from tbe different dairymen. I believe that every man who sells milk in the city should be forced to bring his milk to a central depot, and there) the City Inspector should be for the purpose of examining that milk to keep that milk up to standard, or have it thrown out in the gutter; and a few examples of that character would very soon, I think, convince these people that it does not pay to bring the milk in in an impure state. I believe, further, that, having arrived at the central depot and having had the seal of the -city or the Province placed on that milk, the distribution of that milk in the city should be undertaken by the city. I dare say some of you know that discussion has been going on for some time on the price of milk. You have heard about that. A good deal of the blame for the increased cost of milk was laid at the door of everybody having to keep up a staff to distribute their own milk. Well, ladies and gentlemen, there is one thing more than another that the Germans have taught us, and that is on the subject of organization. What we want in this question of our milk-supply is better organization to reduce the cost to the consumer. And then Dr. Price has brought very well before you what happens to the milk when it goes into the home. It is not much use haying the dairyman all right, having the transportation company put ice in its cars and keep them clean and free from anything that might contaminate, without permitting them to stand out on platforms, and then reaching the central depot with every proper precaution, and the milk leaving there absolutely right and guaranteed, if you are going to have filthy conditions in the homes of the people, such as just described to you by Dr. Price in a home of that kind. That, ladies and gentlemen, is the result of uncleanliness on the part of these mothers who are feeding that milk to their children. They simply do not know. It seems to me it would be a very fine thing if every girl in our schools, rather than being taught the number of bones they have in their body, which is not particularly important or necessary for them to be taught, they should be taught something about the proper care of milk and the dangers of it; and I am sure that could be done, because it is the result of ignorance, and no mother who loves her child would possibly feed milk to It that came, as Dr. Price said, from milk in a pan 6 inches from the toilet. That is incomprehensible; they absolutely do not know. That, I think, is what we want. I think if we educate our people, our dairymen, to tbe great importance of taking care of this milk when they buy it, then I think that the magnificent result in the infant mortality would be greater even than it is now. One thing before I sit down. I am a very firm believer in pasteurized milk. You know the price of pasteurized milk was put up to us by the committee. This pasteurizing of milk creates a sort of feeling with the dairymen all along the line that it does not make any difference how dirty it is; if it is pasteurized it will be all right, anyway. Well, even under the most perfect conditions you cannot be quite sure. Pasteurizing is an easy thing to do and it. does not alter the chemical contents of the milk, and I believe very strongly in it. Indeed, if there is a lack of protection in other directions, it makes doubly sure. While I am speaking of pasteurization, I might say this: that we found they had two methods, one they called the flash method, and another method which is no good at all. It should be done, and can only be done to be efficient, by the Holbein method. That is the only efficient method of pasteurizing. That is the method described by Dr. Price. The Chairman: Mr. McDonald. Mr. McDonald: Mr. Chairman, Ladies and Gentlemen,—I am very glad of the opportunity of being here to take part in this discussion on our milk-supply. I had the pleasure of being present at a previous meeting where we talked a good deal about tuberculosis. As has been G 208 British Columbia 1918 mentioned by Dr. Trice, we have now aii amendment to the "Contagious Diseases (Animals) Act" ; that is, an amendment of that part of tbe Act relating to our dairies and milk-supply. I have brought a number of copies with me, I think I have just twenty; but I should like to have you take a copy, and any of you who want a copy, if we are short of them, I will be glad to send one to you. Now, since the last meeting of Medical Health Officers a good deal of progress has been made in regard to the testing of cattle for tuberculosis and the control of that disease. We have not, however, made the progress that I had hoped we would be able to make owing to lack of money, and also lack of a sufficiently large staff. It has been difficult at times; I am trying to convince the powers that be that we need more money than we are getting. The year previous to this one I wanted to get $50,000 for the work, and succeeded iu getting $10,000, after a desperately hard fight put up by the dairymen themselves. Dr. Proctor paid a compliment to the Government on the work that had been accomplished; I also wish to compliment the dairymen for the stand they have taken iu regard to this work. Now, we have heard from different individuals some opposition to the test, and we have seen a number of letters in the press. That position, however, does not represent by any means the general opinion of our dairy-farmers. And, after all, the progress that has been made is due to a large extent to the manner in which they have gotten behind the work and supported it. I just wish to state that in recent conventions of the British Columbia dairymen they have passed strong resolutions endorsing the work, without a single dissenting vote. In spite of the fact that, with these people assisting us, we haven't been able to prosecute the work as vigorously as we should have liked, about three years ago we were finding—less than three years ago—two years ago we were finding in the vicinity of Vancouver, in a considerable area of the district supplying the milk, 15 per cent, of reactors. At tbe present time we are finding 4 per cent, in these same herds, and, better still, the great majority of these cases are in the incipient stage, showing that the fact that we had got that 4 per cent, is largely due to the fact that we did not prosecute the work as vigorously as we should have done; that is, we have not followed it up as rapidly. What I would like to do would be to retest the herds in which we find even a single reactor, within three months, in order to get the animal that may have the disease in the incubation stage before the disease has evolved to the point where it may be transmitted to other animals in the herd. Now, if we can only do that, we are getting where we can control the situation very nicely. And I will confess that the results that we are getting now are much better than I had expected, in view of the method in which we have carried on the work. Just at this time, too, I am going to take the opportunity of referring to the matter of meat from carcasses of reacting animals being sold for human consumption. Periodically we find a lot of agitation carried out from differed sources regarding that question. Now, we do allow meat from the carcasses of reacting animals to be sold for human consumption, provided it passes a severe and rigid inspection. That inspection is more rigid than the most rigid meat inspection carried ou anywhere else in the world. In order that you may be sure that you are getting good meat free from disease, I would suggest that the best practice would be that, where you can get it, you should buy the meat from the carcasses of reacting animals, because only meat that is fit for human consumption from that source finds its way into our meat market. I am presenting that problem in rather a peculiar manner, but the common argument that we meet is that milk from an animal that is unfit'for human consumption indicates that the carcass will be unfit for human consumption. Now, we don't say that milk from all of these animals that we condemn as reactors is unfit for human consumption. We know that much of it is absolutely free from tuberculosis, but we have got no method, no practical method, of determining whether or not the milk from certain cows is not likely to contain—well, contain the germ, rathe tubercle bacilli, while in many cases it may. The bacteriological test for tubercular bacilli is not very simple—or, at least, it is a little more difficult than the ordinary bacteriological test of milk; and sometimes we might find germs present in certain tests, while in other tests the milk from the same cow might appear to be free. And then, too, we believe we are safe in assuming that in the majority of these cases sooner or later that animal will reach the stage where it will be positively dangerous as a milk-producing animal; and not only that, but that animal is spreading the disease to other animals in the herd, or may do that; and I hope, at least in discussing this question, in setting forth the reasons why we should have tuberculin-tested cattle, you will not fail to mention the economic side of it, as well as the public-health standpoint. 8 Geo. 5 Provincial Board of Health. G 209 I believe that one of the reasons we have made the progress that we have made here, and that we have secured the sympathy and the support—I should not say sympathy, but the support— of the dairymen, is that ever since I have had charge of the work I have at least tried to point out that the dairyman could not afford from an economic standpoint to have a diseased animal in his herd, otherwise he is likely to feel that he is bearing the whole load, that he is paying the bill for public health; whereas, if he is brought to look at it from a broader standpoint—and most of us do not look at it from that broader standpoint—he is going to take more kindly to work of this kind. Since I came here this morning it occurred to me that we might have arranged rather an interesting side-trip up to P. Burns's abattoir, and I thought that at the time, as we had brought over this week quite a large number of reactors to be slaughtered at P. Burns's abattoir, it would have been very interesting and instructive to have arranged, immediately following this Convention, to have had these animals slaughtered in order that you might have an opportunity of making a study not only of these diseases in our cattle, but also the inspection or the method of inspection carried on at P. Burns's abattoir. Unfortunately, P. Burns's abattoir is the only place for the inspection of reacting animals where there is meat inspection in British Columbia. We are working under rather a peculiar system in Canada and the United States; that is, it is assumed that if we are exporting meat outside of the Province, in the United States outside of the city, it must be inspected. That is, if we are selling it to somebody else we must give them a good article; if we are using it at home it doesn't make any difference how badly diseased it is, it is all right for our home consumption. At the previous meeting of the Medical Health Officers I advocated the institution of public abattoirs, municipally owned and operated abattoirs. Now, there are some difficulties in the way, but it seems to me that the only solution of this inspection is that we have municipally owned abattoirs where Government Inspectors or municipal Inspectors will be stationed. It is impracticable under present methods to inspect every little product at the slaughter-house, and probably it would be to-day in the field or the bush, particularly if it happens to be flooded with tuberculosis or some other disease. Some of the diseased portions remain there and the remainder of the carcass is brought into town and sold for human consumption. Now, if there is any doubt in the minds of any person regarding this meat inspection or the sale of this meat, the advisability of its sale, I would be very glad to hear from you, and I would be very glad to have a full expression of your opinion. In the inspection that is carried on where the animals are sent to P. Burns's abbatoir, there is some inspection, they are slaughtered under Federal Inspectors; but where they are slaughtered elsewhere, it is under the supervision of our own Provincial Inspectors. The question of pasteurization has been referred to you, and this is a question which we always have at a conventional gathering of dairymen and those interested in the milk question— quite an argument or discussion. There are different phases of pasteurization, as has been pointed out. There are things to be said in its favour, and there are other things to be said against it. Pasteurization as it is carried on commercially is not perfect pasteurization. Now, we might say here that pasteurization will solve the problem, but when we go to the dairyman he says that be cannot sell perfectly pasteurized milk, due to the fact that you cannot secure perfect pasteurization without destroying your cream-line,' and the dairyman cannot sell milk without the cream-line; that is, unless there is cream on the milk, unless the cream rises, the customer does not want it, because the majority of customers pay a great deal more attention to the cream-line on the top of the bottle than the dirt on the bottom of it. Under commercial pasteurization the nearest we can get to complete pasteurization is 98 per cent, of efficiency. Now, that is up to the present time the very best pasteurization in commercial plant, and you will understand that a great deal of it is going to fall away below that in efficiency. You are leaving, then, a certain percentage of your bacteria in your milk, and you may be leaving pathogenic forms in a field more favourable for their development than was the milk before pasteurization. Personally, I would not care to use pasteurized milk; that is, if I thought the milk was dirty, filthy, and was compelled to use it, then I would waut to pasteurize it of course; but I would not want any one else to use it, and in our own home we do not use pasteurized milk, but endeavour as far as possible to get a good wholesome supply of whole milk, raw milk produced under sanitary conditions. 