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Title: Report of the Conference on the Medical Services
   in Canada held at Ottawa, December 18, 19, 20, 1924
Author: Conference on the Medical Services in Canada (1924)
Date of first publication: 1925
Edition used as base for this ebook: Ottawa: F. A. Acland,
   Printer to the King's Most Excellent Majesty, 1925
   (first edition)
Date first posted: 24 February 2009
Date last updated: 24 February 2009
Project Gutenberg Canada ebook #268

This ebook was produced by:
Ian Deane, David T. Jones
& the Online Distributed Proofreading Team
at http://www.pgdpcanada.net




CONFERENCE _on the_

MEDICAL SERVICES IN CANADA

_arranged by the_

CANADIAN MEDICAL ASSOCIATION

_and held under the patronage of_

THE HONOURABLE HENRI BELAND, P.C., M.D., M.P.,

Minister of Health for Canada

_in the_

House of Commons, Ottawa

_on_ December _18th, 19th, 20th,_

1924

Alexander Primrose, C.B., M.B., C.M., _Chairman_

T. C. Routley, M.B., _Secretary_

OTTAWA

F. A. ACLAND

PRINTER TO THE KING'S MOST EXCELLENT MAJESTY

1925


REGISTRATION

_December 18, 1924_

_Name                    Address                 Body Represented_

Aikens, Dr. H. W.        Toronto, Ont.           College of P. and S., Ontario.
Amyot, Dr. J. A.         Ottawa, Ont.            Federal Department of Health.
Argue, Dr. J. F.         Ottawa, Ont.            Canadian Medical Association.
Arthur, Dr. R. H.        Sudbury, Ont.           College of P. and S., Ontario.
Austin, Dr. L. J.        Kingston, Ont.          O.M.A., Queen's University.
Bates, Dr. Gordon        Toronto, Ont. .         Canadian Social Hygiene Council.
Bazin, Dr. A. T.         Montreal, Que.          Canadian Medical Association.
Blackader, Dr. A. D.     Montreal, Que.          Canadian Medical Association.
Carder, Dr. L. D.        Vancouver, B.C.         College of P. and S., British Columbia.
Chisholm, Dr. H. A.      Halifax, N.S.           Nova Scotia Health Department.
Clark, Dr. D. A.         Ottawa, Ont.            Federal Department of Health.
Connell, Dr. J. C.       Kingston, Ont.          Queen's University.
Connell, Dr. W. T.       Kingston, Ont.          Queen's University.
Cruikshank, Dr. G. R.    Windsor, Ont.           College of P. and S., Ontario.
Fitzgerald, Dr. J. G.    Toronto Ont.            Dominion Council of Health.
Flatt, Mrs. C. L.        Wakaw, Sask.            Dominion Council of Health.
Gardner, Dr. W. A.       Winnipeg, Man.          Manitoba Medical Association.
Gauvreau, Dr.            Montreal, Que.          College of P. and S., Quebec.
Graham, Dr. Duncan       Toronto, Ont.           University of Toronto.
Grant, Dr. J. G.         Ottawa, Ont.
Guerin, Dr. J. J.        Montreal, Que.          University of Montreal.
Hamilton, Dr. T. G.      Winnipeg, Man.          Canadian Medical Association.
Hattie, Dr. W. H.        Halifax, N.S.           Nova Scotia Medical Society.
Henderson, Dr. V. E.     Toronto, Ont.           Canadian Medical Association.
Hill, Dr. H. W.          London, Ont.            University of Western Ontario.
Houston, Dr. J. C.       Charlottetown, P.E.I.   Prince Edward Island Medical Society.
Irving, Dr. W.           Edmonton, Alta.
Irving, Dr. J. F.        Yorkton, Sask.          College of P. and S., Saskatchewan.
Johnson, Dr. G. R.       Calgary, Alta.          College of P. and S., Alberta.
Jost, Dr. A. C.          Halifax, N.S.           Nova Scotia Health Department.
Kidd, Dr. J. F.          Ottawa, Ont.            Canadian Medical Association.
Laidlaw, Dr. W. A.       Edmonton, Alta.         Alberta Board of Health.
Leask, Dr. J. M.         Moose Jaw, Sask.        Saskatchewan Medical Association.
Low, Dr. David.          Regina, Sask.           Canadian Medical Association.
MacCallum, Dr. J. M.     Toronto, Ont.           Medical Council of Canada.
MacKay, Dr. D. S.        Winnipeg, Man.          University of Manitoba.
MacLaren, Dr. Murray     St. John, N.B.          Canadian Medical Association.
Macleod, Dr. J. J. R.    Toronto, Ont.           University of Toronto.
MacMurchy, Dr. Helen     Ottawa, Ont.            Division of Child Welfare, Dept. of Health.
Martin, Dr. C. F.        Montreal, Que.          McGill University.
McCalman, Dr. D. H.      Winnipeg, Man.          Manitoba Board of Health.
McCullough, Dr. J. W. S. Toronto, Ont.           Department of Health, Ontario.
McDermot, Dr. J. H.      Vancouver, B.C.         British Columbia Medical Association.
McGill, Dr. H. W.        Calgary, Alta.          College of P. and S., Alberta.
McKibbon, Dr. P. S.      London, Ont.            University of Western Ontario.
McLaughlin, Dr. P.       Winchester, Ont.
Melvin, Dr. G. G.        Fredericton, N.B.       Department of Health, New Brunswick.
Merson, Mr. Bert         Toronto, Ont.           Dominion Council of Health.
Noble, Dr. R. T.         Toronto, Ont.           Ontario Medical Association.
Normand, Dr. L. P.       Three Rivers, Que.      Canadian Medical Council.
Ower, Dr. J. J.          Edmonton, Alta.         University of Alberta.
Pelletier, Dr. E.        Montreal, Que.          Service Provincial d'hygiene de Quebec.
Poole, Dr. J. S.         Neepawa, Man.           College of P. and S., Manitoba.
Powell, Dr. R. W.        Ottawa, Ont.            Medical Council of Canada.
Primrose, Dr. A.         Toronto, Ont.           Canadian Medical Association.
Rehfuss, Dr. W. A.       Bridgewater, N.S.       Nova Scotia Medical Association.
Reilly, Dr. W. G.        Montreal, Que.          Canadian Medical Association.
Routley, Dr. F. W.       Toronto, Ont.           Red Cross.
Routley, Dr. T. C.       Toronto, Ont.           Canadian Medical Association.
Seymour, Dr. M. M.       Regina, Sask.           Department of Health, Saskatchewan.
Simpson, Dr. J. C.       Montreal, Que.          McGill University.
Small, Dr. H. B.         Ottawa, Ont.            Canadian Medical Association.
Starr, Dr. F. N. G.      Toronto, Ont.           Canadian Medical Association.
Stephen, Mr. W. F.       Huntingdon, Que.        Dominion Council of Health.
Tessier, Mme. Jules      Quebec, Que.            Dominion Council of Health.
Thornton, Dr. R. S.      Deloraine, Man.         Dominion Medical Council.
Wallace, Dr. W. G.       Ottawa, Ont.
Walker, Dr. S. L.        Halifax, N.S.           Canadian Medical Association.
Wodehouse, Dr. R. E.     Ottawa, Ont.            Canadian Tuberculosis Association.
Wright, Dr. A. H.        Toronto, Ont.           Ontario Board of Health.
Young, Dr. George S.     Toronto, Ont.           Ontario Medical Association.
Young, Dr. H. L.         Victoria, B.C.          British Columbia Board of Health.
Young, Dr. A. M.         Saskatoon, Sask.        College of P. and S., Saskatchewan.




=MEDICAL SERVICES IN CANADA=


The Conference on the Medical Services in Canada, arranged by the
Canadian Medical Association, met at Ottawa on December 18, 1924,
under the chairmanship of Alexander Primrose, C.B., M.B., C.M.

The CHAIRMAN: Gentlemen, it is not necessary for me to indicate the
reasons why this conference is called together. Those you all know,
and the programme is in your hands. Before we begin our formal
meeting, I have a very great deal of pleasure in asking the Hon. Mr.
Graham, Minister of Railways and Canals, and Acting Minister of
Health, to say a few words to us.

Hon. GEORGE P. GRAHAM (Acting Minister of Health): Mr. Chairman,
ladies and gentlemen, I have tried a great many things in my life, but
I never presumed to be a doctor of medicine until this morning. I
could not diagnose a physical disability case, but I do try sometimes
to diagnose the ills of the country, and some people have said that my
prescriptions are not much good. I look upon the country's ills very
much as you gentlemen do upon a physical disability; it is not so much
medicine as care that is necessary. All the ills that are ascribed to
the country are natural to all countries after the war, and the duty
of Government and of Parliament is to endeavour to nurse the patient
well, and give nature a chance to restore it.

I am glad to welcome you here. I regret that the Hon. Dr. Bland is
not in the city at the present time, but on your behalf, and on behalf
of the country, he has been doing excellent work at Geneva, and as you
know, has been highly honoured there in being made chairman of the
leading body in the world for the suppression of the opium traffic.
That is a work in which you are interested, and it is one in which Dr.
Bland is representing Canada and is taking a very prominent part
there. I am sure he will regret not being here this morning.

Of the advances made in medical science you know much more than I do.
Sometimes it is said that the health bodies, as I might call them, or
the health departments of the various governments in the world, are
running away from the profession and the profession is trying to catch
up. I do not know how that may be, but this I do know, that your
profession is perhaps the noblest of all in that it gets right at the
hearts of the people and does what no other profession can do in
meeting the wants of humanity, and after all that is what makes life
worth living, that we may be of some assistance each to the other so
that when we go those with whom we have been associated will believe
that the world was better because we were allowed to come into it.

I welcome you all heartily, and trust that the effect of your
deliberations may be such as, if I may say it, to bring the medical
profession in all parts of the Dominion closer together if possible,
for the promotion of that which you all have at heart, not only the
further progress and enlargement of the usefulness of medical science,
but the good of mankind in general. May I add that I trust the
atmosphere that you will leave around the Parliament Buildings will be
such as to ensure good health and long life to the Government.

The CHAIRMAN: I am sure we are very much indebted to the Minister for
his words of welcome and inspiration. We regret that the Minister of
Health is not present with us, but we are glad to hear from Hon. Mr.
Graham that he is filling such an important function in the councils
of the world at Geneva.

I have now pleasure in calling upon the President of the Canadian
Medical Association, Dr. Kidd.

Dr. J. FRANKLIN KIDD: Mr. Chairman, ladies and gentlemen, as President
of the Canadian Medical Association, under whose auspices you are
assembled, it affords me great pleasure to welcome this large group
representing medicine in the broadest sense of the term from the nine
provinces of the Dominion of Canada.

This is the first time in the history of Canada that a meeting of this
character has been held, and it would seem fitting that for this first
national meeting of the Medical Services in Canada you should
foregather in the capital of Canada, and under the distinguished
patronage of the Acting Minister of Health. I understand that we have
with us to-day representatives from the federal Department of Health,
the provincial Departments of Health, Medical Colleges, the Dominion
Medical Council, and provincial Councils, the Canadian Medical
Association, and the provincial Medical Associations. I understand
that for some years it has been customary for some of these groups to
meet nationally, but never before have they met in a congress of this
character.