14 G 210 British Columbia 191S I am leaving certain other phases of the subject of pasteurization to Dr. Wesbrook, if he will be kind enough to discuss them, as Dr. Wesbrook understands the point to which I refer —namely, the influence that pasteurization may have on the food value, particularly the food value for infants. A short time ago in the Pacific North-west there was what was known as the Pacific Northwest Dairy Milk Inspectors' Association, which to my mind is the most influential associationn, the most influential factor in the matter of milk-supply of the North-west. You will remember that a year ago, or a little over a year ago last spring, we held the convention of that association in Vancouver. Although I was the only Canadian member in the association, the association was kind enough to hold its convention here in Vancouver. I regretted that we did not have more of our consumers and more of our Medical Health Officers present. I know that many of our municipalities are pretty hard up, and Victoria, although the distauce was very short, after due consideration decided that they could not afford to send their Medical Health Officer over 'to Vancouver to attend that convention; and we cannot expect other cities farther removed, more distant, to send their Medical Health Officers, although I think all who were present will agree that it was a very excellent convention. In promoting that association we hoped to be able to accomplish certain things in co-ordinating milk inspections, and a few of us gathered together in Seattle decided that it might be advisable to bring in dealers, purchasers, and consumers into our convention, give them associate membership, in order that we might have the benefit of their advice and opinion, because if a certain group of men engaged in a certain line are all working together, and alone so to speak—say, for example, a group of Medical Health Officers—they may overlook some point which perhaps a man engaged in another line of work might think of; and we have found the advantage to be far greater than we ever anticipated. Outside of our association—at least, from that association subsidiary associations have been formed, and I hope that we will be able to have conventions of all our Medical Health Officers from the Province of British Columbia. The next convention will be held in Spokane. Dr. rroctor referred to milk coming from south of the boundary-line. I believe at the present time that we are not having any milk coming from the State of Washington, although at the time he was acting on that Milk Commission there was a very large amount of it coming from the State of Washington; and. by various means, that was shut out by the municipalities enforcing regulations which they were empowered to draft under the " Milk Act," requiring the same inspection that we were enforcing in British Columbia. The Province was not able to do it, but the Province was able to give the municipalities power to do it, although we could not do it ourselves—at least, our department could do nothing in the matter. Another point mentioned, that of a central milk inspection station, has just recently been adopted by the City of Tacoma. I don't know just how it is working ont, although I have no doubt it will prove quite satisfactory. This is a very big question, and I am sorry that I have transgressed so much on the time, but it is a question in which I am very deeply interested; and I hope to hear further, and especially if you have any opinions contrary to those I have expressed, I would be very glad to have you express them, as it would be of assistance to us in our work. (Applause.) The Chairman: The paper is open now for further discussion. Dr. Wesbrook's name has been suggested as one having information on this. May we hear from Dr. Wesbrook? Dr. Wesbrook: Mr. Chairman, Ladies and Gentlemen,—Some of you have been more than kind in listening to me. I have been talking too much this morning and had not expected to speak this afternoon, but to sit here and learn. There are a good many things that are of importance to us which have been brought up in the most excellent paper which has been presented and the discussion which has followed. I was glad that the reader of the paper laid a special emphasis upon the important factors in the production, handling, and distribution of milk from the time it left the cow until the time it came to the consumer. Dr. Proctor added to that, and Mr. McDonald told us about the inspection for tuberculosis. Those are the factors that are important in the handling of milk. It was expressed at one time by a colleague of mine in a literal way, which exactly corresponds with what the reader of the paper said: Since milk is an excellent medium for bacteria, and since temperature is a factor iu the growth—a Provincial factor at least—and since it is ordinarily taken from the cow in a very careless way so as to allow the milk to be polluted, you might express the needs literally as I have said, something like that; it means handling it quickly, cooling it at once, and, of course, 8 Geo. 5 Provincial Board of Health. G 211 cleanliness is the most important. Now, those are the important matters in the handling of milk. About its production, we have had quite a bit of discussion to-day, and they have all pointed out the difficulties in the handling of milk. We know here that it is not a matter of getting a milkman and going out and picking out a cow from which you want your milk, picking out the person who is to milk the cow and keeping him under medical supervision, and the cow under veterinary supervision, and the railroad, and the man that drives the milk-wagon, and various other things; that is not everything, for if you have to do things on a large scale, particularly as the milk-supply for a large city comes from a great distance—Dr. Proctor tells us it will come into the City of Vancouver in a good many instances from across the border. Now, take a place like New York, you must remember that they draw for their milk-supply from the country halfway to Chicago. When they get an epidemic of typhoid in New York which is supposed to be due to typhoid, they make an investigation of conditions on the farm; they investigate the people on that farm where the milk was produced, and that may be anywhere from 50 to 250 miles distant, or perhaps 500 miles, more or less, distant, so these are things which we have to recognize. Now, can we get any one single fool-proof proposition that is going to safeguard us? And that brings us to the point of pasteurization. Now, that is the nearest thing that we can do. We have already seen the difficulties of pasteurization. We have seen that under commercial conditions only about 98 per cent, of the non-spore-beariug bacteria are killed. However, that is pretty good; aud that is only under the very best conditions. You have heard about holding the milk at a certain temperature, the flash method, where they shoot it through a tube, where it goes through very fast; but apparently to secure good results you must hold it at this temperature, and since it is important that the milk should not be too high, it must be held at that temperature longer than it would need to be held if it were higher. Now, the difficulties you have iu pasteurization have been mentioned; here are a few more: In addition to the one that milk which is rotten—I use the word advisedly, I think—in addition to the belief that rotten milk can be made all right by pasteurization, we have this fact: that after pasteurization your milk is more likely, if it is kept too long or in bad condition, to be very problematical as to its condition than if it had not been pasteurized. Now, the common bacteria in milk are those which sour the milk and produce lactic acid. Lactic acid is in itself antiseptic, and that again which the reader of the paper gave us, if these bacteria were largely lactic baeteria they would not harm you particularly. Most of the bacteria passed through by this process, but you leave in the spore-bearing, putrefactive bacteria, and the fermentation in pasteurized milk is much greater than the bacterial fermentation in unpasteurized milk; that is, you get all the bacteria which putrefy and which rot, which form spores, and they are left in there, and although they may be relatively few in number, if you don't keep it very cold and don't keep it too long it may be all right; but the curds you get on that kind of milk are quite different from the cheese-curds you get from your lactic acid, so that you might just as well be eating rotten meat as drinking rotten milk. Now, that brings me to the idea that in all cases where it is at all possible milk ought to be examined where it is brought from, so that everybody should know how old it is, because even certified milk where perhaps you don't get over a hundred bacteria, which is supposed to be the most desirable milk, milk for which you pay probably 20 cents a quart, if you keep it it will be all right. Now, another thing about pasteurized milk, to which Mr. McDonald referred—and it is like what Dr. Adam Shortt said about politics and other affairs the other day at the University Club. We are not faced with a clear-cut decision usually in our lives, as to what is quite right and what is quite wrong. It is usually between one thing which seems to be a little more right thaii another, or the choice between a minor and one that is greater. So it is with your milk. I have indicated here some of the difficulties of pasteurization. Here is the other way: As yet we don't know, we haven't data enough, in my opinion, to say whether pasteurized milk contains all the things that are desirable for young children. Now, take the matter of growth, we are learning a great deal about vital statistics, aud we know these are things that are present in three food products that heating in a great many instances will eliminate—but I think that can be taken care of; but I am on the side of pasteurization; although they can be taken care of as we go along by special conditions, which will give us something raw—it may be a vegetable product—which will look after these things. We have sometimes scurvy right here. We don't have to go to the North Pole to get scurvy, and we have to look out in getting at the vegetable G 212 British Columbia 1918 products or other things. However, from my personal examination, like Mr. McDonald, I should prefer to have a milk that is produced from a cow that has been tested for tuberculosis and found free of tuberculosis, and retested again in three months, so that if it had the incipient bacilli I would like to know that these few bacilli had been grown from a real case of infection; and, secondly, that that cow should be inspected for other conditions besides tuberculosis. We must not think, when a cow is pronounced free of tuberculosis, that it may not have other things about it which may be harmful. Thirdly, I should like to know that that milk is handled by people who have been medically inspected. (Applause.) Now, that is very important. However, I am transgressing somewhat. I would like to say a few things about milk epidemic, that is important; and then I should like to know that it was so handled by that healthy person that he did not get cow-manure or any other objectionable things in it. It is not so many years ago that the Germans startled us by having one of their number report the number of tons of cow-manure that went into Berlin in one year. We might as well look those things squarely in the face. Fortunately we are not so susceptible as a cow to many diseases, but we might as well face some of these things. Then I should like to know that it had not been milked in a dusty place, that the cow had been washed out; if it had been milked by milking-machine, that the milker's hands were clean. Fie need not have on a whole white-duck suit, and he need not milk in an operating theatre. That is where the milk used to cost so much, certified milk cost so much, they thought all these things were necessary; but if you just keep the dust out, keep your bands clean, keep the teats of the cow clean, and keep your milking-utensils clean, we have found now that certified milk can be produced very reasonably; and I feel quite sure that Dr. Underhill—I hope he will show us some samples of the very good milk that has been produced in Vancouver under his supervision. I think that we may say that we have a very good milk-supply in Vancouver, as a general rule. I know, before selecting my milkman, I asked Dr. Underbill's advice. There is no use having expert opinion if you don't avail yourself of it. Now, these are the things I want to know; and then I would like to have that milk delivered to me, if I could, with not more than, say, 1,000 bacteria per cubic centimetre in it. Then if I don't know enough to take care of it after I get it, that is my business. I don't think any of the Government men or municipal Inspectors can follow the milk into the home. I think up to that point we should have inspection, but it must be co-operative inspection, co-operative in this sense—or international inspection—if it is going to be efficient. Now, I hope I have made this thing clear. I believe that pasteurization is the nearest thing to give us what I called, using a rather crude expression, fool-proof, something that the most mediocre brain can keep. Now, about these diseases, we are not specific about these things. I am sure that the writer of the paper will not wish us to infer that the flies carry diphtheria from the toilet into the milk. They don't. They may carry diphtheria or typhoid or other things from a human source or from an intermediate source, like receptacles, to other people, but you don't find that bacilli are in toilet-rooms or in a pan, you find them in people's throats and noses. Sometimes, when you don't suspect it, you find it in the case of people who have had the disease, or in the case of people who have not been suspected at all of having it, who carry it. Now, this idea of carrier is pretty general in application. I might tell you of one—I think Dr. Mullin ran this investigation—we had one time there a case of diphtheria in the vicinity of the university, along the east side; well, what should you do when you are having an epidemic of any disease? Every case should be reported at once by the physician to the Medical Health Officers. In that report it should be; then the Medical Health Officer goes out and he finds out a number of things, the water-supply of the patient, where he was for awhile, for particularly in typhoid cases you want to know what he was doing for weeks; you don't want to know what he. was doing to-day, you want to know what he was doing for weeks, where he was infected; you want to know his milk-supply. Well, these men came in and they said that it was the milk- supply where they detected the presence of bacteria. And in this case he was the best milk- dealer in the City of Minneapolis, and he got a very black eye, and it was very very unfortunate, because he should have been encouraged in every way; but those were the facts. What did we do about it; what did Dr. Mullin's colleagues do about it? Did they go and examine samples of the milk? No; they went out to that man's dairy and they took swabs from the noses and throats of everybody who had to do with the milk, and they found a Swede there who had only been in the country for a few weeks, but he was a good carrier, and be had diphtheria in his throat and nose. He may have talked or he may have sung or he mayliave sneezed, or something 8 Geo. 5 Provincial Board of Health. G 213 of that kind, over the milk. Anyway, that was the dairy. You see, it must carry down to actual observations. How can you theorize when you cannot get any further? You are supposed to begin the theorizing when you cannot find out anything more. In a case of typhoid fever, in the same way you find the cows don't have typhoid fever. You can't get typhoid fever from a cow, you can't get it from any mysterious source; you get it from the individual who carried the typhoid. " Typhoid Mary " is perhaps more historical than anybody else. Now, they didn't know what to do with it. She .seemed to have all these bacilli in her system, the typhoid bacilli. That is not her fault, but it is her misfortune, and somebody else's. They had ber on the island for quite a number of months; there was no legal machinery to hold her. She might just as well have all her boxes and her hands full of bonds so far as the community was concerned. She is supposed to have been the cause of twenty-two different typhoid outbreaks. They found on a Russian estate some years ago a woman who was a typhoid-carrier, and had been for seventeen years, and she had 'been distributing typhoid; she had been the cause of typhoid outbreaks for a number of times because she was in the dairy of that estate. Now, as soon as anybody gets diphtheria or anybody gets typhoid, and you find one of these people in a dairy, you have got to get control, cut that dairy off for the time being; then you have got to segregate that person and cut him off in the meantime until you have examined everybody else in the whole household and the whole establishment, until you find out by this examination that they don't have diphtheria or that they don't have typhoid. That is where you are getting milk that is not pasteurized, and you ought to do it, anyway; you ought to do it, it is good business from a public-health standpoint. So it is with your tubercular bacilli; as Mr. McDonald pointed out, the main factor involved in tuberculosis was not perhaps the question of public health, because perhaps a different person—I mean you have a number of percentages—there are only a limited number of percentages of those cases in which you cannot find the tubercular bacilli of the bovine type. Of course, there is another disease group, where you find children infected in infancy; there may have been a change from the bovine type to the human type, but nobody can prove it. There is no conjecturing about it; but the main consideration is of the cow only. You cannot afford to have tuberculous cattle; they don't produce as much milk, and if they are beef animals they will not as a rule take on beef so fast; and, furthermore, he gets his whole herd infected; and we have seen to-day that it is to his interest to get rid of tuberculous cattle, and if he does that then we will be safe. Now, you see, in all these cases we must keep quite clearly in mind that there are definite special methods for finding out these things. You do not examine a sample of milk for the tubercle bacillus, you go and see if you can find the cow that is tuberculous. You don't examine the milk to see if there is any typhoid in the milk, you go and find out whether there is a case of typhoid, or whether the man who is handling the milk or his wife is sick with typhoid, or whether, where the case is water, for the purposes of dilution or perhaps for domestic use, it is on a farm where they have typhoid, and you go and examine the individuals to see whether they have diphtheria in their mouths or noses, diphtheria bacilli; and that is the reason that medical inspection of the people who handle the milk is very very important. But as a last safeguard it seems to me that we will be driven to pasteurization, but not pasteurization, as the doctor intimated, in the unscientific commercial way that the commercial man sees it. We will come to have city pasteurization. We will probably come to have a city system, because you must not blame the producer now for the high price of milk—alone, I mean ; you must not blame the producer alone for the high price of milk, for that producer only gets half of what you pay for his milk; but if you are going to insist on each one of us having a separate milk- wagon driving up to his door and then driving off a quarter of a mile before he reaches his next customer, when right across here there is another milk^wagon doing tbe same kind of thing, that is not economy. That has been pointed out. We have had it up before; I think we were discussing this at the food-control meeting yesterday. Mr. McDonald, I think it was, told us that they are getting so particular now in certain places, competition is so keen that they have a separate milk-wagon going down one side of tbe street and he is not allowed to run across to the other side with a can of milk; he just takes care of those houses in that row, and there is another one for the other side. Now, that is what German economy can do; but we can flatter ourselves that we have a very much better supply than Germany has, just the same, because we have been trying to educate the people with meetings of this kind. G 214 British Columbia 1918 Now, this is not a small problem. It is going to cost you more if you are going to have this kind of milk; but we heard this morning that health was a purchasable commodity, and we still hope to get from Mr. McDonald, if he would tell us his opinion, that not only is this the one article that contains all the things needed by everybody, but that after all, even at the present high price, it is the cheapest food that we can buy; so that makes it. I think, one of the most important things with which we have to deal, and that is the reason that co-operation is so necessary; and T hope that before we get through the organization will advocate pasteurization of milk, as being such an important article of food which should be used by everybody, a great deal more than it is. I beg your pardon, Mr. Chairman, but this is an important matter and I was carried away, as I am so liable to be when I get interested. (Applause.) Mr. McDonald: Mr. Chairman, if I may be allowed just a word in regard to this question that Dr. Wesbrook referred to;. there is in our office, if any of you have time to read it—I haven't yet had the time to read it thoroughly—a report from the Wisconsin Experiment Station which shows the work they have carried on, that the vegetable oils do not contain the principles of this growth that is contained in these other things. It may be that some one present has read this report. I just glanced over it hurriedly. The Chairman : Is there any other member who would like to discuss this paper? Dr. Petersky: Mr. Chairman, Ladies and Gentlemen,—All this theorizing about milk will not help me in my work. As we all know by this time, I am in the country. What I want to know is how to get pure milk in the community under my jurisdiction; that is my particular difficulty. The same information that you get here can be obtained by reading the papers of others. I have learned a great deal by hearing these papers, but what I am going to carry away from this Convention is this: that everything in public health is a purchasable commodity, anyway, and pure milk is one, and it all comes down to a question of money. Now, just to give you a little illustration in our community: The milk comes along in a baggage-car to the town, and if the train is late the milk is spoiled before it gets there. The result is that condensed milk is used. Now, we have all heard about the infant mortality, and I believe in providing cow's milk where infants can progress favourably. Now, what are you going to do there? You all know what is said about using condensed milk. Condensed milk contains carbohydrates which are very bad for infants. Now, we are up against it there. The merchants, however, say: " If you pay me more for the milk I will get it transported specially in a box of ice." In other words, you will have to pay freight on the ice as well as the milk. And what do those people do? They absolutely refuse to pay another cent for that milk, and as a result I have had some babies there with diarrhoea, the mothers have been unable to get them what they wanted. I gave them modified cow's milk ; that is what I prescribed. Where are they to get the milk? The milk came in one day, the train was late, and the milk was spoiled before it got there, and the merchant refused to take it. As a result there was no food for that child unless they used condensed milk, and I had to condemn it. Well, you are up a tree. You were saying it would be a good idea to have a central milk depot, that the city shall deliver. I say, why not the Government deliver to communities of a certain size. If you want to have the babies live there is a way to do it. Then, on the other hand, that brings us down to that question, if it were going to mean a difference of life and death for their babies they might be willing to pay an extra 10 cents a quart which they absolutely refuse to pay there. Now, as regards the milk after it goes into the home, if I may be permitted to disagree with Dr. Wesbrook, I say no, by all means, it is not our own business. It is all right for Dr. Wesbrook and for men who know when they have good milk in their homes; but these ignorant people, and we find, I might say, over 90 per cent, who don't know what to do with it when they do get the milk in the home, they should get that education that we have been talking about all day yesterday with respect to child-welfare, and so on, as to what to do with their milk. If they don't know what to do with it, I don't see that they should be allowed to simply lie down and die. I think that is one of our duties a# Health Officers and the duty of the Health Department to teach these matters. That brings us back again to the high-school girls getting lectures on that point. Now, if the Chairman will allow me to mention that subject, although it is not on the paper The Chairman: You will not be long? 8 Geo. 5 Provincial Board of Health. G 215 Dr. Peterskjv No, just for a moment. I just want to call your attention to the question of food inspection by us. The Health Officer in the country is supposed to be a check on all this. They-have to examine the carcasses. Now, what do I know about meat inspection? I might do a post-mortem perhaps, and know a little about pathology. Now, I was called in a particular case, and I read through my " Health Act" thoroughly, aud found that I had the power to condemn, under the " Health Act," that which I thought was unfit for human consumption ; and this particular carcass, I did not attempt to use a medical expression, the symptom alone, but tbe symptom complex of the whole case; in other words, I tried to use my bead. I found one man that sold meat was notoriously a man that was very, very severe and would not undersell to anybody else, and he sold it so cheaply that it aroused my suspicion. And then the carcass itself. I had never examined meat before; well, I simply told the sanitary officer—the Provincial policeman—I said: " I wouldn't eat it, and I don't see that anybody else should." Well, the meat was condemned. I had to leave that place for a few days, and some sea-lawyer advised him to send a sample to the Department for analysis, and that they would put it over me. I saw the letter; it arrived the day that I came back, and the Provincial police showed me: " This sample contains actinomycosis and the carcass is unfit for human consumption." And the Government Inspector was sent up to examine the herd. Now, that shows you what we are up against in the country. Another thing: Meat is sold in some places the day that it is killed, and it was always with fear and trembling—there was no other way of getting it—■ I eat that meat myself. Now, I take it that this Convention wishes that all the problems that we have and that have been discussed here should be looked into, as they are not easy to get over. (Applause.) Dr. Underhill: Mr. Chairman, Ladies and Gentlemen.—We have heard the scientific side of the milk question, but we poor Medical Health Officers have another side—the practical side— and that is what I want to deal with at the present moment. It is always instructive to meet a man who can give us a paper such as Dr. I'rice has given us to-day, and I wish to congratulate him upon his achievement. Looking at the matter from the practical side, I cannot see of what use it is to have laws if they are not carried into effect. The Acts of British Columbia relating to milk are plain and straightforward, and it is the duty of all of us to see that they are put into practice. I regret to say, however, that they are not put into practice. Now, Mr. McDonald has taken the sting out of what I wanted to say, because he has honestly said that he has neither the money nor the Inspectors necessary to properly carry out his work. Now, just keep that in mind. Don't run away with the idea that all the herds in British Columbia are tuberculin-tested to anything like the extent they ought to be, for they are not. I am simply stating facts—facts that I can prove; and Mr. McDonald can bear me out. It is quite true that they want money; it is quite true that they want Inspectors; that is not my business. My business is to see that the milk-supply of the City of Vancouver is from tuberculin- tested herds, and I say it is not. There may be a small percentage, but it should all come from tuberculin-tested herds. We hear that the farmers object. They may have a good reason for objecting, but I am not speaking from their point of view; I am speaking clearly from the point of view of the Health Officer who has the care of the milk in this city to-day. Dr. Wesbrook was perfectly correct in stating that we have a very excellent supply of milk here, but it would never do for any Health Officer to sit down and be content with anything. (Applause.) Therefore, if the Health Officer is doing his duty, he has always got a kick, always a grunt, coming; he should have in this business. Every one else is kicking at him, and he should have an opportunity of returning that kick. Now, the " Milk Act" here is all right; I don't object to it, but it is the manner in which it is enforced that I object to. Dr. Price mentions the sterilization of utensils. That is a very excellent thing; I think they should be sterilized, but, like most other things, when you come down to actual practice it is not carried out—it is simply played with. Why is it neglected? Because the farmers and dairymen don't know what they are doing. Of course, there are good, bad, and indifferent farmers, .as there are good, bad, and indifferent men in every branch; this is not intended as a reflection upon them, but I am telling you what we must face as Medical Health Officers. We may imagine that these utensils are sterilized, but they are not. They can't be sterilized; the farmers haven't got the machinery to sterilize them, and they haven't got the system to sterilize them. G 216 British Columbia 1918 Now as to the question of the classification of dairy farms: What has classification done in the past ? It is a» puzzling phrase. With all due deference to Mr. McDonald, I say it is an absolute farce. Every farm that does not come into Class A or B is in Class C Class C is the ultimate quantity; you cannot get down any further, and so to save the face of the farmer they put his farm in Class 0. You might as well call it Z or anything else. I don't know that we have any milk coming from Grade B farms. Of course, they may have altered recently from what they used to be. Two or three years ago I brought this matter to the attention of the Secretary to the Provincial Board of Health, and he seemed very much exercised about it. The Inspector has gone to tbe farms and graded the animals, but not the dairies. Now, Mr. McDonald will tell you that there is a gentleman appointed for that purpose—to examine the dairies. Is that correct? Is there any gentleman appointed to inspect dairies? Mr. McDonald: You mean municipal dairies? Dr. Underhill: No, outside dairies; I might use the word " farm." Mr. McDonald: We have got no Inspectors. Dr. Underhill: You have got no Inspectors? I thought you had one for that particular purpose. Mr. McDonald: Well, his duties do not take him over this whole thing. Dr. Underhill: What I mean is that the Veterinary Inspectors should inspect those dairies. Well, it comes to the same thing, that there is no practical dairy inspection of the farms. I may have used the word