In initiating this unique gathering the Canadian Medical Association
is actuated by one motive, namely, the development of an
ever-increasing co-operation on the part of all those charged with
the medical responsibilities of this great Dominion, in the hope and
to the end that such co-operation may bring about cohesion, foster
harmony, and develop a higher type of service in keeping with the best
traditions of our noble art.

It is not my purpose to go into details with regard to the programme,
as Dr. Primrose, our chairman, and also chairman of this conference
will no doubt deal with that matter presently. A year ago, in company
with Dr. Routley, our general secretary, it was my privilege and
pleasure to attend a medical conference in the city of Winnipeg, at
which were gathered representatives from the four western provinces.
Out of that conference there developed a plan of co-operation which
has worked during the last summer with most excellent results. I refer
to the four splendid medical conventions which were held in sequence
at Winnipeg, Vancouver, Edmonton and Moose Jaw, attended by over
twelve hundred practitioners, and addressed by a travelling group of
speakers. It was only because the provinces referred to worked
together strongly that these splendid results were made possible, and
with this knowledge in mind it seems to me that this larger
conference, representing as it does the whole Dominion of Canada,
should be productive of the greatest possible benefit to the public
and ourselves.

On behalf of the Canadian Medical Association I desire to take this
opportunity of thanking the Hon. George P. Graham, Acting Minister of
Health, for placing at our disposal this splendid meeting room, and
for the various services which have been so cheerfully performed by
members of the staff of the Health Department in the way of assistance
in making this meeting possible. As president of this association, and
as a resident practitioner in this city, it gives me very great
pleasure indeed to welcome you all to the city of Ottawa.

I am sure you are all as glad as I am that we have to-day with us the
President-Elect of the Canadian Medical Association, Dr. David Low, of
Regina. I will now introduce Dr. Low and ask him to address us.

Dr. DAVID LOW: Mr. Chairman, ladies and gentlemen, I find myself in a
somewhat difficult position this morning, facing such a large
gathering from all parts of the Dominion of the most prominent members
of the profession. I realize that I myself am only an ordinary general
practitioner from a small town in the west, but it gives me very great
pleasure to be here and meet with you all, particularly so as to me it
appears that this gathering is in one sense a culmination, and in
another sense the opening of the gate to further progress towards
unity, and the bringing about of closer co-operation between the
profession in the different parts of this great country of ours.

As Dr. Kidd has mentioned, the medical men of the four western
provinces have held national meetings, and there is no doubt whatever
that great good has come from these conventions. You may not all
agree, but it appeared to some of us on the outskirts looking in, and
not actively engaged in the very heart of the profession, that there
might be a possibility of some branches just getting a little ahead of
the others, and we thought it would be a good thing for us all to get
together and compare notes, so that we might go forward shoulder to
shoulder without any possibility of a break in the ranks, and to
eliminate any possible weak spots. It therefore gives me exceedingly
great pleasure to be present at this meeting. I think we can
confidently look forward to results that will probably be greater than
any one conceived of at the inception of this Conference. I expect
that it will only be the beginning of such meetings, which will be
carried on each year in the future, and that we shall have as a result
closer co-operation and less possibility of divergencies of opinion
creeping in. I hope that the profession from Halifax to Vancouver will
show a united front not only in advancing the science of medicine, but
in developing our usefulness to the public at large.

The CHAIRMAN: I am glad we have heard from the President of the
Canadian Medical Association and from the President-Elect. I think
they have sounded the proper note for this conference when they
suggest that the main thing we have in view is to unify the forces of
the profession in Canada so that we may proceed with a common purpose
and common ideals to great achievement. It is only by such unity, I
think, that we can accomplish such a purpose. We are very much obliged
to these two gentlemen, representing our national institution, for
having addressed us this morning.

Before proceeding to the more formal work of the conference, I want to
say that the press is present here to-day, and it is for you gentlemen
to decide whether you wish the press present or not. It seems to me
that at a national conference of this character we should welcome the
press, but I want to know the pleasure of the meeting. Is it your
pleasure that the press should be present? As there is no objection,
we are glad to have the press representatives with us this morning.



ADDRESS BY ALEXANDER PRIMROSE, C.B., M.B., C.M., EDIN.

Dr. PRIMROSE: At the meeting of the Canadian Medical Association held
in Ottawa in June, 1924, it was determined to convene a conference in
Ottawa for the purpose of discussing matters of interest common to all
sections of the medical profession in this country. The various
activities of the public health service; medical education; the role
of the licensing bodies, the provincial licensing boards in their
relation to the Dominion Medical Council, and the relation of all such
bodies to the teaching universities, on the one hand, and the
profession on the other; health Insurance; procedure in our law courts
in the matter of expert evidence; these and other subjects may be
discussed in the light of experience gained by different groups of
medical practitioners from all parts of our vast Dominion. It seemed
fitting that the Canadian Medical Association, which represents all
sections of our country from the Atlantic to the Pacific, should
inaugurate this movement; a conference so widely representative is
capable of accomplishing much good. In Canada, where the large centres
of population are so widely separated, we are apt to lack
co-ordination in effort; we get self-centred, and we fail to
understand that many of the problems which confront us are national
and not merely provincial or sectional. This conference is convened
for the purpose of uniting our forces. Instead of individual units,
each seeking their own selfish interests, we hope to combine our
forces and to present a solid front which will be effective in our
determination to secure the highest ideals.

State control of public health and the enactment of laws for the
prevention of disease are entirely of modern development. By the
common law of England, "the only remedy for any act or omission
dangerous to health was an action for damages or an indictment for
nuisance." Following the plague, an Act was passed in 1603 making it a
capital offence for an infected person to go abroad after being
commanded by the proper authorities to keep his house. Then again,
after the great fire, the Act for the rebuilding of London (1668) made
provision for the height of houses, the breadth of streets, the
construction of sewers, and the prohibition of noisome trades. Later,
in the most important towns in England, local Acts provided the
authorities with power to control public health. The first public
health Act embracing the whole of England was passed in 1849; this did
not include London which had its own health laws and regulations. The
Act of 1858 extended the powers of the general board of health which
had been created by the Act of 1848. The present controlling authority
in England is the "Local Government Board," which was created by the
Act of 1871.

In the latter part of the nineteenth century the economic value to the
State of the health of the community was recognized in a manner which
had not hitherto obtained. That famous British statesman Benjamin
Disraeli, Earl of Beaconsfield, who was noted for his power to
epitomize in concise and forcible language the importance of public
questions of the day, said in a speech at Battersea Park in June,
1877,

     "The health of the people is really the foundation upon
     which all their happiness and all their powers as a
     State depend."

Numerous Acts dealing with public health have been passed in England
since that date. It might be interesting, had one time and
opportunity, to summarize these and to observe how various laws,
bearing directly or indirectly on the health of the public, have been
enacted in England, so that hardly any phase of human activity has
been overlooked in the effort to regulate these activities in such
fashion that they should not become a menace to health and for the
prevention of disease. As an example of the minute detail observed in
these regulations, one might cite "the cleansing of persons" Act of
1897, which "enables local authorities to permit persons who apply to
them, on the ground that they are infected with vermin, to have the
gratuitous use of cleansing apparatus." Then we have Acts regarding
vaccination, the control of various infectious diseases, the
Children's Act of 1908, Acts regarding factories, work shops, etc.,
etc., all of which are effective in preserving the health of the
community.

The principal Acts which are at present operative in England have been
summarized by a recent authority as follows: (1) the Education Act
with the provision for meals Act, etc. (2) The Old-Age Pensions Acts.
(3) The National Health Insurance Acts. (4) The Public Health Act; (a)
as to hospitals and the treatment of disease, (b) as to maternity and
child welfare. (5) War pensions and Ministry of Pensions Acts. (6)
Housing of the working class Acts. (7) Acts relating to the relief of
the Poor. (8) Unemployed Workmen's Act. (9) Unemployed Insurance Act.

England was the pioneer of all the nations in instituting effective
legislation for the maintenance of public health and the prevention of
disease.

In the United States of America the care of the public health has
secured an ever increasing amount of attention in recent years from
both Federal and State Governments. The federal public health service
is a well organized body with wide powers; it has been freed from
"political restrictions and petty annoyances" so that it is not
hampered in rendering effective service to the State. As an
illustration one might mention work accomplished in preserving the
health of children. To quote from a recent article on this subject one
may mention that "as early as 1892 New York City provided for the
inspection by health officers of school children, and by 1920
practically every city had organized some form of health examination
for all pupils attending public schools." The work has extended, and
in the late years qualified medical examiners have been employed to
examine the eyes, throat, teeth, etc., and treatment is often given at
the public expense where necessary. Schools in the open air have been
opened for tuberculous children and means have been employed to secure
fresh air, and suitable nourishment for such children. The extent of
this work may be appreciated by the statement that "in 1919 cities
having each a population of more than 30,000 expended an aggregate of
$1,849,624 on medical work for school children, and an additional
amount of $908,742 on other child conservation work, such as the
employment of trained nurses to visit mothers in congested districts,
and the establishment of infant welfare stations where mothers could
obtain medical advice and free treatment for their babies."

In Canada we may congratulate ourselves that we are not one whit
behind other countries in the solution of such questions. Our
activities, federal, provincial and municipal, will compare favourably
with those of other countries, and indeed in some respects we are in
advance of others in our effective management of matters concerning
public health.

In the various problems which we are to discuss in this Conference,
including public health and the different ramifications of that
important subject, we are confronted with conditions peculiar to the
country in which we live. The extent of this Dominion, with widely
scattered centres of population, the nature of our climate and in many
instances the divergent interests of the people in different parts of
Canada, make it difficult to combine effort and to establish effective
measures which will have the whole hearted support of the entire
population. The supreme purpose of the present Congress is to secure
the co-operation of the entire country: we hope to be of assistance to
the federal authorities, to strengthen their hands and inasmuch as we
represent the whole of Canada from the Atlantic to the Pacific, we
trust we may by combined effort provide something of real service in
attaining ideals of the highest order in dealing with these questions
for the betterment of our people.

It is difficult to overestimate the revolutionary effect of modern
methods of transportation on our national life. Quick transportation
by sea and land, more recently in the air, with added comfort in
travel, has induced an ever increasing number of people to go abroad.
A continuous stream of travellers pass from one country to another.
Not only so, but there is a constant interchange of commodities
including food stuffs and the transportation of cattle. The most
potent factor to be considered, however, is produced by the movement
of immigrants. It is no longer possible for any nation to remain
isolated and self-contained: the destiny of each country is inevitably
affected by its relations to other countries. This fact was
demonstrated and forced upon the attention of the nations of the world
during the great war and its aftermath. Among the many points of
contact thus established, none have demanded greater attention than
those which affect health. The preservation of public health and the
prevention of disease has thus become an international problem.

Embodied in the Treaty of Versailles as an article of the Covenant of
the League of Nations are these words: "Subject to, and in accordance
with, the provision of international convention at present sitting, or
hereafter to be agreed upon, the members of the league will endeavour
to take steps in matters of international concern for the prevention
and control of disease."

The Assembly of the League of Nations at its first meeting in Geneva
in December, 1920, in accordance with the responsibilities placed upon
it by the various Treaties of Peace, established a permanent
international health organization as an important part of the
activities of the league.