wrongly there; I was not thinking of city dairies, I was thinking of the source of supply. The fact is, from my point of view, there is no true inspection of these farms, and the classification, taking into consideration the condition of some of the farms, is not equitable. It is not fair to the good man who has an excellent farm that he should be classed with a very indifferent man. Now, as to the milk in the home: Since the introduction of the bottle there has been comparatively little trouble in keeping the milk good in the home. In the old days, when the milk was carried round in bulk, it frequently happened that the utensils placed for its reception by the householders were anything but clean; consequently the milk would not keep and the dairymen got the blame. To a great extent this has now been done away with, but there is a great deal to be done yet in educating our people as to how to take care of the bottled milk. Well, to speak the truth, I have had some difficulty in my own house, and if you have difficulty there you may expect to find the same conditions prevailing generally. The bottle of milk is brought in from the cooler and a certain quantity taken out of it for immediate use; the bottle is forgotteu and is left often in the warm kitchen, and then after a while taken back to the cool receptacle. It Is this change of the milk from one temperature to another that is so detrimental. If it was kept at an even temperature there is no doubt that it would keep much better. With regard to infectious diseases, inquiries are made in every reported case as to the dairy from which the milk is obtained; by this means, should it be shown that the same dairy is supplying milk in several cases, it might be possible to trace the disease back to its source. I would recommend my brother Health Officers also to keep tab on the milk-supply in cases of infectious diseases. With regard to diseases carried by milk, I believe that impure water had a great deal to do in the past with many of our tuberculosis cases, or typhoid cases particularly, possibly through a drain on the farm leaking into the water-supply which was used for washing out the cans— or possibly for adulterating the milk. Now, however, that the milk is being purchased from the dairies on the butter-fat basis by weight, there is not the same temptation to adulterate it. Pasteurization I simply look upon as a means to cover up dirt. That is my personal opinion about it. Samples of milk are taken from the dairies at frequent intervals for bacterial examination, and it sometimes happens that the count in a particular sample is especially high. A special inspection of the dairy is at once undertaken on the assumption that the milk may have beeii contaminated at the dairy. Samples are taken at different points of the machinery and examined for bacteria, and the cause of the trouble may thus he located. This is one of the most important duties of a Health Officer, to find out the point of trouble and see that it is corrected; and this is where the bacterial examination of milk is especially useful. A question has been asked with regard to milk coming from Washington. Some time ago we were getting about 3,000 gallons a day from that State. Now, I have inspected many of these 8 Geo. 5 Provincial Board of Health. G 217 dairy-farms personally, and I wish I could say that ours compare favourably with them, but they do not. In addition to that, the milk received from there conformed with all the regulations of this city. The herds were tuberculin-tested by competent men and the certificates were produced to my department, and I wrote to the State Board of Health of Washington and obtained a list of veterinarians who were authorized to apply the test. It does not matter whether the milk comes from Washington or China as long as it is all right. At the present time I don't think there is any milk coming across the border, only a little cream. All these things have a bearing on economic conditions. You have to be very careful in putting your Acts into force, because if they are enforced too stringently the milk may be diverted to other uses; the farmers may send it away for cheese or butter, and as far as I know there is no inspection made of milk for that purpose. I do think that if you lay down regulations that are too stringent, you have always before you the question of a milk famine, for which we should be to blame. There are many other little points that I might touch upon, but I think it unwise to prolong this discussion further, and will simply say that I am glad to have been here and to have heard such an excellent paper. Mr. McDonald: I think I should be allowed a word or two. I might say that to my mind we have in British Columbia provided a more healthful-milk supply than they have in any other Province of Canada. Now, I can say that without any fear of successful contradiction; and I too, perhaps, am somewhat optimistic in my work. If I wasn't optimistic they would have me over in Westminster in the " bug-house " before very long. However, Dr. Underhill may have left the impression quite unintentionally that there is no inspection of dairies to speak of. Now", there is inspection of dairies, and our Inspectors The Chairman: Excuse me, may I ask you to confine yourself as closely as possible to answering the matters connected with this paper which Dr. Underhill raised. I think he said, not the dairies, but the farms. Mr. McDonald: That is what I am referring to. The Chairman: All right, thank you. Mr. McDonald: Yes, and the farm dairies, if you wish to put it that way; and I have the grades of these dairies, they are coming in there every day. Dr. Underhill also said that there was no limit to the fllthiness of milk in Class C Now, Class C reads thus: (reading). Class C is a very good milk as milk goes. The Chairman: I think we have all enjoyed this discussion, and we might prolong it almost indefinitely, and still to profit; but I think that at this stage we will have to ask that any one who wishes to go further into it will bring on a resolution asking Dr. Young to bring it up at the next session of the Medical Health Officers, so that we can get more on this line. A member: I would like to know if there is any other subject The Chairman: In fairness to the other subjects on the programme, I think we must close this discussion. There is lots more to be said, but there are two other papers on the programme, so unless you insist on the resolution I should ask Dr. Price to close the discussion. Dr. Price: Mr. Chairman, Ladies and Gentlemen,—I was very much flattered by the amount of discussion which my paper has brought forward, and in view of the time taken up in that discussion, all I have to say is to thank you for listening so patiently to the paper, and I think I have derived great benefit from the discussion that has been brought forward. I do not intend to make any further reply, because the time is getting on and we have some excellent papers to follow. (Applause.) The Chairman: There are two other subjects on our programme this afternoon, both of them of great interest. The first is " Rural Sanitation," by Mr. W. J. E. Biker, District Engineer, Nelson, B.C. The discussion on this paper will be introduced by Mr. A. G. Dalzell, City Engineer. RURAL SANITATION. By W. J. E. Biker, A.M.Can.Soc.CE, District Engineer, Water Rights Branch, Nelson, B.C. Mr. Chairman, Ladies and Gentlemen,—Public health or the science of living together in large communities with comparative immunity from disease is, when analysed, simply a matter of education. I think you will agree with the statement that it is the chief function of a medical practitioner, and particularly of a Medical Health Officer, to solve problems, and to obtain not only a solution, but the best solution considered from all points of view. G 218 British Columbia 1918 The effectiveness of the Medical Health Officer in the fulfilment of his duties is very largely dependent upon the support given to him from headquarters, but more particularly from members of his own profession in the education of the public to proper policies of sanitary administration. To be a success the doctor holding such a public position must have the collective support and advice of his profession. In other words, I maintain it is " up to you " on every possible occasion to educate the public mind regarding the simple function of living, in order that we may not be a menace to ourselves or those around us. To illustrate: Most people wash their faces to suggest cleanliness, unless they are indifferent or wish to be regarded as abandoned characters. Would it not be possible to introduce precisely the same feeling, that there is want of propriety in not attending to or keeping perfectly sanitary all the domestic .offices that are essential to the health of individuals as well as communities? The need of community co-operation has grown more and more urgent with greater concentration of population, and with the development of conditions in America similar to those which have existed in Europe for between one and two centuries. Such undertakings as water-supply, drainage, sewerage, prevention of pollution of our streams, town-planning, park-developments, and particularly sanitation or hygiene, are all accomplished much better under united or centrally directed effort. It is no longer right for apy unit, be it a community or an individual, to disregard the rights of others. We must not lose sight of the sovereignty of the State or the fundamental requirement that individual communities, as well as persons, must give way to the common good and the ultimate need of the most good to the most people. Many of you may say: "But what has all this to do with a Medical Health Officer?" To illustrate the point, I will digress into personalities for a moment. Some of you may not have given the matter a great deal of thought, but as members of an old-established, honourable profession each one of you exerts an influence in your community which is second to none in that community, and particularly so in matters relating to health. In fact, you have under your control (in a very great measure) the health of the people within your area, and whether the contributory surroundings of the people are sanitary or unsanitary is a matter that is up to you for mitigation. Therefore, I say you are the custodians of a very noble trust, and have the power within your grasp of ruling or guiding the majority. Since all our laws and institutions receive their sanction by the ruling majority, you, gentlemen, in so far as sanitary legislation is concerned, are therefore the motive power of the people. It is the boast of science that its only quest is truth, and that in its pursuit the inductive method of research is never departed from. The average lay mind has become so accustomed to accepting as truth whatever bears the scientific label, and as valid whatever conclusions are alleged to have been reached by the process of induction, that it is now a comparatively easy matter for any of you to wield this potential asset for the good of the people. In other words, to inculcate in the people the simple study of cause and effect as it might be applied to living. Upon whom rests the responsibility of the contagious infections or epidemic diseases that quietly take their toll of human life? Who can be blamed for permitting many of the preventable diseases to thrive in this enlightened age? Is it the Governments, the municipal authorities, or the people themselves? A Province or State may start out with the best intentions in the way of legislative enactments to protect the public health. This is simple, for none but the framers of health laws really know what they signify; hence there arises no antagonism to their enactment. The trouble or cause of these laws not becoming a real factor in any community is, in many cases, the lack of adequate financial appropriation. The average sum available per capita per annum for the enforcement of health regulations for cities having a population of 25,000 or more is only about 30 cents. In looking over the estimates of the Province for the ensuing year, one finds an appropriation of $50,708 for public-health administration, or. worked out on a per capita basis (on an assumed population of 400,000). a little over 12% cents per head. Secondly, the officers in charge of such administration have to go about the country almost apologizing for causing any trouble, and in fear and trembling of the political pull that Jones or Smith (whom they have just reported) may use against them when opportunity offers. I speak this to the shame of all political persuasions, both here and elsewhere, and add, without fear of contradiction, that no 'efficient public-health administration caii be formed unless, in the first place, you can secure men who are capable of acting above personal interest, and, secondly, give them adequate protection and continuity of service to make it worth while. 8 Geo. 5 Provincial Board of Health. G 219 The status quo of the sanitary problem in this Province to-day can fittingly be compared to that of England prior to her acquiring a dense population. The laws governing the public health were and still are good, and gave to the officials all the power necessary, with what result? Sewage-disposal, the unrestricted pollution of the rivers and streams, increasing death-rate, and other factors took such a toll of the best lives in their midst that finally arrested the attention Of Parliament to the issue, resulting in the appointing of a Royal Commission to deal with the question of sanitary legislation. This Commission has been in existence for seventeen years, and the expense and results of the findings of this tribunal have cost England millions of pounds sterling. Now comes the point to be made, and surely we are able to draw something from their experience. We are still in the initial stages of development, and I take this opportunity of going on record, in September, 1917, to the effect that we in this room have it within our power to save British Columbia and its future administrations from the condition that Great Britain found herself in when she appointed her Royal Commission for the protection of public health. Over there, through bitter experience, they have learned that sanitation almost amounts to a religion, and even at this time, when we are fighting for our very existence, they are debating the advisability of creating a new portfolio to be named the Ministry of Health. I do not propose to detain you with figures, but give to you a problem to work out for yourselves. How many of us nave conceived the value of a human life in actual dollars and cents, the producing and earning power of that life to the State, to the community, and to the home that has cradled it? Taking as an index to our attitude towards the various administrations of the people the actual cash set apart for those administrations, we find that more value is placed on a stick of timber than on a human life. For forest-protection we spend on an average $1.25 per capita per annum, as compared with about 12y2 cents per capita for the preservation of human life. These opening remarks may have the appearance of being very dogmatic, but my justification for the thoughts just given is drawn from twenty years' experience in sanitary engineering, and for fifteen of those years it was my duty to administer and be daily iu touch with problems regarding the public health. The Honourable the Minister and Dr. Young have, no doubt, placed in your hands the new Sanitary Regulations, which, coupled with the " Health Act," completely cover your sphere of operations. The appropriation of $50,708 is unquestionably inadequate to obtain results, except in a small degree, particularly so in view of all the problems with which this Department has to cope. However that may be, I want to make an appeal to you on behalf of the people of this Province, that the laws you have to administer and the problems under your control are questions apart from the remuneration you may receive. Therefore it will be observed that the one thing needed is a policy which has for its object a common ground on which we can all work for the same ends—viz, the public health. So much for general statements. I now desire to cover a few practical points on rural sanitation, the betterment of which enlists at all times my sympathy. My work of the last six years as District Engineer in the Lands Department has been spent in the East and West Kootenay Districts, and has necessitated at intervals stays in mining, logging, and construction camps. While every courtesy and hospitality has been shown me, the sanitary condition of those camps to me is a thing quite apart. There are no figures to prove or disprove the statement that I believe between 30 and 40 per cent, of the population in the Kootenay District live under camp conditions. No doubt many of you remember having a1 hurried call to some of those camps and, being unable to get back, stayed the night under usually very respectable conditions. Why? Being the doctor and a visitor, the foreman or superintendent gave up his room or his bed for yon. But drift into one of these camps as an ordinary individual, when the space for visitors is limited, and what do you find? A low bunk-house with no ventilation, down each side of the room a row of double-deck bunks made of boards covered with hay that has probably never been changed since the place was built, blankets that in places are stiff with body- perspiration, finally being compelled to double up with a man who has worked and slept in his underwear for weeks without change, and perhaps not had a bath since he was last in town. I have seen in a log shack 24 x 26 x 6 feet high at the walls as many as thirty-two to thirty-six men sleeping. Imagine how refreshed you feel each morning on rising. (Have any of you associated our increasing death-rate from tuberculosis with the overcrowded conditions of camps?) Anyway, you live through it, and with the strength you have left you struggle off to G 220 British Columbia 1918 the cook-house. If in summer, you find it impossible to enjoy the food because of the millions of flies. You may want a drink of water. It is kept in an open galvanized pail near the door, with a tin dipper hung just above. Under average conditions the privy is placed near the cook and bunk houses, quite close in, usually of the open type, and flies simply have a great time chasing each other from here to the cook-house. What do you find regarding the disposal of offal, kitchen waste, slops, etc.? You find that the cook is true to type, designed on the lines of least resistance, and finding room for this material not an inch farther than he can throw it from the kitchen door-step, or it may by chance arrive in a pigsty adjoining the kitchen, and it may not. Section 60 of the " Health Act" sets forth that the Health Officer shall in every year in April or May inspect the sanitary condition of these camps, also the water-supply. The above is a very serious state of affairs, true as it is, with only a few exceptions, and the following suggestions are given for your consideration:— (1.) The cook is the chief regular offender in camp. Why not have him registered and make him, under penalty of dismissal, responsible for the sanitary condition of the camp? h! printed set of regulations could be got up to cover all the essential points. (2.) Log cabins should not be built to house more than from ten to twelve men, and should be provided with iron camp-beds with spring mattresses. (3.) All habitable buildings to be whitewashed at least once in every year. (4.) Fly-screens for all windows and doors in cook and bunk houses. (5.) Waste, offal, empty cans, slops, and all debris to be removed daily (and kept until removal in a covered receptacle), to be finally disposed of by burning. (6.) Stables or privy to be at least 100 yards distant from the camp. (7.) Bath-room or shower an essential. (8.) Good water-supply, and where possible piped into the buildings. (9.) Earth-closet to be of approved design to exclude flies. Camps for this purpose may be divided into two classes, permanent and temporary, distinguishing permanent camps as those having been built over twelve months. Many other points may suggest themselves to you, but in starting a progressive movement which attacks established custom, it is first necessary to convince the interested parties that you seek their co-operation and help. On the other hand, some one may be tempted to say: "Why not enforce the law?" On this point, as in the majority of cases in health matters, the actual letter of the law is for our guidance, to be used with great discretion and enforced only as a last resource. It is often worth while spending a whole day with some men in convincing them that you are working in their interests, because, once convinced, you have a booster for your cause. In support of the better-camp movement, it is only necessary to state that it has made possible the Panama Canal, and at this moment, in France and on the Allied fronts it is preserving daily more lives than the guns of the enemy are destroying. Pollution of Streams. There is an old saying that " constant dropping wears away a stone " ; likewise, the constant pollution of our streams destroys their usefulness. It is a significant condition to observe that the three most scientifically advanced nations in the world, England, France, and Germany (by the standard of present knowledge), allowed the incipient pollution of their streams to overtake them, until it finally became so intolerable that vigorous campaigns costing millions of dollars were instituted to mitigate the evil. England seems to have suffered most in this regard, presumably by virtue of her possessing more inhabitants to the square mile. With the exception of a few small streams, we are in a very favourable position in this Province (providing we realize our present opportunities) for keeping the streams free from serious pollution. If we are to preserve the amenities of our streams, a very careful and systematic scheme will have to be evolved, enlisting the aid of the greater part of the population. The Royal Commission of Great Britain has had this problem under consideration for a great number of years, and its conclusion, as set forth in the 1912 report, is as follows:— "We are satisfied that rivers generally, those traversing agricultural as well as those draining manufacturing or urban areas, are necessarily exposed to other pollutions besides 8 Geo. 5 Provincial Board of Health. G 221 sewage, and it appears to us, therefore, that any authority taking water from such rivers for. the purpose of water-supply must be held to be aware of the risks to which the water is exposed, aud that it should be regarded as part of the duty of that authority, systematically and thoroughly, to purify the water before distributing it to their customers. " Apart from the question of drinking-waters, we find no evidence to show that the mere presence of organisms of a noxious character in a river constitutes a danger to public health or destroys the amenities of the river. Generally speaking, therefore, we do not consider that in the present state of knowledge we should be justified in recommending that it must be tlie duty of a local authority to treat its sewage so that it should be bacteriologically pure." It must be conceded that the conclusion of the Commission is sound in principle, since under average prevailing conditions water-purification rather than sewage-purification affords a better safeguard of the public health in the state of present knowledge. It also has financial considerations, since water-purification is not only more reliable, but is also cheaper under the average conditions. It is necessary to consider the future as well as the present regarding stream-pollution, for since it is a question of degree there is a limit to the permissible dilution of sewage. It is perfectly obvious that as civilization advances and the population of the Province increases there can be no longer any streams of original purity. On the other hand, if the system of discharging crude sewage into our streams, without realizing the " limits " of such a system, the Board will have to face a condition which has cost Great Britain millions of pounds sterling. The writer was very much interested in this whole problem in England, and it has been with increased interest that he has noticed a gradual change of opinion by all the leading experts in their attitude towards the dilution method. In this regard, it is only necessary to quote Dr. A. C. Houston, Chief Water Examiner of the Metropolitan Water Board of London, and Dr. T. M. Drown in his special report of the Massachusetts State Board of Health, wherein is stated in reference to sewage-polluted waters: " It would be necessary to drink half a gallon at once of the waters under test in order to get as much nitrogen and carbon as is contained in a single medicinal dose of strychnine, which is acknowledged to be one of the most energetic of recognized poisons." At the same time, both the above authorities are advocates of " clean rivers," but have brought themselves through their research-work to look more favourably upon the dilution method of disposal, and to take advantage in point of economy of the many intermediate procedures of this system. To apply the above reasoning to British Columbia resolves the problem into what is the actual safe " degree of dilution." The Chicago drainage-canal, constructed under and with the approval of the Illinois State Board of Health, was established on the legal limit of 3% cubic feet of river-water per second to dilute the sewage of each 1,000 persons connected with the sewers. This limit has been criticized and was probably too low for the crude sewage of a city which has such a large proportion of manufacturing wastes in its sewage-flow as is the case of Chicago. For a city without such wastes it might be termed a fair limit. Generally speaking, without prior treatment a dilution of 4 cubic feet per second per 1,000 persons is a reasonably close figure for crude sewage, although undoubtedly there are many local factors which have a bearing on the complete dilution and may be said to establish a range as wide as from 3 to 7 C.F.S. Such simple pre-treatment devices as "screens" and "sedimentation-tanks" in certain cases (other conditions being equal) may reduce the standard to 2.5 C.F.S. per 1,000 persons. One very large factor in reducing the standard, in so far as the majority of our large streams are concerned, is: " Owing to the rivers having their feeders come from high altitudes, many of which are glacial-fed, the water is the year round very cold, therefore strikingly unfavourable to all biological activities of bacteria, worms, and other organisms which operate to decompose, digest, or oxidize the organic and mineral matters in sewage." Fish Requirements. Data are somewhat meagre as to the amount of dissolved atmospheric oxygen which is required in streams to protect major fish-life. In the lower Elbe near Hamburg it is stated that a margin of dissolved oxygen during the ordinary summer periods falls as low as 20 per cent, and the figure in the lower Thames is understood to be about 30 per cent. G 222 British Columbia 1918 Future Requirements. While a firm believer in tbe dilution method of sewage-disposal within controlled limits as roughly outlined above, it is the part of wisdom to only approve such designs for sewer systems, so that if filtration, screening, or other pre-treatmeuts are not needed at the outset, they can be adopted as conveniently as possible in later years, without involving pumping-stations or the abandonment at too great sacrifice in works already undertaken. In the initial stages of the development of the Province this feature should have full consideration. The writer has been in touch with many cases in England where, through the recasting of the regulations by the Royal Commission, authorities or municipalities had to face problems which involved the loss of present works, or resort to expensive pumping in order to obtain the fall necessary to install additional treatment-works for securing an effluent equal to the new standard set by the Commission. Therefore, from what has been said, it will be seen that the consensus of expert opinion based on present knowledge has aimed at the conclusion, " That it is proposed now to take full reasonable advantage of dilution " and to safeguard the future by so arranging the works that a more complete treatment and higher standard of effluent may be secured when and as required. It must not be understood from the preceding remarks that sewage is the only contributory factor in the pollution of our streams. I venture to tell yon that in 09 per cent, of our preemptions that have streams running through them the farmer has erected his buildings to include the stream iu his barnyard, and in scores of cases under my observation the pigsty, corrals, and manure-piles are actually on the creek. The farmer is not to blame for this state of affairs. As usual, you find him built on the lines of least resistance, inasmuch as bis stock can secure all the water they require with little attention. You have in sections 42, 43, 44. and 47 of the new Sanitary Regulations all the authority you need in handling these cases. Have you also thought of manufacturers' trade refuse, sawmills, lead, zinc, and copper mines or refineries, all of which come under this head and require attention? It will take a number of years to round out each district, because it will be necessary to quietly accumulate data or sanitary survey of the streams, in order to be able to deal with existing pollutions, and when this is accomplished it will only be a matter of keeping in touch with proposed developments. The Board in the near future will have to set up a standard of effluent from sewage-works, which they will allow to be discharged into the streams, and at the same time provide means of inspection to see that such standards are lived up to. In this connection I would suggest closer co-operation between the officials of other departments and the Health Department. For instance, there are Engineers iu the Public Works and Water Rights Branches, Fire and Game Wardens, Pre-emption Inspectors, Assessors, policemen, etc, all of whom are travelling round the country, who could easily report ou stream-pollution, providing they are circularized as to ■what to look out for and given a simple standard post-card report form to fill out. Disposal of Liquid and Solid Domestic Refuse in Rural Areas. I know of no other phase of rural sanitation that directly affects the health of the population more than the one just named, nor one that is capable of creating more dissatisfaction if badly