The health organization of the League of Nations as at present
constituted is most comprehensive in its scope and activities. It is
well for us in Canada to become familiar with its work and the method
of its organization.

The central executive body is called the Health Committee, composed of
sixteen members, namely, the Chairman of the Advisory Council, nine
members chosen by the Advisory Council, and six members appointed by
the Council of the League after consultation with the Health
Committee. Four additional members may be appointed by the Council.
The appointments extend over a period of three years.



MEMBERS

Dr. Th. Madsen, President, Director of the State Serum Institute, Copenhagen.
M. O. Velgne, Vice-President, Director-General of the Health Department of
    the Ministry of the Interior and of Health, Brussels.
Sir George Buchanan, C.B., M.D., Vice-President, Senior Medical Officer of
    the Ministry of Health, London.
Surgeon-General, H. S. Cumming, Vice-President, Director-General of the
    United States Public Health Service, Washington.
Professor Leon Bernard, Professor of Hygiene of the Faculty of Medicine,
    University of Paris.
Dr. H. Carriere, Director of the Federal Health Department, Berne.
Dr. Carlos Chagas, Director of the Instuto Osweldo Cruz, Rio de Janeiro.
Dr. Chodzko, Former Polish Minister of Health.
Dr. A. Granville, President of the Conseil Sanitaire Maritime et
    Quarantinaire, Alexandria.
Dr. Alice Hamilton, Associate Professor of Industrial Hygiene, Harvard
    Medical School, Boston.
Dr. Jitta, President of the Health Council of the Netherlands, The Hague.
Professor Ricardo Jorge, Director-General of Public Health, Lisbon.
Dr. A. Lutrario, Director-General of the Health Department of the Ministry
    of the Interior, Rome.
Dr. P. Mimbela, Professor of the Faculty of Medicine, Lima.
Dr. Nocht, Director of the Institute of Tropical Diseases, Hamburg.
Professor Donato Ottolenghi, Professor of Hygiene of the Royal
    University, Bologna.
Dr. L. Raynaud, Inspecteur-General des Services d'hygiene d'Algerie,
    Algiers.
Dr. Tsurumi, Japanese League of Nations Office, Paris.
Dr. Rajchman, The Medical Director acting as Secretary of the Committee.


The Health Committee directs through a Medical Director the health
work of the League of Nations.

We had the great pleasure of meeting the chairman, Dr. Madsen, in
Toronto recently.[1] He is a Dane: Director of the State Serum
Institute in Copenhagen, an organization which has a world-wide
reputation for its valuable contributions to scientific medicine.

There are a large number of sub-committees which have already
accomplished much even in the few years of the committees' existence.
Some of these we may refer to as an example of the type of work
accomplished.



THE EPIDEMIOLOGICAL INTELLIGENCE SERVICE

The Epidemiological Intelligence Service of the League of Nations
Health Section, organized with the financial assistance of the
Rockefeller Foundation, gathers information on the prevalence of
infectious diseases throughout the world and endeavours to promote
collaboration between the National Statistical Services in order to
co-ordinate their efforts.

Weekly or bi-monthly reports are issued from seventy-six countries or
colonies with mortality and public health statistics. Statistical
experts from various countries have been invited to Geneva. The
Central Office is in Geneva, and a projected branch office in the Far
East. Reports on health organizations in various countries have been
published, and others are in preparation. Current reports have been
published on such subjects as plague, cholera, yellow fever, typhus,
relapsing fever, smallpox, enteric fever, cerebrospinal meningitis,
acute poliomyelitis, encephalitis lethargica, influenza, scarlet fever
and diphtheria. Then published every month in a form enabling
comparison with previous periods, are data for malaria, dysentery,
measles, trachoma, and other infectious diseases are presented when
warranted by their prevalence.

[Footnote 1: The details of the activities of the Health committee of
the League of Nations were mainly obtained from charts left by Dr.
Madsen, now in the possession of Dr. J. G. Fitzgerald of Toronto.]

For the first time official and contemporary records of epidemic
movements in the greater part of the world are concentrated in easily
accessible form.


_Standardization of Sera, Serological Tests and Biological Products_

On the proposal of Dr. Th. Madsen the provisional Health Committee
initiated joint investigation of the principal medical research
institutes of the world with the view of obtaining an agreement on the
standards of potency of Therapeutic Sera.

The London Conference of December, 1921, fixed the general programme
of laboratory investigations. The Danish State Serum Institute,
Copenhagen, is acting for the purpose of this investigation as the
Central Laboratory.

There was a special meeting at Geneva in September, 1922, to consider
the agreement regarding the International Unit of Diphtheria
Anti-toxin.

A Paris Conference in November, 1922, considered completed
investigations re diphtheria anti-toxin and arranged that states might
apply to the institute in Copenhagen for the retesting of their
diphtheria standards gauged in accordance with the accepted
international standard.



PERMANENT STANDARDS COMMITTEE

Dr. Th. Madsen, Chairman, Director of State Serological Institute,
    Copenhagen.
Dr. McCoy, Director of the Hygienic Laboratory, Washington, D.C.
Professor Calmette, Deputy Director of the Pasteur Institute, Paris.
Dr. H. H. Dale, Director of the National Medical Research Institute,
    London.
Professor Nocht, Director of the Institute of Tropical and Experimental
    Medicine, Hamburg.
Dr. L. Rajchman, Secretary, Medical Director, Health Section, League of
    Nations.
Director of Research, Dr. Th. Madsen.
Director of Biological Research, Dr. H. H. Dale.


_Research in the Sero-Diagnosis of Syphilis._--Simultaneously in
laboratories in Vienna, Brussels, Heidelburg, London and Warsaw.


_Standardization of Biological Products._--During the International
Congress of Physiology at Edinburgh, July, 1923, a technical
conference convened by the Health Committee of the League of Nations
was held. Dr. Dale was elected Director of Research.


_Research on the Standardization of the following Products_ is being
carried on: Digitalis extract, Pituitary extract, Thyroid extract,
Insulin, Ergot, and Arsenobenzol.


_Standardization of Anti-Dysentery Serum_ is being carried on in
London, Paris, Warsaw, Basle, Moscow and Tokio.


_Standardization of anti-tetanic serum_ is being carried on in Paris,
Prague, Washington, and Frankfurt.


_Standardization of anti-pneumococcus serum_ is being carried on in
London, Paris, New York, and Berlin.


_Standardization of anti-meningococcus serum_ is being carried on in
London, Paris, New York, and Berlin.

A number of problems demanded solution in Eastern Europe. An
investigation was made regarding typhus and relapsing fever in Eastern
Europe.

An epidemic of typhus and relapsing fever of unparalleled severity
visited Eastern Europe in 1919-20. In Russia there were 900,000 cases
of typhus and 375,000 cases of relapsing fever.

It is noteworthy that no serious extension of the disease farther
westward took place. The population in Russia in 1920 was
110,000,000.

In Poland in 1919 there were 34,000 cases of typhus.

The general mortality in Leningrad in 1919 rose to 80.7 per thousand,
and in Moscow 40.5 per thousand.

_Asiatic cholera in Eastern Europe_ has also been considered.


In 1848 there were 1,743,000 cases in Russia.
In 1892 there were 620,000 cases in Russia.
In 1921 there were 180,000 cases in Russia.


Anti-choleric vaccinations were performed by the Russian Health
Administration in 1922.


_Post-war Refugee Problems in Eastern Europe._

The number of returning emigrants and prisoners of war who passed
westward across the Russo-Polish frontier during the four years
1919-22 exceeded three millions.

The mass movements of the population occasioned by the famine in
Russia were of great importance in spreading infections of louseborne
and other diseases.


_Refugee Problems in Greece._

At the advance of the Turkish armies in the autumn of 1922, more than
one million of the Greek population of Asia Minor and Eastern Thrace
found a refuge in Greece. The continuous movements of the refugees and
the unsanitary conditions under which they lived were favourable to
the spread of epidemic diseases of many kinds and constituted a
serious menace to the resident population of Greece as well as to the
neighbouring countries.

Total number of refugees registered for assistance in May, 1923,
920,000.

Population of Greece, 4,970,000.

The epidemic diseases among refugees in 1922-23 included plague,
smallpox, typhus, typhoid fever and dysentery.

The manner in which some of these problems have been tackled is
evidenced by the activities of the Epidemic Commission.

The commission was created by the League of Nations in May, 1920, to
assist the countries of Eastern Europe in their campaign against
devastating epidemics of typhus fever and other communicable diseases,
and an appeal for funds was issued.

Contributions were received from the Governments of Albania, Austria,
Belgium, Bulgaria, Canada, China, Czecho-Slovakia, Denmark, Finland,
France, Great Britain, Greece, Holland, Japan, Norway, Persia, Peru,
Siam, Sweden, Switzerland, and the League of Red Cross Societies. The
funds subscribed amounted to $800,000.

A subvention of the League of Red Cross Societies enabled the Epidemic
Commission in collaboration with the Russian Soviet Health Services
and the Polish Health Service to organize in Warsaw, Moscow, and
Kherkov special courses for the training of public health officials in
modern methods of combating epidemics.


_Activities in Greece in 1923._

A vaccination campaign was carried on among refugees and the civil
population. Total number performed:--

Tetra (typhoid, para-typhoid, cholera)  1,170,461
Smallpox                                1,238,889
Anti-plague                                93,243
Anti-dysenteric                            28,880

Medical sanitary stores and laboratory equipment have been supplied to
the Russian Health Administration to assist in the anti-epidemic
campaign.

A survey of the health conditions of Persia is being undertaken at the
request of the Persian Government.

It is hoped to co-operate with the local authorities in carrying out a
plague investigation in the Russian Kirghiz Republic, and an
epidemiological inquiry into typhus fever and cholera in Ukraina.


_Activities in Eastern Europe, 1920-23._

Hospitals constructed by the Epidemic Commission.
Hospitals aided by the Epidemic Commission.
Newly erected bath-houses and delousing establishments.
Bath-houses and delousing establishments partly equipped.
Sanitary installation of quarantine stations.
Installation and equipment of a quarantine station at the port of
    Libau (Latvia).


_The International Incomparability of Mortality Statistics._

The international list of causes of death prepared by the late Dr.
Jacques Bertillon in 1886, and revised by international agreements in
1900, 1909, and 1920, constitutes the first practical advance towards
international comparability of vital statistics. It is used in full
detail only in a few signatory countries, and the utility of the
statistics is further impaired by the absence of uniformity in
registration methods, medical definitions and statistical procedure.

The gathering of medical statistics has advanced but slowly and with
little international co-ordination, so that the quality and coherence
of the data no longer correspond to the highly developed methods of
statistical research. Recognizing this fundamental weakness of
medico-statistical work, the epidemiological intelligence service was
undertaken:--

     1. To study, through groups of experts, the
     incomparability of mortality and notifiable disease
     statistics viewed internationally.

     2. To publish hand books on the vital statistics of
     various countries.

     3. To organize groups of medical statisticians to
     collectively study statistical procedures in various
     countries.