administered. *- It is a subject on which great difference of opinion exists, even amongst those who are supposed to know. Therefore, a few suggestions on which a future meeting could be called may not be out of place. The new regulations, sections 59 to 63, will serve as a guide only to your actions in this matter, and I earnestly desire to prevail upon you to " go slow " until the time arrives that each one of you perfectly understands the policy of the Department. I very much doubt my ability to focus the true position on this subject, and therefore ask your indulgence if the salient features are not made quite clear. The majority of experts in sanitation have accepted the following as a guide :—■ (1.) In towns and populous places, where sewers and public water service are available, the use of dry closets of any kind is inadvisable, on grounds of both health and economy. (2.) In sparsely populated rural localities, where sewers and public water service do not exist, the use of dry closets of improved kind (preferably those in which dry 8 Geo. 5 Provincial Board of Health. G earth is used) is generally to be preferred to that of water-closets, especially for the smaller houses. In such places the closet can be placed at a sufficient distance from the house not to cause a nuisance if neglected, and the contents can be disposed of on tbe laud. (3.) The intermediate case of a rural parish or urban district containing a closely built village, or built-up areas adjoining cities but not under city administration, with the balance of the district partly agricultural or mountainous, is often difficult to deal with iu the absence of sewers or water-supply, as many houses may have little or no space for the proper placing of a closet or septic tank and the disposal of their contents, although the majority of houses may have sufficient space for these purposes. «In the circumstances, there is usually strong local opposition to the provision of water-supply, sewers, or public scavenging, since I believe, in the present state of the law, the cost of such works has to be spread or levied over the whole contributory district and paid for by ratepayers who receive no direct benefit from them. It would assuredly help the rural sanitary problem if it were possible to assess portions of a district pro rata according to benefits received. The introduction of a public water service in a village without sewers undoubtedly aggravates sewage nuisances by increasing the volume of waste water. Also, the connecting of house-drains, especially if conveying water-closet contents, to highway drains not constructed or suited for conveying sewage is a source of nuisance and pollution of streams. The Board seem to have pinned their faith to the septic tank with surface or subsoil irrigation, and there is little doubt of this procedure making good in the majority of cases. But, at the same time, I doubt the expediency of such a method with a well on the same lot or even on adjoining lots. Again, this method would fall down completely ou a clay soil and ultimately become a great nuisance. Therefore, enough has been said to show that the best regulations it is possible to frame have little or no finality in them, and, if enforced, would work a hardship on some one. It would almost seem that each case is a law unto itself, calling for the resolving of a few practical points, and even with the greatest scope given yon, cases will arise that will be beyond satisfactory economical solution. While on the subject of methods in dealing with human excrement and waste, I cannot impress upon you too strongly: " That whatever system is evolved, you cannot allow excreta or stable manure to be exposed to the atmosphere in the vicinity of dwellings, because of the breeding of flies." The ordinary house-fly is one of the most active agents known to modern sanitary science as a conveyer of the germs of disease. Many of you will no doubt recall and have personally watched how the rising curve of the summer death-rate follows the curves of flies and heat. Case after case under your own observation has proved the relationship of the fly to the toll from this seasonal prevalence of intestinal diseases, typhoid, dysentery, and the fatal summer diarrhoeas of infancy. But I find myself travelling on thin ice, since this is more in your sphere of work. However, notwithstanding, we have an urgent need of stimulating and strengthening at home our machinery for the conservation of the public health, and especially is this true at this time of those activities concerned with the protection of infant and child life. In this regard. I recommend for your perusal the Delineatoi for September, in which appears a cleverly inspired article entitled. " Save the Seventh Baby, or How the Fly Kills Him," by C E. Terry, M.D. A " swat-the-fly " campaign inadequately serves the purpose and has no bearing on the root cause of the evil. Let us eliminate exposed excreta and manure-piles, which are the breeding-grounds of flies, and you have in that'one action eliminated 95 per cent, of the fly problem. Statistics in the United States go to show that between 60 and 70 per cent, of infantile mortality can be directly attributed to the fly in his capacity of germ-carrier; also, the birth-rate of the different warring nations is estimated to be from 30 to 50 per cent, of normal times. I respectfully suggest that we make an attempt to enlist the sympathy and help of all the women's organizations in British Columbia. To this as well as other phases of preventive medicine, for once you have the ladies convinced, I know of no other factor in our social or economic life that is half so powerful. G 224 British Columbia 1918 House Plumbing. All cities of any importance in the Province have plumbing by-laws, but how many take the trouble to see that they are effectively carried out, and why? Because it costs money to have this done. In consequence, the only safeguard agaiust sewer-gas being admitted into dwellings is at the mercy of the plumber, who usually secures his work on competitive bids, and who is usually more interested in the few dollars he can make (often at the expense of the work) than in the matter of the public health. You will certainly do a good thing by urging the cities in your areas to have all plumber's work inspected and made to pass a water-pressure test. Cases have come to my attention where soil-pipes (which, under the present system of house plumbing, ventilate the sewers) finish through the roof below the upper-story windows. Also, the joints in same above the water-line are usually carelessly made. Again, what protection is there in this system against the housewife cleaning out the toilet and wash-basin traps and leaving them unsealed, in complete ignorance that by so doing sewer-gas is admitted to the dwelling? Or take, for instance, houses that are empty, or even temporarily empty for about three months, during a hot, dry spell such as the one we have lately experienced, and you will find the water in all the traps to sinks, wash-basins, and toilets evaporated below the sealing-point, thereby ventilating the sewers into a closed house, all the furniture and hangings, in many cases, becoming simply saturated with sewer-gas. There is no doubt in my mind that the single-trap system, as is the practice in British Columbia, is not the best one to adopt. It may be the least expensive, but surely this is not all. In its place I suggest the double-trap system, or what is termed the intercepting trap, with manhole. This has been statutory law in England for many years, and has to its credit not only the prevention of sewer-gas to dwellings, but it also gives access by inspection to the drains, enabling the location of stoppages and the clearing of same by rodding. The time has arrived in certain towns in the Province when, in letting or selling a house, a Sanitary Inspector's certificate as to its habitable and sanitary condition should be just as much an essential as the clear title. Gentlemen, I am afraid that this paper is getting too long, and it has not been possible to touch on the subjects of water-supply, contamination of wells, scavenging, dust-removal, "public bathing-pools, recreation-grounds, building by-laws, etc, all of which fill an important place in the chain of a sanitary regime. However, it is impossible to recount here all the detailed functions of sanitary reform. Suffice it to say at this time: " We have gained accurate knowledge of the nature of many diseases and the modes in which they are spread—a knowledge based on observation and statistical research. It remains then for those who have that knowledge to awaken and educate the public opinion to the importance of hygienic requirements. The State has realized its responsibilities and we have a sound body of sanitary legislation, not perfect indeed, but comprehensive and workable; we have central and local boards responsible for the due carrying-out of the law, and in every district in the Province we have a qualified Medical Officer of Health charged with the sanitary welfare of his community. In short, the Province has taken medicine into its service, and availed itself in a small measure of expert advice on sanitary engineering." Finally, to summarize, we want co-operation and a higher standard of efficiency in the administration of public-health laws :— First: In improved camp conditions. Second: Prevention of pollution of our streams. Third: Better disposal of our liquid and solid domestic refuse in rural areas. Fourth: Regulations to dispose of the fly problem. Fifth: Enforcement of the laws in regard to securing better house plumbing. Sixth: The people of this Province are looking to you to guide them, and your responsibility cannot be side-tracked. Seventh: I look forward to the time in the very near future when the Province will be divided into administrative public-health districts, with a full time Medical Health Officer in charge, who will act under and be responsible to the central board in Victoria. I realize that I may have aroused in some of you resentment, inasmuch as the suggestions contained in this paper call for guidance in duties of an engineering character. As stated at 8 Geo. 5 Provincial Board of Health. G 225 the beginning, this guidance should be forthcoming from headquarters, and I have no doubt it will be if you send along your troubles. I also have to suggest that every Medical Health Officer in the Province be provided with a copy of Dr. Poore's book on " Rural Hygiene." which is one of the best books I have perused on this subject. I now leave you with a plea to make the year 1918 and successive years banner years in the reduction of our death-rate, which can be realized only by steady, painstaking effort. Personally, you have my sympathy, and again repeat: " It is up to you." Discussion on Mr. Biker's Paper. The Chairman : The discussion will be opened by Mr. Dalzell, City Engineer. Mr. Dalzell: Mr. Chairman, Ladies and Gentlemen,—I presume that the hour is so late that tbe discussion will be very limited, so I will try to be very brief. I congratulate the reader of the paper on the excellent way in which he has presented this subject. There are a great number of civil engineers in the Province—or were. I might say that I understand that a third of them are on active service; but the civil engineers who practise in this Province have not, many of them, been trained or had much experience in sanitary work, and of those whose training has been in the older countries, it seems to me remarkable that so little advantage has been taken of experience of that kind in the older countries, and that you are beginning here where England and Scotland began years and years ago in many of your regulations. For instance, the Bell trap has been absolutely prohibited in the Old Country for years. It is a commercial output here and in common use. Dwellings in basements are prohibited, and where they exist in the Old Country they are regulated; but here in your new apartment-bouses you make the regulation that there shall be no suites in the basement except the janitor's. Why the poor janitor should be put into the basement, when he surely requires greater protection than any other person in tbe building from the dust and from the chance of getting tuberculosis—but there are in this city modern apartment-houses which in that respect, in the accommodation for the janitors and in certain sanitation in the basements, would not be tolerated in any ordinary town in the older countries, and a great deal I think must be done, as the reader of the paper has said. We have to depend upon you as Medical Officers, and the medical profession especially, to do the educational work. As I said, the engineers who are responsible for a great deal of work that is carried out have not, many of them, been trained in sanitary work, and they are not heard or attended to as a medical would be. Take one instance, in one ward in this city: A fourth of that area is a muskeg swamp. Now, it is absolutely impossible that that ground will ever be fit for human dwellings to be put on, as we regard it in modern sanitation, but yet is has been permitted, and I can only imagine that this was because the surveyor who surveyed that ground in the first place had no idea of the sanitary significance of land of that description. But I do think this: I am optimistic in this respect, that I believe Canada is going to see in a very few years a tremendous influx of population, and that it is up to us, and up to the medical profession especially, to so try to provide legislation that some of the mistakes that have been made in this city in the last ten years shall not be repeated. If, for instance, we find in a city like this dwellings situated in a place which is unfit for human residences, why should we allow another city to take up the same land? And yet I take it that is what has happened at Prince Rupert. I am told that half the area of Prince Rupert is muskeg, and I don't think that any ground of that description is fit ground for human dwellings to be erected on. I could give reasons.for it, because I have had a little experience in this city in that respect; but it is these points that we want the medical men to impress, to prepare for the next influx of population into this Province, which I feel is sure to come very soon, and it will come very rapidly. We want to avoid the mistakes which the older countries have made, and try to so learn, so prepare, that it won't cost us thousands or possibly millions of dollars to remedy the mistakes whiph, by taking the observation and experience of other countries, we might avoid. I congratulate the writer on his paper and am glad that he is a member of the Provincial staff. I am sure, if we have more men of that description, many of these mistakes that I deplore, and that I think will be costly in the future, will be avoided. I thank you. (Applause.) (At this point Dr. Wrinch occupied the chair.) The Chairman: Ladies and Gentlemen,—Even at this late hour I want your indulgence while I call your attention to some points in the paper. I might say that while the writer of tbe previous paper was complimented on having an optimistic view-point, I would hardly be able 15 to compliment the writer of the present paper on having an optimistic view-point; but I am not one who has much experience in relation to mining camps; in fact, I never knew anything about mining, except what