     Gives examples such as: The fatal issue of an
     appendicitis is largely conditioned by the occurrence
     of peritonitis; the latter cause is accepted as
     sufficient in Italy and the Netherlands, while the
     primary cause is demanded in the United States and in
     England. The statistics are therefore not comparable.

Many of these points could be regulated by international agreement, but
uniformity of procedure is, as yet, entirely lacking.


_Interchange of Health Officers._

Aided by subventions received from the International Health Board of
the Rockefeller Foundation, the League of Nations Health Organization
has arranged a series of interchanges of health officers of
forty-three countries, who have thus been able to study sanitary
progress and administration in countries other than their own,
accordingly promoting efficiency and international solidarity between
health administrations.

From October, 1922, up to June, 1924, thirty-nine countries have taken
part in interchanges, and some 230 individuals have profited by them.

Tuberculosis Specialists have interchanged, also School of Hygiene
Specialists.

_1922._--The first general interchange commenced in October 9th, 1922,
with 23 Health Officers from 8 countries in Belgium and Italy.

_1923._--A second interchange in England and Austria took place in
which 29 participated; Malaria experts interchanged. In 1923, 12
senior Bacteriologists from Belgium, Denmark, England, Germany,
Italy, Kingdom S. C. A., Poland and U.S.A. have been given grants to
enable them to study at one or several Institutes of Public Health in
foreign countries the laboratory methods and the administration of the
Institute.

Third general interchange in the United States. On the
Surgeon-General's invitation 24 health officers from 18 countries
studied the public health practice of the United States. For two weeks
they remained with the Federal Health Service in Washington. Divided
into three groups, they visited during ten weeks, 3 southern and 3
northern States, studying state and local health activities.

_1924._--Specialists interchange.

4th General interchange in Great Britain.

5th General interchange in Holland and Denmark.

6th General interchange in Switzerland.

Seventy-eight officials from 36 countries participated in the three
general interchanges.

Statisticians from Brazil, Bulgaria, Czechoslovakia, Hungary, Italy,
Norway, Poland, Russia and the Serbo Croat Slovene Kingdom met in
October 1923, at Geneva, for six weeks collective study of vital
statistics. They visited next the statistical offices in Berne,
Interlaken (Switzerland), Paris, The Hague and London, and the
National Research Institute in London.

_1925._--Provisional Programme:--

Countries to be visited: Great Britain, Kingdom S.C.A. and Japan.

Interchange in the Far East limited to a few post medical officers.

Interchange of specialists in Child Welfare in France, Russia, Sweden,
etc.


_Sanitary Conventions._

As a result of the European Sanitary Conference held in Warsaw, March
1922, the following bi-lateral sanitary conventions and anti-epidemic
agreements have been conducted:--

Bulgaria--Kingdom of the Serbs, Croats and Slovenes.
Czechoslovakia--Poland.
Germany--Poland.
Latvia--Poland.
Latvia--Russia.
Poland--Roumania.
Poland--Russia.
Austria--Kingdom of the Serbs, Croats and Slovenes.

In connection with the committee for communication and transit of the
League of Nations, the Health Committee has prepared a model
convention for the sanitary control of traffic on Waterways.

Inquiry in the Near East in 1922. A commission has examined the
arrangements for the prevention of transmission of epidemic disease.

There are many other activities carried on by special sub-committees
appointed to deal with special problems. These may be enumerated as
follows:

Sub-committee on sanitary control of traffic and waterways.

Sub-committee on legitimate requirements of raw opium and its
derivatives.

Sub-committee to study the health chapters of reports of the mandatory
powers on the administration of the territories under the League of
Nations mandates.

Sub-committee on anthrax.

Sub-committee on tropical diseases.

Sub-committee for the study of the cancer problem.

Sub-committee for the study of the malaria problem.

Sub-committee on the training of sanatarians in public health.

These various committees work in collaboration with the International
Labour Office, the International Red Cross organizations, and other
advisory and technical committees of the League of Nations.

It will thus be seen what a colossal amount of work is being
undertaken by the Health Committee of the League of Nations.

Individual members of our Canadian profession have been active in
International health work. In the summer of 1923 the late Dr. C. K.
Clarke, Professor of Psychiatry in the University of Toronto,
delivered the Maudsley lectures in England, and aroused great interest
among the health authorities of Great Britain by his fearless and able
discussion of the question of the emigration of the mental defective.
The public and professional Press of that country paid high tribute to
the manner in which he handled the subject, and approved of the
helpful suggestions he made.


_The International Health Board of the Rockefeller Foundation._

Another of the International Health organizations of recent origin is
that which has been inaugurated by the Rockefeller Foundation. The
International Health Board of that Foundation has already accomplished
much for the benefit of humanity. A vast amount of capital has been
invested for international service. By a munificent bequest they have
made it possible to establish in London what is known as the London
School of Hygiene and Tropical Medicine, an institution which is truly
international in its aim. It is inaugurated under the able direction
of Dr. Andrew Balfour, and is unique in its organization, equipment
and objective. More recently the Rockefeller Foundation through its
International Health Board has made provision for the establishment of
a School of Hygiene in Canada.

On May 20, 1924, the International Health Board of the Rockefeller
Foundation approved of a proposal to assist financially in the
creating and endowment of a School of Hygiene in the University of
Toronto; and the following day the Rockefeller Foundation pledged
$650,000 to the governors of the University of Toronto for that
purpose. The governors of the university have accepted the proposals,
and the above-mentioned sum will be utilized to provide a building to
cost not more than $400,000; the remaining $250,000 will be used for
the endowment of the school. While final details of organization
remain to be perfected, the school will include the Departments of
Hygiene and Preventive Medicine and Public Health Nursing, and the
Connaught Laboratories. The operating or public-service divisions
(namely, the anti-toxin and insulin units) of the Connaught
Laboratories will be merged to constitute a public-service section of
the school.


_A Summary of the Activities of the International Health Board of the
Rockefeller Foundation for 1923_ is as follows:--


The creation of Departments of Rural Health Organizations:
    In the United States and other countries

Hookworm diseases in South America, West Indies, Central America, China
and the Far East.

Yellow Fever--Victories over such in South America, Central America and
Mexico. It has been eradicated in many communities.

The board co-operated with State Services, not only in the United States,
but in Australia, Philippine Islands and Czechoslovakia.

Co-operation with the League of Nations.
    Interchange of public health personnel.
    Epidemiological Intelligence Service.

Tuberculosis in France--Public health nursing in France, Philippine
Islands and Brazil.

Public Health Laboratories in Honduras, Costa Rica, Nicaragua, Salvador,
Guatemala and Manilla.

Malaria--in United States.

The pioneer work of the International Health Board in malaria control
began in 1916 in tropical areas--Nicaragua, Palestine, Philippine Islands
and Brazil.

Public health education in Sao Paulo, Brazil--Institute of Hygiene of the
Faculty of Medicine.

Prague--Institute of Hygiene.

Warsaw, Poland--School of Hygiene.

London--London School of Hygiene and Tropical Medicine.


_Fellowships._

For the year 1923 fellowships were provided for 130 men and women in
22 countries:--


Australia       4  France         2  Peru            1
Austria         3  Great Britain  1  Philippines     1
Brazil         13  Hungary        7  Poland         11
Canada          7  India          5  Salvador        1
China           2  Java           1  Siam            2
Colombia        1  Mauritius      1  Spain           3
Czechoslovakia 13  Mexico         1  United States  42
                   Netherlands    3


The year 1923 has seen the entry of ex-fellows into important public
health positions in many countries.

In two countries, men who have studied on fellowships from the board now
hold the position of Chief Health Officer.


_Publications._

In 1923 many contributions to medical and public health literature
have been made by staff members and others directly associated with
projects in which the board participated.


_Canadian Activities._

[Several courses regarding matters of public...] health have been
available to graduates in medicine. These courses extended over one
winter session of eight months and one summer session of three months.
After passing a satisfactory examination the candidate received the
Diploma of Public Health. These courses have undoubtedly served a
useful purpose in the past, but adequate provision has not been made
for the complete training of the specialist. We require better
equipment and a special staff to meet the demand which is now made
upon us. We congratulate ourselves that through the generosity of the
Rockefeller Foundation a school is about to be established in Canada
where facilities unsurpassed will be available for those who desire to
take an intensive course of special study leading to a degree in
public health. It is difficult to overestimate the value of this
recent addition to our education institutions; it is a development of
national importance, of which we in Canada may well be proud.


_Schools for the Training of Specialists in Public Health._

We have already noted certain schools endowed by the Rockefeller
Foundation, in Prague, Warsaw and London. We may refer to two other
schools endowed by the foundation which are successfully accomplishing
their object. _The Johns Hopkins University School of Hygiene and
Public Health_: this was opened in October, 1918, with Dr. William H.
Welch as Director; Dr. Wm. H. Howell assisting in the work of
organization.

The school which was established in Baltimore by the Rockefeller
Foundation instituted certain courses:--


1. A course leading to the Degree of Doctor of Public Health (two years).

2. A course leading to the Degree of Doctor of Science in Hygiene (three
years).

3. A course leading to a certificate in Public Health (one year).

4. A course leading to the Degree of Bachelor of Science and Hygiene
(two years).

5. Intensive course for Public Health Officers (three months).

6. Intensive course in Medical Zoology (three weeks).


_The Harvard School of Public Health_

For many years Harvard University has shown a very considerable amount
of activity in Public Health work. In 1909 a Department of Preventive
Medicine and Hygiene was established. The Degree of Doctor of Public
Health was first conferred in 1911. In the same year a Department of
Sanitary Engineering was inaugurated. In 1913 a Department of Tropical
Medicine was formed, and in 1918 a Division of Industrial Hygiene with
clinical and laboratory facilities was organized. There were other
activities jointly with the Massachusetts Institute of Technology.
Thus a substantial nucleus was formed in the university for the
establishment of a School of Public Health of larger scope. This was
founded in 1921 and endowed by the Rockefeller Foundation.

It constitutes one of the most comprehensive and complete schools in
existence, where all the varied problems of public health may be
studied effectively.

Another well-established school on this continent is the School of
Hygiene and Public Health in connection with the University of
Pennsylvania at Philadelphia. It is an independent institution in that
regard.

Apart from the training of the specialist, we must not overlook the
education of the general practitioner in matters of public health. No
matter how efficient the medical health officer may be, he must ever
be dependent upon the intelligent co-operation of the general
practitioner. More particularly would we emphasize the importance of
providing for preventive medicine, in the many phases of that subject,
as a part of the curriculum in the under-graduate course in medicine.
It is incumbent upon our Canadian universities to provide adequately
for special study in a subject, which, of recent years, has become of
ever-increasing importance as a progressive branch of medical science.

In recent years an increasing amount of attention has been paid to
_the education of the public_ regarding matters concerning public
health. This has been carried on through various agencies. One might
instance as an example of municipal activity, the excellent bulletin
published monthly by Dr. Hastings, the Chief Medical Health Officer of
the city of Toronto. This bulletin is issued to every ratepayer and
discusses in simple language the best methods of preventing disease.
It also contains suggestions for the care of the sick. Bulletins of a
somewhat similar type are issued by the federal and provincial health
authorities, either to physicians or to the lay public. The Bureau of
Health and Public Instruction of the American Medical Association
issues a magazine, "Hygeia," which first appeared in April, 1923. It
is an attempt to educate the American people on matters of health and
disease. Other methods are adopted for the purpose of reaching the
public, such as health expositions, and broadcasting of talks on
health by radio. Certain other organizations pay special heed to this
type of publicity, such as the Canadian Social Hygiene Council in
their effort to combat venereal disease, and the Anti-Tuberculosis
League. The American Society for the Control of Cancer is in my
opinion accomplishing good results both in the United States and
Canada. An enormous amount of effort has been expended in the hope of
solving the cancer problem, its etiology and effective treatment. The
only practical result of clinical observation is to establish the fact
that cancer is a curable disease if removed early. The public is being
instructed as to the importance of this fact. The Society for the
Control of Cancer began its work in the United States and Canada. More
recently the Royal Society of Medicine has taken the matter up, and as
a result in Great Britain a very active propaganda, with similar
objects, has been inaugurated.

Turning now to _Canadian organizations in the Department of Public
Health_, we find that these are federal, provincial and municipal.

The earliest recognition of public health in Canada was the enactment
of the Quarantine Act, in 1794. Boards of Health were formed in
1832-1834 by the legislature of Upper Canada to combat an epidemic of
cholera. In 1847 no less than 98,106 immigrants passed through the
port of Quebec. Of these 8,691 were admitted to Grosse Ile hospital.
Deaths from typhus fever among those admitted to hospital were 3,226;
in addition 2,198 died on ships detained in quarantine. These victims
of typhus were buried at Grosse Ile. There was a typhus epidemic in
Canada in the years 1845-47, of cholera in 1849 and again in 1854-55.
In 1849 a Central Board of Health was established in Canada. I am
indebted to Dr. J. W. S. McCullough for giving me these figures, which
I abstracted from his recent monograph. "Ten Years Experience on the
Provincial Board of Ontario."

Federal activities in connection with public health have thus been
carried on in Canada for many years. For more than half a century
(1865-1920) Dr. Frederick Montizambert, I.S.O., as Director General
was responsible for safeguarding the health of the Dominion.
Conspicuous in effective administration may be noted his development
of the quarantine and marine hospital services both on the Atlantic
and the Pacific coasts. He attained an international reputation as an
authority on these matters. He was president successively of the
American and the Canadian Public Health Associations. In the early
days after Confederation he encountered many difficulties, such
difficulties as are always attendant upon the initial development of a
great public service in a new country. How splendidly he accomplished
his purpose is universally acknowledged. We do well in Canada to pay
tribute to a public health servant who has accomplished so much for
the welfare of his fellow-countrymen.

In connection with _federal activities_ we may note the formation of
the Canadian Public Health Association, under the patronage of the
Duke of Connaught, in 1911. Then again in 1919 a health ministry was
established in the Dominion Parliament with Dr. John Amyot, C.M.G., as
Deputy Minister. Under this ministry was established the Dominion
Council of Health, in which the various provinces are represented by
their chief executive health officer; these along with five members
representing agriculture, labour, etc., including educational bodies,
constitute the council.

The work of the council has included, among other activities, an
effort to standardize the health regulations of the provinces, the
publication of public health literature, the franking of vital
statistics and public health returns, the study of public health
questions, and securing federal aid in promoting such work as the
clinics for the treatment and control of venereal disease.

This Conference would do well to use its influence to the utmost in
urging the necessity of continuing the grant of $200,000 per annum
which has been provided by the Dominion Government for the past five
years for the purpose of combating venereal disease in Canada. We
learn with concern that it is proposed to diminish this grant. It is
true the grant was only guaranteed for five years, and the plea has
been made that it was intended for the initial cost of organization.
Let there be no misunderstanding on that count. It is easy to show
that the expenditure was made not on organization, but on the actual
cost of the conduct of these clinics. Those who know the situation
recognize the splendid work which has been accomplished for our
country under these grants in the last five years. We view with
consternation the proposal of cutting them down, and in the interests
of our fellow-citizens we would appeal to our federal Government to
provide whatever financial aid is necessary for this purpose. It might
easily be shown that an increase of the present grant would be
justifiable for Canada. The problem is first an international one, as
is recognized by the Health Committee of the League of Nations in
establishing and maintaining researches in various countries in the
sero-diagnosis of syphilis. Then it becomes a national problem in
which our federal Government has already taken effective action, which
we pray in the interest of the community will be continued with
increasing effectiveness. The provinces and the municipalities are
already doing their full share.

In addition to other matters the Federal Health Department has under
supervision: Quarantine against other countries, the supervision of
foods and drugs, patent medicines, narcotic drugs, child welfare, the
superintendence of Marine Hospitals, the medical examination of
immigrants, publications on public health, research laboratory work,
and the organization of the Dominion Council of Health.


_Provincial Health Organizations._

I am not in a position to speak historically of the Department of
Public Health service in the various parts of the Dominion. We know
the various provincial boards are doing effective work. The problems
differ in different provinces. Those with an ocean seaboard, with
ports open to the outside world, have problems peculiar to that
situation. Others are concerned with an international boundary, on our
Great Lakes, etc. The federal and provincial services must act in
harmony in connection with problems arising from such conditions. The
local provincial boards of health are under the control of the
different provincial governments.

I happen to be in possession of some facts regarding the development
in Ontario, which I may cite:[2]

After Confederation a Public Health Act was passed in Ontario in 1873,
and local health committees were formed in various municipalities.
These were the forerunners of the present local boards of health. In
1882 the Provincial Board of Health was established as a permanent
organization in Ontario. Dr. Peter H. Bryce became the permanent
secretary. In 1890 the first public health laboratory was established
under the direction of the late Dr. J. J. MacKenzie, subsequently
Professor of Pathology and Bacteriology in the University of Toronto.
This was the first public health laboratory to be established on this
continent. Dr. John A. Amyot became director of the laboratory in
1900. Dr. George G. Nasmith was the first chemist on the staff; he was
appointed in 1902. He continued to serve until 1910, when he became
chief of the laboratories in the city of Toronto. From 1904-1910 Dr.
C. A. Hodgetts served as Chief Officer of Health and Deputy
Registrar-General. He was in turn succeeded by the present incumbent
of that office, Dr. J. W. S. McCullough. He still is chairman of that
board.

Doubtless the other provinces have had a somewhat similar evolution,
from a small beginning up to the present standard of efficiency.

[Footnote 2: Monograph by Dr. J. W. S. McCullough already quoted.]


_Municipal Health Organization_

Once more I must plead your indulgence by citing as an example of
efficiency, organizations with which I am familiar:--

In the city of Toronto the cost for public health service showed a
remarkable increase in twenty-five years; 1909, $80,610; 1923,
$835,132.

Under the regime of Dr. C. J. O. Hastings the death rate has
diminished from 15.3 per thousand to 11.4 per thousand. Numerous
tributes have been paid to the excellence of the public health service
under Dr. Hastings, in Toronto, who has just passed through a somewhat
critical illness, and, I am glad to hear, is improving. Of these
activities, one might mention the following: Sanitary dwellings; pure
milk and water supply, and pure food; control of communicable
diseases; the work done by doctors, dentists and nurses; clinics and
child welfare; work in the public schools; health examinations; infant
mortality was almost cut in two in ten years; the practical wiping out
of typhoid fever; the Toronto city nursing service is a pioneer
service in many respects, with 114 nurses on the city pay-roll. These
nurses are engaged in district nursing, pre-natal, infant and
pre-school supervision; School service, physical examination, dental
service, etc.

The Victorian Order of Nurses, engaged chiefly in bedside nursing,
work in close harmony with the public health nurses of the city.

Once more we recognize that municipal activities in Canada are
effectively organized and maintained in the different portions of our
Dominion.

The Conference at present assembled is capable of accomplishing
results of immense value. Representatives of all branches of the
public health service, federal, provincial and municipal, are met for
the purpose of studying problems of common interest. By the
interchange of ideas, the demonstration of individual problems and the
frank criticism of existing conditions we may be helpful to one
another, and thus we hope to increase efficiency and to promote
harmony and good will in our common endeavour.



MEDICAL EDUCATION

The advances which have been made in the standard of medical education
in recent years are noteworthy. There is no branch of education in
which more rapid and revolutionary changes have taken place. These
changes have been forced upon us because of the ever increasing
progress of scientific knowledge and in clinical observation. The
present high status of medical education is not confined to a few
centres, but is found in all progressive countries of the world. In
Canada our progress has on the whole been satisfactory, and we have
been accorded a position second to none in our achievements. This is a
young country. While we perhaps lack the experience and prestige of
older communities, we possibly have an advantage in being free from
certain traditions and precedents which often frustrate the effort to
make revolutionary and radical changes, even when these are obviously
demanded by the changed conditions induced by progress in science and
discovery.

The teaching faculties in medicine of our Canadian universities have
evolved a course and curriculum of study peculiarly their own. In the
earlier days, it is true, we modelled our curriculum largely on those
of the Mother Country, in particular those of the Scotch universities.
But of recent years we have evolved our own course, and in not a few
instances we have been pioneers in the raising of standards and in the
improvement of the course of study in medicine. Looking abroad to-day
we find we fulfil the requirements of the most exacting schools in
other countries. If we take, for example, the exhaustive and
illuminating report of Sir George Newman, entitled "Recent advances in
Medical Education in England" (1923), we find we measure well up to
the standards therein set forth as approved by the British
universities and enforced by the General Medical Council of Great
Britain. It is of interest to observe that in the report referred to,
the distinguished educationalist, in his analytical study of medical
education in its various branches, refers more than once in
commendatory terms to the conditions which exist in Canadian
universities.

Twenty-five years ago it was possible for a man to practise medicine
and to attain success (measuring success by comparison with the
results achieved by his fellows) without the application of more than
the very rudiments of pure science in its application to medicine. I
recall a personal experience of some thirty years ago when I
approached one of the leaders of his profession of that time, and
asked him to assist in the inauguration of a small club for the study
of pathology. He told me he was "a practical man" and was not
specially interested in the minute study of pathology. He was no
exception among men of his class, men many of whom were able to
produce results in practice well in advance of the large majority of
practitioners. In the last quarter of a century the practice of
medicine, using that term in its broadest sense to include all
specialities, has thrown over empiricism and has now been established
on a scientific basis. The effect is twofold as far as the curriculum
of study is concerned. First it means a more intensive study in the
fundamental sciences of physics, chemistry, biology, physiology and
anatomy. These, together with the specialized training in these
sciences such as biochemistry, pathological chemistry, pharmacology,
hygiene, applied physiology, applied anatomy, etc., demand a great
increase in the time allotted to their study. Secondly the student,
having acquired this intensive training, must apply his knowledge
clinically, and so in turn the clinical teaching demands a great
accession to the time previously allotted to it. With his clinical
work is linked up the minute study of pathology and bacteriology,
which is now of such fundamental importance in his training in the
clinical years. The inevitable result all along the line is a
tremendous increase in the length of the curriculum.