I saw in the papers, until I came to the Province some years ago, but since coming to the Province, in the northern part a mining district has been opened up. I don't know whether I heard the right definition of a mine the other day, but it was rather precise and pointed—a hole in the ground and a liar on top. Of course, I wouldn't say that all of our mines are of that nature. I want to say that while the mines in the Kootenay and Boundary Districts may be such as the writer of the paper describes, the only two mines that I know of that are mining—beginning to operate in any kind of permanent form—the camps are not in the shape he has described. I would not like it to go forth from this meeting that our mines are all of that description, or the camps are all of that description that have been stated here. I have in mind one mine that I went to visit. There they were supplied with bunk-rooms which were furnished with single-beds, iron frames; the bunk-houses have shower- baths and hot and cold water, and I have seen tbe miners come right from the work and go to the bath-houses, take their shower and go back to their room; and it is most convenient and appropriate. They have ventilation in the rooms in the mines—these two mines—and the camps and bunk-houses are ventilated, and certain of them are fumigated; water is piped into their building. The closet—at least, one of them—is made of a large box receptacle for a number of houses. At certain times, frequently, that box is hauled out and burned and a new one put in its place. That is only just another view-point, another feature which I would like to show, if there is any question about it, that there is that kind besides the other one. (Dr. Underhill then took the chair.) The Chairman: Any further discussion on this paper? I will call on Mr. Biker to reply. Mr. Biker: It is so late, and I feel that we have had a rather long session this afternoon, so that I don't want to discuss any point at length. I did not intend to put forward that I condemned all the mining camps. That was far from my view-point. The point I tried to put forth was to have better camping-ground and better conditions for living in our camps than we have in the majority of cases. Thank you very much. The Chairman: The next paper is " Vital Statistics," by Mr. Miller, Deputy Registrar of Births, Deaths, and Marriages, Victoria, B.C, VITAL STATISTICS. By Munroe Miller, Deputy Registrar of Births, Deaths, and Marriages, British Columbia. Mr. Chairman,—A few days since I was directed by the Secretary of the Board of Health, H. E. Young, Esq, M.D, to prepare a paper or report on the " Vital Statistics of British Columbia," to be read on this occasion before the Medical Health Officers of our Province. Not being a professional man, simply one of the staff in a department in which all members of the medical profession should take a deep interest, allow me to make the assertion that the direction "to prepare" has been obeyed; yet, let it be granted that when it comes to my turn to " read," and I find myself surrounded by the very foremost men and women of our commonwealth (actual participants in and contributors to the success of the meeting), a still small voice admonishes me, " You are in the company of distinguished strangers." Immediately self- reliance vanishes, and the position of that great factor of success, when fortified by a familiarity with the subject, is succeeded by one of extreme diffidence. Tbe task assigned me being statistical may, to many, prove dull and anything but entertaining, particularly at this stage of our proceedings when many are tired, yet, when presented almost as a critique by one who is not given to speaking " smooth things," it may be possible to so arouse the combativeness of hearers as to secure at least trifling attention. Tbe Vital Statistics Department of British Columbia has control of returns and registrations of all births, deaths, and marriages happening within our Province. The figures to be presented cover the first six months of the year 1917, and will be dealt with in order of births, deaths, and marriages. The returns of births come under two separate headings, delayed and current, which by our system of indexing is made perfectly plain. For the purpose of showing how necessary and 8 Geo. 5 Provincial Board of Healtfi. G 227 important a thing it is to have prompt registration, figures for each year, from 1913 to June, 1917, will be cited:— 1913, registrations 11,088, of which 9,199 were current. 1914, „ .. 10,418, „ 8,754 1915, „ 10,516, „ 8,558 1916, „ 9,S39, „ 7,475 1917, „ 4,798, „ 3,889 Total 46,659, „ 37,875 A difference in four years and a half between delayed and current of 8,784. Permit me here to make an explanation, and at the same time lodge a complaint against members of the medical profession—under our Act the parent shall within sixty days register the birth of a child. Many are perfectly ignorant of the law and have the idea that registration is effected by the doctor, and so suffer the matter to go by default. By section 15 of the Act the doctor is required to notify the District Registrar of the district in which the event took place of the birth of a child to John Brown and (maiden name of mother) Susan Smith. This, however, is not registration. Here is the ground of complaint: The doctors do not make the reports and the Department is in perfect ignorance of many births that may have taken place. Now, to show the bearing: Every ninety days the notices of births received are compared with the registrations effected, checked, and delinquent parents are, by mail, provided with a blank form, and requested to register the birth and save themselves the penalties provided by the Act. This plan is followed by all Registrars in the Province. Allowances must be made for people who leave the country, etc, and who cannot be located. Let us allow 5 per cent.; 8,784 who are not registered, less 5 per cent, leaves 8,345. Let us be liberal; at least 8,000 of the births have never been reported by the doctors, and of which events the Department had no knowledge whatever—a very palpable offence, or clear case of absent- mindedness, neither of which can be condoned. To show, in order to explain: Where we have had notice from physicians, and where the people have moved away, by mailing notices and forms we have had registrations effected from all portions of the United Kingdom, France, various Provinces of the Dominion, and nearly all the leading cities of the United States. Had notices never been given, registration would have been lost. Registration of births may be by some considered a matter of trifling importance, but any sudden or violent activity in the real-estate market or winding-up of estates, such as we have lately passed through, where validity of titles were affected by lack of registration, has had an awakening effect; but when we add to that the demand for certificates of registration occasioned by the present war, in order that women and children may be enabled to establish their identity before being able to secure their allowances, then the result is, truly, brought forcibly home. The Department must have the co-operation of the physicians. They must give notice of every birth, whether premature, still-born, or congenitally deformed so as to prevent living, and the Department must be held responsible for the registration of births by enforcing the provisions of the Act against all offenders. As nearly as possible, following are returns of births for the different localities specified for the first six months of the year:— Victoria 514 Nanaimo 258 New Westminster 469 Alberni 151 Beaton to Nelson 237 New Denver to Wilmer 192 Ashcroft 76 Fairview 399 Vancouver City 1,124 South A'ancouver 237 North Vancouver City 58 North Vancouver District 18 Point Grey 47 Richmond 71 West Vancouver 3 Unorganized 35 Total 3,889 The total includes premature and still-born. Re Death Returns.—Total number of deaths, 2,088, including still-births. Of this number, including still-births, under one year were 383, being 9.84 of all births and 98.48 per 1,000 of births. Deaths, up to five years, including still-births, 485, being 23.22 of all deaths and 232.27 per 1,000 of deaths. Almost one-quarter of all deaths are under five years of age. A pertinent question is, What makes the rate so high? We enjoy, almost, immunity from diseases of the digestive system peculiar to children, there being only eleven deaths reported from summer complaints. The answer can be found in deaths of children under one year of age under the following headings :— Congenital malformations 33 Congenital debility, icterus, and sclerema 22 Premature 49 Still-born S4 Total 188 Nine per cent, of all deaths and 38.85 per cent, of all classed under infantile mortality. The three principal divisions, Vancouver, Victoria, and New Westminster, are responsible for:— 75 out of 84 still-births. 196 „ 299 under one year. 271 „ 383 The figures show that 70.75 of deaths under one year occur iu the congested centres. Why should it be so? The Health Boards are untiring in their efforts to better sanitary conditions and put forth every effort to make life worth living; but there is a subtle something abroad which thwarts their efforts. Plainly, is the pace at which we travel in cities so fast that the virility of parents becomes undermined to such an extent that they are rendered physically unfit to become fathers and mothers, or has a natural life been abandoned for a scientific one, thus making a class the legend on whose banner does not read " Be ye fruitful, multiply, and replenish the earth"? Is the time ripe for changing our school curriculum? Shall we teach the coming generation, as far as we are able, what life is, and that nature not only provides, but inflicts a penalty on all who violate physical laws? Or shall we make it a law of the land that all persons shall, by examination, prove their fitness to enter into the holy bonds of matrimony? Perhaps too much time has been given to this particular line of vital statistics, but all foundations must be well and truly laid. By way of finale re infant mortality, allow me to interpolate; in round numbers, registered and unregistered, we have lost 500 children under five years during the first six months of the year. Let us be sordid enough to view this matter from a financial angle, for, after all, it does seem that he makes the best argument who can show that his plan will result in a handsome credit balance. Let us consider the children a source of natural wealth. It is asserted that every child born represents a value to the State of $1,000. At the rate we are moving our annual loss in this one source of natural wealth is close upon $1,000,000. Why not give the whole matter a business turn and endeavour to save one-half the loss by providing funds with which to secure proper supervision and institutions for treatment of children? I do not mean to deprive parents of their little ones, but to provide inspection, etc. A little further—save one-quarter of what is now a complete loss, and we have an annual gain of $250,000 in one source of natural wealth. I have been impelled to these remarks by reading the estimates of revenue and expenditure of our Province for the year ending June 30th, 1918. Therein I find every source of natural 8 Geo. 5 Provincial Board of Health. G 229 wealth carefully guarded by officials provided by the Government. Even wild game is capitalized at $700,000—that amount at 6 per cent, will yield $42,000 per annum; and the Game Wardens' Department costs $41,300 to maintain, the chief end and aim of the whole branch being to gratify man's lust for the destruction of helpless creatures, so that he may be amused, gratified, and provided exercise. If there be any analogy between preservation of wild game and the conservation of infant- life, why should we not ask for the sum of $15,000 per annum from the Government for the purpose pointed out? The subject is worthy of more elaboration than time and this occasion will permit at my hands, but the hope is indulged that members of the medical profession will deem it worthy of consideration. Here is a fulcrum—provide the lever. In the end, if successful, untold numbers will rise up and call you blessed. If our fair Province is to remain for ever the personification of " Sleepy Hollow," perhaps we should be content and still hug the delusion that " whatever is, is right" ; but the world is moving, other countries are making gigantic strides for the betterment of child-life, and we must keep abreast, or expect reproach. I have here a tabulated statement which shows the number of deaths in each division as well as the age (approximately) at death, together with the percentages of all deaths belonging to each particular age. Should any one feel interested the document is at hand for inspection. In the beginning of this paper the co-operation of physicians was asked. It seems to me that no better place could be chosen than this to bring home my reasons. In returns of deaths the following immediate causes have been assigned:— Hemorrhage of Lungs.—Man was shot. A case of homicide. Haemorrhage and Shock.—Man's skull and legs fractured toy rolling log in lumber camp. Paralysis of Respiratory Organs and Heart-failure.—The cause was undoubtedly quite sufficient, but under what heading shall it be classed? Fracture of Base of Skull.—How did it happen? Bronchitis.—Respiratory failure. One, actually, want of breath. Convulsions of Infants.—Twenty-four deaths. Cause of convulsions not explained. In one case return reads " Convulsions following measles." Under diseases of the respiratory system ninety-five deaths were returned, of which seventy-eight were reported under various forms of pneumonia without specifying what induced immediate cause of death. Induced Abortion.—It is not explained whether it was the last resort of the physician to save the patient's life, or whether the patient was endeavouring to save her reputation, and as a last expedient called in the physician to save her life. Immediate cause should be explicit and nothing left to conjecture. Iii short, not to particularize, the immediate causes of death assigned are, in many cases, made in such a careless manner that a compiler of tabulated statements is frequently compelled to throw up his hands in despair. Let us pass on. Deaths from Cancer (All Forms).—This disease is on the increase. One can hardly say rapidly, yet so surely as to merit serious consideration. For instance, for the first six months of the year we have had 132 deaths resulting from cancer, seventy-five males and fifty-seven females. On looking back it is found that deaths from cancer stand in this light: 1914, 195; 1915, 221; 1916, 259; 1917 (first six months), 132, being 6.32 of all deaths, and rate of 0.34 per 1,000 population. Tuberculosis.—In considering this disease, it may be well to consider it for a series of years, showing deaths and population for each year from 1906. Estimated Population Deaths from 1,000 in Even Tuberculosis. Numbers. 1906 283,000 178 1907 304,000 243 1908 325,000 180 1909 346,000 137 1910 367,000 172 1911 392,000 316 1912 432,000 368 G 230 British Columbia 1918 Estimated Population Deaths from 1,000 in Even Tuberculosis. Numbers. 