We all deplore the increased length of the course in medicine. It is
obvious to any one who studies the situation that it could not be
avoided. If you take, for example, the English-speaking countries of
the world, you will find in all schools of medicine there is an
unanimity of opinion and of action in this regard. We may have
different terminology as to the different years of the course; some
may speak of "pre-medical years," others include such years in the
complete course and call all years "medical years". But if you analyze
the situation, you will find that the course embraces seven years of
special study. Most men (over 90 per cent in one of our Canadian
Universities) take an additional year as interne in a general
hospital. Thus it comes about that a student entering medicine must
look forward to a period of eight years before he is qualified to
practise his profession. Any school that does not line up to this
standard is courting disaster. Graduates of a school with inferior
requirements will find themselves handicapped in practice; they will
be unsuccessful competitors with their more highly trained fellows.
The public are beginning to demand a knowledge of a man's credentials
and are no longer satisfied with the mere fact that he is licensed to
practise.

It is very interesting to study the gradual evolution in clinical
training due to the introduction of so-called laboratory methods. At
first there was an outcry that students were being taught technical
methods with the use of scientific instruments and laboratory tests,
to the exclusion of the essential study of the physical examination of
the patient. We admit frankly the danger of such disastrous methods of
instruction. We also admit that the discussion along these lines was
advantageous. The danger, however, has been averted, and in every well
organized clinic the methods of physical examination are taught more
intensively, more persistently and effectively than has hitherto been
the case. On the other hand, students are taught laboratory methods in
the diagnosis and treatment of disease. It is absurd to condemn
laboratory methods; they must hold their proper place in clinical
teaching. A student to-day must be able to utilize the training he has
had in the preliminary sciences in its application to disease.

A more recent phase in the evolution of clinical training has been the
demand to have such subjects as physiology and anatomy carried over to
the clinical years as applied subjects. More recently still is the
suggestion that clinical subjects should be taught, in their
elementary phases, along with the sciences in the preliminary years of
the course. Lastly we have been urged to curtail the preliminary
science course and restrict it to those parts of such subjects as
physiology, chemistry and anatomy as apply in medical practice. As it
appears to me the situation is at present confused and demands some
clear thinking. I believe many of the suggestions are made without
logical consideration of the actual problem in hand.

Everyone admits that a knowledge of physics, chemistry, biology,
physiology and anatomy is essential in medical education. Obviously we
do not require to train men as specialists in these subjects;
therefore careful supervision and restriction in the scope of these
courses is demanded. I take it, however, that we wish a man to be
trained in chemistry so that he can apply his knowledge of chemistry
in the diagnosis and treatment of disease. Similarly he must be able
to approach a clinical problem from the standpoint of physiology,
biology, physics or anatomy.

To attempt to apply these sciences to medical practice at a time when
the student is ignorant of clinical problems is waste of time. It must
inevitably lead to confusion. In my opinion these subjects should be
taught as pure science. There is, I believe, a great deal of nonsense
talked about water-tight compartments now-a-days; the logical
alternative would be a compartment filled with fragmentary material
which has leaked in from neighbouring compartments causing a premature
precipitation of false conclusions, and resulting in a conglomerate
mixture which is hopelessly puzzling to the unfortunate student and
impossible for him to digest and assimilate. Surely it is the part of
wisdom to do one thing at a time. The student trained in pure science
has, to my mind, the best possible equipment for the practical
application of that science in the diagnosis and treatment of disease.
The course in science, however, should be modelled and arranged by
experts who realize that the ultimate goal of the student is that of a
general practitioner in medicine. A common sense view of the situation
will result in placing these preliminary science subjects in their
proper relation to the other subjects of the curriculum of study. The
student under such conditions will be better trained, capable of clear
thinking and imbued with the scientific spirit, which is more
essential to-day than ever before if we in the medical profession are
to utilize the advances made in science from time to time in the
relief of suffering humanity.

I would like to urge the undesirability of uniformity of curriculum in
universities. It has been suggested, for example, that licensing
bodies should issue schedules of study in each of these sciences,
physiology, anatomy, etc. not only so, but to stipulate the method of
instruction, e.g., so many didactic lectures and so many hours of
laboratory work. There is a craze for standardizing everything,
including industries and education. The inevitable result will be to
kill initiative and to destroy individuality. If we take the subject
of physiology, for example, it is surely conceivable that of two most
effective and efficient teachers, one may cover ground and utilize
methods of instruction of an entirely different character from the
other. Both have the same ultimate goal, namely, to teach the student
the principles of physiology in such fashion that he may later be able
to approach a clinical problem fully equipped to use physiological
methods in his bedside work. This end may be gained with equal success
by very different methods of approach in the teaching of the
particular science. The teacher should be free to use his own peculiar
faculties for the attainment of the ideal result. Here again, in my
opinion, the standardizing water-tight compartment of a fixed schedule
is to be condemned outright.

I have touched on a few of the problems which are "live issues" in
medical education to-day. We can never produce on a permanent basis an
ideal curriculum. Progressive schools of medicine will change their
curriculum of study from year to year. We hope to have discussions at
this Congress which will assist us throughout Canada in meeting the
requirements of to-day and if we continue, as I trust we will, to meet
in annual session, we shall be able to stimulate one another to
maintain high standards of medical education, constantly keeping pace
with the requirements thrust upon us by ever advancing knowledge in
all departments of medical science.



MEDICAL LICENSURE

Each province in Canada, under the British North America Act, controls
educational matters; among other things it exercises its right to fix
the standard of medical education required for a license to practice
medicine. In each province there exists a provincial Medical Council
operating under an Act of the legislature. This is the official
licensing body. It accomplishes its purpose in two ways; first by
insisting upon a certain curriculum of study, including matriculation
standards, and secondly by examination. In some provinces the
examinations conducted by the university are accepted by the
provincial Medical Council: in other provinces the Council conducts
the professional examinations in whole or in part.

In addition to the provincial Council we have a Dominion-wide body,
the Medical Council of Canada which, under certain provincial
restrictions, issues a license for practice in any part of Canada.

A general survey of the situation shows that no two provinces of
Canada have agreed upon the requirements for license. In fact, the
divergence in the regulations is extraordinarily, and one might add
unnecessarily, great. The Dominion Medical Council as at present
constituted under the federal Act is not concerned in curriculum of
study. It conducts examinations and it accepts as suitable candidates
for examination those who present what may be called an "enabling
certificate," indicating that the requirements of the Medical Council
of the province from which he comes have been fulfilled. These
certificates are issued by the registrars of the individual provincial
councils.

Canada is a vast country in area, with a population relatively small.
We have common ideals in many things and perhaps in no sphere is this
more evident than in educational matters. Effort is made from time to
time to get the Educationalists together in order that each province
may contribute towards the establishment of standards of education
worthy of the country as a whole. One might instance, for example, the
annual Conference of Canadian Universities, which is accomplishing
much toward that end. Surely along similar lines it would be possible
to improve the conditions under which we grant the license to practise
medicine in Canada.

An effort has been made to secure representatives from each provincial
Medical Council at this Conference to discuss medical licensure. Let
us hope a beginning may be made to secure, if possible, something
approaching a uniform standard of requirements for the various
provinces. We as a profession in Canada would be greatly strengthened
by uniting our forces in this respect. Is it too much to hope that one
day the Dominion Medical Council, the federal body, may be the medium
through which all the provinces, with something approaching uniformity
will unite? Would it not be ideal that the various provincial councils
should agree to accept the Dominion Medical Council as the sole
examining body for license to practise medicine in Canada?

Why should Canada with a population of 8,350,000 require nine
licensing bodies, when in Great Britain with a population of
45,000,000 there should be one such body only, the General Medical
Council of Great Britain?

This is a national ideal for the attainment of which we might well
sacrifice certain of our provincial rights and prejudices.

This Conference of individuals concerned in the administration of
medical services in Canada is an experiment. The inevitable result of
conditions which obtain in this country is to produce varied
interests, often conflicting interests, which are difficult to unify.
Everyone will concede the desirability of creating national ideals,
which will unite the provinces for common effort. No great
revolutionary effort of this kind can be brought about without
sacrifice, and it is hoped the representatives of different provinces
will be prepared to consider how far they can forego local
considerations for the attainment of national ideals.

We hear a great deal now-a-days regarding the evolution of Canada as a
nation. The union of the scattered provinces of Canada in national
effort has presented many difficulties in varied activities of life.
Success has been attained in many directions, but as yet the medical
profession is divided with scattered provincial groups each operating
without due consideration of the requirements of the other. We trust
the beginning made at this Conference will result eventually in
combined effort and the establishment of a national spirit which will
greatly strengthen our hands. It is hoped the day is not far distant
when the medical profession, in all its varied activities of public
service, will be united in national organizations, second to none in
efficiency and achievement among the great nations of the world.

The CHAIRMAN: I understand there are now some resolutions to be put.

Dr. W. T. CONNELL: The programme is necessarily incomplete, and as
there are a number of matters of importance which gentlemen present
wish to bring before the conference, I think it would be advisable for
us to have a more detailed programme, and I would therefore move, Mr.
Chairman, that you nominate a Programme Committee so that those
members who have matters other than those which appear on the
programme which they wish to discuss shall be given the opportunity.

Dr. AUSTIN: I second the motion.

Motion agreed to.

Dr. GEORGE YOUNG: I move that the chairman be empowered to nominate a
Committee on Resolutions whose duty it will be to crystallize the
results of our discussion in a series of resolutions to be presented
before the close of the conference.

Dr. AIKENS: I second the motion.

Motion agreed to.

The CHAIRMAN: I will nominate the Committees after we have heard from
Dr. Amyot, Deputy Minister of Health, whom I will now ask to address
the conference.



HEALTH SURVEYS, HEALTH NURSES, AND THE RELATION OF THE MEDICAL
PROFESSION THERETO

Dr. AMYOT (Deputy Minister of Health, Ottawa): Ladies and gentlemen,
Dr. Primrose has given us food for thought. I did not know that anyone
could compress as much information into such a small space, and he has
finished his address right on schedule time. This all shows that there
is a big ideal behind this medical profession in Canada; there is an
attempt to make ourselves more useful to the public. It is a serious
attempt. We are all thinking of it, and those of us who have had any
university experience in drawing up a curriculum know well how earnest
that endeavour has been.

Public health, that branch of medicine which looks towards the
prevention of disease, has made immense progress in the last few years
since we have had certain scientific facts upon which we can base our
action. We owe the discovery of these scientific facts to the energy
and efforts of the medical profession chiefly, with the one exception
possibly of Pasteur, and after all we look upon him as part of
ourselves. All these discoveries have been given to the world freely
by the medical profession, have been put into the common pot. It is a
principle, it is an ideal, it is something that is inground in us,
that since we have learned from the experience of our predecessors,
since they have without any reserve put all their knowledge into the
common pot, it is for us when we find anything also to put it into the
common pot for the benefit of all.

The medical profession has also this to its credit. Its work has been
of an idealistic type. Did anyone of you ever in your practice in a
city or in a town ever attempt to keep people sick in order to make
your living out of them? You have made every effort that it was
possible to make to prevent people getting sick. I do not know any
other profession that does that. It is idealistic work when you get
out and fight a condition that is resulting in typhoid, let us say,
and as Mr. Graham remarked this morning, did any of you ever think of
the practice that you were going to abandon when you were carrying on
such work? You never did. You have gone out idealistically to try and
stop human misery.