1913 492,000 422 1914 495,000 403 1915 395,000 425 1916 383,000 367 1917 383,000 (6 months) 220 For comparison: The year 1911 has a nearer estimated population (392,000) to 1917 (383,000) than any other; still, the population of 1911 was greater than 1917 by 9,000, yet we will use the figures as they are. In 1911 there were 316 deaths from tuberculosis, or 0.80 per 1,000. For the first six months of 1917 (population estimated at 383,000) there were 220 deaths, or a rate per 1,000 of 0.57. If we for a moment compare 0.80 for twelve months (1911) and 0.57 for the first six months of 1917, the increase stands out prominently. Now for detail; for the first six months of the year. Tuberculosis pays no respect to age, and its victims may be found from the cradle to those who have exceeded the allotted span. To illustrate: Our present returns show 6 under 1 year; 8, 1 to 2 years; 7, 2 to 5 years; 21 infantile, or 9.50 per cent, of all deaths from tuberculosis. The remainder—199—comprise all ages from 5 to 79, plus 1, age not given; 90.45 per cent, of deaths from tuberculosis, and taken as a whole—220—show 10.53 per cent, of all deaths. Further: 23.63 per cent, of deaths from tuberculosis occurred among Orientals. It is found that the nativity of decedents total up as follows: British Columbia, 35; Orientals, 52; Italians, 6; U.S.A., 6; Germany and Austria, 5; other Provinces of the Dominion, 37; Norway and Sweden, 7; Great Britain, 42; various countries, 30; total, 220. Of the total, 185 were born outside the Province, and of those born outside 139 had resided in British Columbia for a period exceeding three years. The document containing this information is ready for inspection. In returns of marriages we have from various offices in the Province the following:— Alberni 54 Beaton 125 Ashcroft 26 Fairview 120 Vancouver City 560 North Vancouver City 18 North Vancouver District 3 Point Grey 22 Richmond ■ • • - 1 South Vancouver 47 West Vancouver 3 New Westminster City 70 Burnaby 0 Chilliwack 8 New Westminster (outside) 36 Nanaimo -7 Alert Bay -1 Comox 12 Ladysmith 5 Victoria City 180 Oak Bay u Esquimalt 8 Saanich 14 Cowichan ° Showing a total of 1,368 for six months, as compared with 3,169 for tbe whole of last year a falling-off at the rate of 443 per annum. 8 Geo. 5 Provincial Board of Health. G 231 Discussion on Mr. Miller's Pj*s.per. The Chairman: We have heard this excellent paper. Any one wishing to discuss it, we will be very glad to hear their remarks. Dr. Price: Mr. Chairman, Ladies and Gentlemen,—It affords me great pleasure to congratulate Mr. Munroe Miller on his remarkable and excellent paper on this subject, and especially for the way in which he treated a subject in which I am very much interested; that is, the infantile birth-rate, especially the cause, the prenatal causes, of still-births, of malformation, and of premature birth. These are all, as you know, registrable in this Province. In England, in Ireland, we never register still-births. I think that is a mistake. I think we are doing the right thing in this Province to bring these to the notice of the Registration Department, but Blr. Miller put it in words, well-chosen words which no one can use better, explaining—it is a very difficult subject to touch upon—these prenatal causes of infant mortality. And 1 think this is a subject which requires a very great deal of attention. The idea is prevalent in families that families should not be more than a certain number, and, unfortunately, I know of many cases where there is one child, and the second one is an accident, and there was never a third. Now, in the present state of this country, where every man is wanted—and every girl baby is wanted, too—it is a crime, a crime which is unspeakable, that these things should happen. I am speaking from experience. I come from a country—Ireland—where it is part of the religion of that country that babies should be born into the world; it is part of their religion. In that country I practised for many years; I do not recollect a still-born child in my place, and I have seen hundreds of babies into this world. True, there were instances of premature births, but the number in that country was so small in comparison to British Columbia that the only way I could account for it was that the religion of the people of the country had something to do with the full-time birth of the child. It is a very difficult subject to speak of, but Mr. Miller has put it so well and so clearly that I really need add no more to it, but to congratulate him on the way he put it. But infant mortality is, counting still-birth, counting these other causes, appalling In British Columbia; but it is no more than other countries, when we count natural deaths among infants. I do not think the rate is any more in this country than any other. Real infant mortality of children is not very great. Now I leave that subject, and condole with Mr. Miller upon the careless way in which we medical men—I take the fault to myself—fill up these death certificates. I have the pleasure of calling upon Mr. Miller regularly once a month, and I wish here to express my appreciation of the courtesy with which he always receives me and the wonderful way in which he always has statistics ready, and which at any moment I can get from him, because I report monthly in Victoria the vital statistics of the city. Well, I can't help saying that our death certificates are filled up in a most careless way, and it is certainly annoying to him and very trying to him to have them filled up in this way; and I would suggest taking up his suggestion that medical men, both practitioners and others, should be more careful in the filling-in of the cause of death in these certificates. True, I think the certificate is wrongly ' drawn up. There are three small lines, a space at the bottom of the certificate; one, primary cause; and then, was an operation performed, and then the immediate cause. In case of some diseases I do not till up the two lines. If it is tuberculosis, I simply put tuberculosis down; I do not fill up, as some people do, neurasthenia, or stoppage of breath, or something like that. That is unnecessary. We simply fill in the primary cause. I think there is room for discussion on that; there is room for improvement in the form of the death certificate, and I think that is a question that should be taken up by a meeting of the statistical officers to alter that certificate. I believe strongly in collecting the statistics of the country correctly. Now as regards cancer: I am taking rather a special interest in the number of deaths from cancer which have recently occurred in this country, and I think, from what I gather from statistics, that cancer is running a very close race with tuberculosis, and it is a neck-and-neck race, and I think that we are not studying nearly sufficiently the subject of cancer in its many forms. We are doing good work for tuberculosis, but we are to do that work and we are not to leave the other work undone; and I think there is quite a lot to be done in the study of cancer. It is extraordinary how very prevalent it is becoming. Now, again, about the number of tuberculosis cases, and the reference made to the fewness of cases in Great Britain: Well, I know, having lived in Great Britain, that we are dumping our cases out in this country, and great care should be taken in the examination for the admission G 232 British Columbia 1918 of people into this country. I know when I came I was put into a queue with a lot of others, and I was not very strong at the time, and my wife and children were passed by. Oh, they are all right, no examination whatever of any kind. Well, I know to a certainty within the last fortnight a man who came from England in an advanced state of tuberculosis. How he got through—well, it has been carelessness on the part of the examining officer. I think that is a matter which ought to be taken up. We really do not want British Columbia to be a dumping- place for consumptives. I think that is all I have to say, except to congratulate Mr. Miller on the excellence of his paper. (Applause.) The Chairman: Are there any others who wish to make remarks? If you will permit me to speak from the chair, as time is getting late. I want to congratulate Mr. Miller on many of the things he has spoken of. I very much regret that there is not a larger attendance of the medical men here, because he is speaking words of wisdom on a matter that is most interesting to Medical Health Officers—that of vital statistics. One point particularly attracted my attention; that is the large number of still-births occurring here. In 1916, for instance, there were 119 in the City of Vancouver. I feel certain, however, that a great many cases of still-births occur throughout the Province that are not reported. My early experience in this particular city of ours was that many of the still-born were buried in the back yards, one reason for that being that the funeral expenses would be too great. This matter was taken up, and we arranged that for a nominal fee of $1, on the production of a doctor's certificate, the burial would be taken care of at the cemetery. Since then we have had far more notified to the Department. I regret that births are not notified as they should be. It is impossible for Mr. Miller or any one else to keep the vital statistics of this Province, which are so important to ourselves at the present time, and also to future generations for comparative purposes. I regret that some machinery cannot be evolved to settle this important question, and to bring the people to realize the necessity for reporting births. With regard to the certificates of death: I feel most strongly ou this point. On the form now in use there is a list of diseases which are not supposed to be accepted by the Registrar, and yet which are constantly being certified as the cause of death by the medical men. Personally, I think that the remedy is in the bauds of the Registrar himself. I have a note here of a number of these instances taken from the death certificates, such as convulsions, gastritis, asthma, heart- failure, and so on, which have apparently been accepted at tbe Registrar's office and no prosecution has been undertaken. I deplore this very much. The method we pursue in my department is, when such a case arises, we immediately get in touch with the medical man responsible and get from him the correct cause of death. We cannot correct the death certificate, but we can correct our vital statistics. The medical men are far and away too loose and too careless. I quite agree with Dr. Price in his remarks regarding the form of death certificate, and would like to inform him that this matter was taken up in 1899 and on numerous occasions since 'by the Medical Associations of A'ancouver, New Westminster, and Victoria, and they all agreed on a form. I think it is a very excellent one, but it has never been adopted. I would like to see a different form from the one at present in use. However, that is a matter we can leave in Mr. Miller's hands. Cancer is certainly increasing. Out of a total of 1,097 deaths in 1916, there were S7 deaths from cancer in this city, and I notice from the statistics that they are increasing from year to year. I thank Mr. Miller for what he has brought to our attention to-day. Mr. Miller will reply. Mr. Miller: Ladies and Gentlemen,—It seems to me that I haven't anything to reply. I feel flattered at the reception I have received. As to the form and as to the mode and method adopted by Dr. Underhill,, I see how there happens to be a difference between his reports and mine. 1 take the reports we have received. He calls in a physician for the purpose of the City of A7ancouver and has him correct it the way it ought to be. When I once receive that document I dare not let it out of my hands. I cannot send it back for correction; and if I write to the physician recommeuding him to make a correction on the cause of death, I cannot change the original document, but I must underline in red ink that such-and-such a correction is requested and authorized. You see, the thing becomes difficult; and then, as far as the machinery of the law goes, British Columbia has always been a kind of patriarchal institution 8 Geo. 5 Provincial Board of Health. G 233 and had a great love of the people; under the dominion and control of the Government from October, 1872, to date, as far as I know and believe, there never has been a prosecution undertaken for violation of the registration law. Dr. Young: Mr. Chairman, I am not going to speak in reference to the paper. This winds up the proceedings of the Convention, and I am sorry that the majority of the members are not here to allow me to express my great appreciation of the attendance and the great evidence of the interest which the members of the Convention have taken in the proceedings. I have to thank those who have very kindly prepared and read their papers here. I do not think that any of us who have attended here regret the time that it has taken. The papers have been excellent. They have been prepared by those especially interested in the subject which they have undertaken to deal with. They have presented views modern and up-to-date, and they have contained many very valuable suggestions, which I hope will be acted upon by the profession, and I know will be acted upon by the Department. It is the intention to collect all these papers, together with a report of the discussions that have taken place upon them, and to publish them in the Annual Report of the Department; but they are so good that it is my intention to print them in pamphlet form immediately (Applause), accrediting each to the author, and to add to the paper the discussion; and I hope to have the pleasure shortly to send to the authors a sufficient number for themselves, and also to distribute to the profession in general copies of the proceedings of this Convention. I want further, Mr. Chairman, to be allowed to move a vote of thanks to yourself for the able manner in which you have presided at our meetings, and also personally to thank you for the great interest you have taken, and also the great assistance you have been to me in making this Convention a success. You have shown a great deal of interest, as I know personally, in health matters, and your activity has been a great help, especially when it is manifested in this the largest centre of population in the Province, and an incentive to tbe Provincial Board of Health. I have much pleasure, ladies and gentlemen, in moving a vote of thanks to Dr. Underhill for his presiding at the meeting. (Applause.) Dr. Vrooman: Mr. Chairman, I have great pleasure in seconding Dr. Young's motion of thanks to Dr. Underhill for his able conduct of the meeting. (Dr. Wrinch in the chair.) The Chairman: It has been moved and seconded that a vote of thanks be tendered to Dr. Underhill for the valuable services which he has rendered on the occasion of this Convention. Now, if you are all in favour of that, will you manifest it again, please? (Applause.) The motion was carried unanimously. Dr. Underhill: Ladies and Gentlemen,—I thank you for the kind manner in which you have spoken. I know I have always taken a great interest in this matter of public health. Sometimes I speak rather quickly, too fast, without due consideration to the seriousness of the subjects we are discussing, but if I have occasioned any harm or inconvenience I am sorry for it. Gentlemen, I thank you very kindly for your reception of my little efforts here. VICTORIA, B.C.: Printed by William H. Cullin, Printer to the King's Most Excellent Majesty. 1918. 16