It is often said of us that we are a sort of a close corporation, that
we are licensed, and licensed for our own protection very much as a
labour union is. But is that so? We are licensed for the protection of
the public. When we get into difficulties with reference to our
property or our liberties are infringed, we go to somebody who knows
what the law is, and the provinces and the Dominion that we live in
see that these lawyers know the law sufficiently well not to leave us
in jail, and not to allow our property to be wrongfully taken away
from us. The lawyers are not licensed to make themselves a close
corporation; it is simply that there shall be a degree of protection
for the public, to ensure that they shall have a sufficient knowledge
of the law to protect our property and our liberty. When we want our
children educated we see that the teachers come up to a certain
standard of qualifications, and the country also when it comes to deal
with us demands that a certain standard of instruction and experience
shall be required of us. We are not a close body. It is not for the
protection of the medical profession that we are licensed; it is for
the protection of the public, and wise legislators have provided for
that. Experience has shown that it is necessary to have it so.

Now advances in public health have resulted out of that idealistic
principle that is in every medical man's heart from the time he
becomes a first year medical student until he goes out to practise. I
do not know any college that teaches him selfishness. You try to teach
him from the start that he is a peculiar type in the community. He is
the type that of necessity becomes a sacrificer for the rest of the
community.

The medical profession has advanced public health. The public have
become interested in public health. The principles laid down by the
medical profession, based on the scientific knowledge which they have
evolved at the cost of great effort and sacrifice, have benefited the
public, and the public is commencing to see the necessity of it. This
knowledge of matters pertaining to public health is becoming common
property. The public knows far more about public health to-day and the
possibility and necessity of protecting their lives and their
happiness than ever before, and who is responsible for that? The
medical profession has taught it to them. You have only to look at the
group of health officers in a province or municipality to know what
efforts they have made to teach that public. And now the knowledge is
becoming general: it is wider than it ever was before. Compare
conditions to-day with conditions twenty-five years ago. Time has
brought certain changes in the situation. The public has demanded men
who knew more and who could spend more time on public health than it
ever did before. The subject of public health has become a specialty
just as much as neurology, internal medicine or surgery, and the men
interested in public health, you must realize as medical men, have
gone just as far in their special lines of work and done just as much
hard work as you have done in your special lines of work. They have
obtained what is really specialized knowledge. That is not always
realized. I can take my own experience as an example. I quit the
practice of medicine in 1900, after practising nine years. I had made
as much effort as I could during that time to make myself fit for that
work. Since 1900 I have spent every hour of the twenty-four thinking
of public health. I have, and the other public health men have done
that kind of work; we think of public health day and night. A man one
time questioned my right to say anything about a water system in a
certain city. I said: "I have been at this thing now something like
ten years. I have done all the work; at least, I have studied the
water question as a bacteriologist and as a chemist; I have done it
experimentally. I have seen all the water purification plants of this
country and the United States. I have checked all my work
bacteriologically and experimentally. I know intimately what they are
doing. I have studied the physics of water filtration; I have studied
the results of water filtration, and at the same time I have been
studying why these filters and so on were necessary, and at the end of
ten years of intensive study of that kind I think I have some right to
a personal opinion on this subject. I think I am better qualified to
speak on it than a man who has been doing work in medicine in other
directions and has never been thinking about these questions." I give
that as an example simply to show that public health men have gone out
specializing in certain lines and you will excuse that personal,
perhaps selfish note that I have sounded. But this you must realize,
that we are doing a specialized line of work, and the men who are
doing that work effectively have had to have a special kind of
knowledge, and we have some right to our opinions. Sometimes we meet
opposition in our endeavour to try and have things improved. Consider
always that the public health men probably have some reason for the
statements they make and the things they are advocating.

Public health men come more intimately into contact with the public;
we have somewhat got away from the ordinary work of the medical
profession. We are in the public's confidence and they are in ours,
and we have points of view that the medical profession would do well
to bear in mind, and reasons for the things we are advocating. I am
not going to touch on that any further.

Certain developments have taken place. Sometimes we meet with
opposition that we feel aggrieved at, particularly when we think of
what the profession has done, and when we think we have sufficient
basis for what we want to do. As to the great bulk of the profession,
we know their heart is absolutely true. When you criticize, try and
see our point of view.

There are certain points I have been put down on the programme to
speak about this morning--health surveys and the public health nurses.
We have got to the stage where we want to appraise and find out
exactly what we have to do. We want to know the enemy we have to
fight, and what are the possibilities of his putting up a real fight
against us. Provincial bodies--of course, we have no right to step
into any province except they ask our advice--have established what we
know as health surveys. In the province of Quebec at the present time,
in the City of Three Rivers, such a survey is being held by men
skilled in their work. The object of that survey in the city of Three
Rivers is to find out how much tuberculosis there is actually present
there. Why is it there is such a large child mortality in that place?
Why, if we can clear it up there, and make a demonstration in that
one place, the knowledge that will be gathered there will be used in
other places. The province has put into that place, with the help of
the Anti-Tuberculosis League of Canada, officers who are specialists
in tuberculosis and child diseases, and they are inviting the public
to come and have themselves and their children examined. That is
reaching people who did not get to the medical profession at all. The
aim of the survey is not to treat the people. It is to find out
whether they are sick, and if they are sick the officers send these
people to the local doctors to be treated. They are attempting to make
an examination of these people to find out just what should be done,
and to wake up the public to the fact that there is an evil there that
needs to be corrected. Public health men know just how much exists,
but there must be a demonstration. Now they ask for the co-operation
of the medical profession. I know that in some quarters this method is
questioned. But it can be carried on without friction. It does no harm
to the medical profession. These people are sick, and when they are
found to be sick, they are treated by the local medical men. There
cannot be any harm in that. We have to use public health nurses. The
public health nurse has come to stay. It is not possible in the
present state of things to employ full-time medical men for all the
work that we need done in examining school children, and so on. We
pick the most skilled ones we can get, and the ones we can get with
the greatest economy, and we are using the nurses who have had
experience with the people close at hand, and who have their own
peculiar ways of getting information and gaining the confidence of the
people. The public health nurse is developed to do that work, and is
being used in the public health service to get where nobody else could
get. They can get information about the people and win their
confidence in a way that no one else could. They go into the families
and find out what really is wrong. Often there are conditions that
could very well be corrected if the people only knew, and the public
health nurse is the one who can go and find that out. There is an
endeavour always, and this is always at the back of the mind of the
public health authorities, when they find out what is wrong to direct
those who are sick to those who have the skill to treat them for their
ills. In no place is the public health nurse taking the place of the
physician. The nurses are directed in every well organized public
health service to send the people who are sick to those who can treat
them and look after them. Many laymen's associations want us to go
further. The public health service is the buffer between you and the
public, and it is through the public health nurse that this work can
be done. The public health nurse has come to stay; the health survey
has come to stay; the public has demanded it, and you cannot get away
from it. So co-operate with us to the best of your ability, and try
and find out just what the object is, and do not obstruct it. When I
say, do not obstruct it, I mean use your influence to keep those who
do obstruct from doing so. Encourage us as much as you can. It is for
the benefit of the public, and you can do it. I know that before this
meeting is over there will be criticism of the public health service
on both these grounds. We leave the matter until the criticism is
made, and the situation can be clarified then. I know that the great
heart of the medical profession is right, and is behind this movement,
but there are those who are in opposition and criticize this method of
dealing with sickness among the public and this attempt to discover
their ills, but I think the criticism has come because of a lack of
knowledge of what actually is taking place. The general profession
knows, and it is for the general profession, for you gentlemen to try
and smooth out that little opposition. Thank you.

The CHAIRMAN: I nominate the following gentlemen to the Programme
Committee:--

Dr. A. Bazin,
Dr. J. F. Irving,
Dr. S. L. Walker,
Dr. G. R. Johnson,
Dr. H. W. Hill,
Dr. J. H. McDermot.
Dr. Glen Hamilton,

I nominate the following gentlemen to the Resolutions Committee:--

Dr. J. C. Connell,
Dr. W. A. Gardner,
Dr. W. H. Hattie,
Dr. MacG. Young,
Dr. G. G. Melvin,
Dr. J. J. Ower,
Dr. L. P. Normand,
Dr. L. D. Carder.
Dr. R. T. Noble,

Dr. ROUTLEY: It has been suggested from the floor that every member
should rise in turn and announce his name and where he comes from, so
that we may become better acquainted.

The CHAIRMAN: It is just an illustration of what I said before. We
come from such a vast country that some of us are perhaps meeting one
another here for the first time. I think there would be a certain
advantage in doing as the secretary suggests.

A MEMBER: I was going to suggest that the roll be called this
afternoon, not simply of individuals, but of the organizations as
well, who are represented here. Those who are representing them could
stand and give their names and say what body they were representing.

The CHAIRMAN: Then if there is no objection, the roll will be called
this afternoon. If there is no further business we will now adjourn.




=THURSDAY AFTERNOON SITTING=


The Conference resumed at 2 p.m., with Dr. Primrose in the chair.

The CHAIRMAN: In order to keep the proceedings regular I propose to
conduct the meeting under parliamentary rules unless any member of the
conference wishes to move otherwise. Before proceeding with the
programme I would ask if there is anyone who would wish to discuss the
address that has been given by Dr. Amyot. If there is no discussion of
that paper I would request Dr. Bazin, the chairman of the Programme
Committee, to present his report.

Dr. A. BAZIN (Montreal): The Programme Committee desires to report as
follows:

Any members of the conference desiring to submit papers which are not
perhaps cognate to the papers already down on the programme are
requested to communicate early with myself, the chairman of the
Programme Committee, so that the committee will have an opportunity of
placing his paper.

It has been decided that the rules governing the discussion should
include a time limit of twenty minutes for papers, five minutes
discussion by any individual, and ten minutes for reply.

On Friday forenoon a paper will be added to the programme, if time
permits, "Maternal Mortality" by Dr. Helen MacMurchy, and on Friday
afternoon a paper on "The Purity of Drugs," by Dr. V. E. Henderson.

The committee has considered the advisability of cutting short this
conference in order to permit certain members getting away on Friday
evening who are specially desirous of reaching home before Christmas
Day. The committee feel, although they would like to meet the
individual views of these members, that this conference has been
arranged at a very considerable sacrifice of energy and time; we are
all here at a considerable sacrifice of time, and it has been
announced that this conference is to be a three-day conference. We
have also plenty to occupy us during these three days and we therefore
feel it would be inadvisable to, as it were, break faith with the
majority of those present by in any way transposing the programme as
printed, or by shortening the duration of the conference. I move the
adoption of the report.

The report was adopted.

The CHAIRMAN: The first paper this afternoon is "Medical Licensure,"
By Dr. Jas. MacCallum, of Toronto.



MEDICAL LICENSURE

Dr. MACCALLUM (Toronto): Too often it is assumed that medical
licensure is for the protection and benefit of the practitioners of
medicine. Nothing can be farther from the fact. Protection of the
profession is not the purpose of licensure--it is a result. Protection
of the public is the real object of licensure. To discuss licensure on
any other basis is not merely futile--but dangerous--dangerous both to
the public and to the profession.

Medical licensure is a function of the individual province, not of the
Dominion. Each province has, for administrative purposes, confided
this function to some body, educational or professional. The action of
the administrative body requires the consent or confirmation of the
province, and may--and often does--come under its scrutiny, criticism
and even revision.

In every province the governing body--the College of Physicians and
Surgeons, commonly known as the Medical Council--has set forth certain
requirements for the acquiring of a medical license: A. Preliminary
education; B. A course of instruction, (i) in certain subjects, (ii)
for a certain number of years; C. Passing of certain examinations.


_A. As to Preliminary Education_

It should not be forgotten that, by the British North America Act,
education is a matter solely under provincial control--the Dominion
has nothing to do with it. Those of us who have had experience in the
Medical Council of Canada have learned that some of the provinces are
very jealous indeed of their provincial rights, and that uniformity as
to preliminary medical education is not the simple matter it may
appear. Educational ideals are different in the several provinces.
That one ideal is better or more desirable than another I leave you to
decide.

The provinces do not even approximate uniformity in their
matriculation requirements. The announcements of the several
provincial councils reveal a wide difference in the matriculations,
dependent upon educational ideals, or upon the equipment of the
primary schools. This difference is not to be wondered at, for
education is not compulsory in all of the provinces. In some it is a
matter of comparatively recent enactment. Because of this there must
be a difference in the educational requirements of the public schools,
and of the high schools--this in turn necessitates differences in
matriculation. These differences are not irreconcilable. Time will
probably bring an equality of preliminary education. If it is thought
wise to discuss the requirements of preliminary education I would
suggest that the minimum requirement that will enable a student to
grasp the subject of medicine engage our attention. We can, without
coming into conflict with educationalists, discuss the second
requirement which is purely professional.

The second requirement is Courses of Instruction, (_a_) for a given
number of years, (_b_) in certain medical subjects.

There would seem to be but little difficulty in coming to an absolute
uniformity of standard and yet there are serious variations. One
practical difficulty is that the councils are not teaching bodies.
Instruction is given, not by the Medical Councils, but by the
universities which are independent of the councils, and each of which
has ideas and ideals of its own--ideas and ideals which in the very
nature of things must change more quickly than those of the Medical
Councils, and which are not uninfluenced by financial and local
conditions and even by political considerations.

The western provinces--Manitoba, Alberta and Saskatchewan--form a
group which has recognized the value of the practical association of
the licensing and the teaching functions and has confided the
curriculum and examinations to the provincial universities. Other
provinces have no provincial universities or have so many universities
that it has been impossible to confide the examinations and curriculum
to any one university, so that the Medical Council has been forced to
keep these matters under its own control.


_Number of Years_

The number of years of professional studies demanded varies from five
years of six months to six years of eight months of teaching. In other
words, some provinces demand a course half as long again as others.

One province demands two years of pre-medical study followed by five
years professional study. Other provinces do not demand any
pre-medical study. The tendency of the universities is increasingly to
demand the pre-medical years. This demand no doubt arises from
dissatisfaction with preliminary education and from a knowledge that
an adequate medical education requires an increasingly broad
foundation of general education.


_Medical Subjects Demanded_

The provinces are at one as to the subjects regarded as essential,
viz, anatomy, practical anatomy, chemistry, practical chemistry,
physiology, materia medica and therapeutics, surgery, clinical
surgery, medicine, clinical medicine, obstetrics, diseases of women
and children, medical jurisprudence, hygiene and pathology.

How great a variation may exist is shown by the fact that in the
syllabus of some of the provincial councils there is wanting one or
more of such subjects as chemistry, physics, histology, embryology,
pharmacy, toxicology, bacteriology, ophthalmology, diseases of the
ear, nose and throat, psychology, psychiatry.

The requirements in practical subjects exhibit a like variation,
especially in obstetrics and hospital attendance.


_As to Obstetrics._

Some councils ignore all practical experience in this subject. Others
demand ten or even twenty cases, and one demands in addition to ten
cases eight months practice in a lying-in hospital.


_In the Matter of Hospital Attendance._

The requirements vary from nothing to three years. The regulations
reveal striking differences as to how many beds a hospital needs in
order to afford proper and sufficient clinical opportunities. One
province is satisfied with twelve months at a general hospital of
fifty beds under the charge of not less than two qualified
practitioners. Another demands eighteen months in a hospital of one
hundred and fifty beds under charge of not less than four
practitioners of whom two must be surgeons. Twenty-four months in an
incorporated general hospital is the requirement of one, three years
of another. One province demands not merely a certificate of hospital
attendance, but goes a step further and requires six months service as
an interne. This interne requirement is a dead letter, but so
confident is that province of the necessity of an interneship that it
now proposes to demand it for one year.


_In Examinations_

At least four plans exist.

1. The provincial university conducts the examinations for the
councils, or gives a certificate of university examination, which
presented to the council, ensures registration.

2. The provincial council accepts the university examination in the
primary subjects, but itself conducts the final examination for
license.

3. Council conducts both primary and final examinations.

4. Council conducts examination at the end of each year with the aid
of assessors. The percentage necessary to be obtained is in no case
less than 50 per cent and goes up to 60 per cent.

From this analysis of the requirements and procedure of the various
councils it appears that some provincial councils are too lax, or
others are too severe in their requirements for licensure; or the
needs of the various provinces differ, or the council has not given
sufficient consideration to the question of what is needed by the
practitioner who must possess at least "usual and reasonable skill."

If licensure is for the protection of the public, surely the people of
one province have the right to protection of the same grade as those
of another.

In this lies the argument for standardization of requirements for
medical licensure.

You must consider the question whether standardization or uniformity
is desirable. If desirable, is it feasible? If feasible, how is it to
be accomplished? Is it to come from within each province or is it to
come from without? What standard is desirable?

The problem has already been attacked from one standpoint--not the
standpoint of uniformity of preliminary education, medical education,
hospital and laboratory instruction, but of examination. Whether this
is the most desirable way, whether it is grasping the shadow and
losing the substance may be a moot question, but it seemed the only
feasible way, and resulted in the Medical Council of Canada. The
Medical Council of Canada was made possible only by the bold step of
ignoring all questions of preliminary education, of medical education
in all its details, and insisting only on a standard of examination.
This is the strength of the Medical Council of Canada, and its
weakness.

One must not lose sight of the fact that the license of the Medical
Council of Canada exists only by the grace of the provincial councils
which accept it without any question of curriculum, mutual reciprocity
or standard--a courtesy which they deny to their sister provinces, of
whom they demand both mutual reciprocity and an equality of standard
and curriculum. As has already been said, by the British North America
Act, education is a matter strictly within the jurisdiction of the
individual provinces, so that standardization of medical education is
a matter for individual action of each of the nine provinces.

Because of the British North America Act, the Medical Council of
Canada is limited to examination in professional subjects only. The
Canada Medical Act says that its "standard of examination shall not be
lower than the highest for the like purpose (registration) in any
province." So far no question has arisen as to the construction to be
put upon the word "standard"--but what does it mean?--Is it percentage
of examination marks, or character and number of professional
subjects, or quality of the examination?

Sooner or later this question must arise. In Ontario, men rejected at
the provincial examination have one week later procured the license of
the Medical Council of Canada, and demanded registration in Ontario.
Nova Scotia has provided for such cases (p. 11, paragraph 5) by
enacting "no candidate shall be admissible to examination who has
been rejected in the subjects of the examination by this or any other
licensing board within the three preceding months."

In the working of the Canada Medical Act, the greatest source of
trouble has been section 12 (_a_). "No candidate shall be eligible for
any examination prescribed by the Council, unless he is the holder of
a provincial license, or"--and I draw your attention to the word
_or_--"unless he presents a certificate from the registrar of his own
provincial Medical Council that he holds a medical degree accepted and
approved of by the Medical Council of the said province."

There are here two practical difficulties. Some of the provincial
councils do not hold their examinations until after the date of that
of the Medical Council of Canada. The results of the university
examinations are often not known in time for the provincial council to
give the enabling certificate. The difficulty has been met by the
Councils giving a certificate that the candidate is eligible to take
their examination and later forwarding a certificate of the medical
degree having been obtained.

If the Medical Council of Canada were to postpone its examination
until the results of the university and provincial council
examinations are announced, it would not have any candidates, as the
students at once scatter to their homes, rather than be put to the
expense of waiting the announcement of results and then writing on
another examination.

Quebec alone of the provinces has seen fit not to acquiesce in this
modus vivendi, and refuses to give an enabling certificate unless the
candidate has passed the provincial examination for license and has a
medical degree, and has satisfied all the preliminary requirements for
license.

Another difficulty is what construction is to be put on the words "his
own provincial Medical Council." Is it the province in which his home
is, that in which he matriculated, that in which he has pursued his
medical studies, or that in which he intends to practise. A candidate
may be a student of medicine _in_ a given province and yet not be _of_
that province.

It is not for the Medical Council of Canada to put an interpretation
on these words; it leaves that to the provinces and accepts without
question the enabling certificate of any province. This enabling
certificate clause holds within it practically the same danger as will
be pointed out in connection with British reciprocity. The student
naturally seeks the line of least resistance and will present an
enabling certificate from the province whose requirements are the
least stringent. And there will spring up a money order business in
enabling certificates.

Another problem productive of serious complications is that of British
reciprocity. Since the onset of the Great War every province, with the
exception of British Columbia, has had reciprocity with the General
Council of Medical Education of Great Britain.

Provincial licentiates avoid the examination of the Medical Council of
Canada. They send to Great Britain their certificate of provincial
registration together with a fee, obtain British registration thus,
and then register in any province. It is a real money order business
in registration certificates, and is resented by many of the
provinces. It works out practically as interprovincial registration
without any equality of standard of preliminary education or of
medical education. To close this back door Saskatchewan has had its
Medical Act changed so that it grants registration only to those
registered by passing the examinations of the General Medical Council
of Great Britain. As the General Medical Council does not hold any
examinations Saskatchewan has closed the door on the whole British
register.

New Brunswick has sought to protect the Medical Council of Canada, by
demanding proof of a bona fide residence in Great Britain from those
possessed of a certificate of British registration.

The result--a result not foreseen--is that a graduate from
Saskatchewan or New Brunswick can, through British registration enter
any other province of Canada but graduates from the other provinces
cannot register in Saskatchewan or New Brunswick.

The Medical Council of Canada has sought reciprocity with the General
Council of Medical Education of Great Britain. The latter has done its
best to bring this about, but has failed. Not merely has it failed--it
has caused Saskatchewan, New Brunswick, and I believe, Manitoba to
give up reciprocity. British Columbia has not had it for years.

Interprovincial reciprocity by the medium of the General Council of
Medical Education of Great Britain is impossible so long as provincial
pride exists, and there is any disparity in the requirements for
medical licensure. Comparison and criticism of standards are
inevitable and will always be heard, yet I do not despair of equality
of preliminary and professional requirements being attained. Equality
is not necessarily uniformity. Equality once attained, there can be no
possible objection to interprovincial reciprocity, British reciprocity
being given up entirely, and the provinces agreeing to accept the
license of the Canada Medical Council.

This brief resum of the requirements for licensure reveals a state of
chaos which this conference may help to reduce to at least a semblance
of order.

The CHAIRMAN: This address by Dr. MacCallum gives us food for thought.
I fancy we all agree in the principle, that it would be exceedingly
desirable, if possible, to come to some uniform standard of education
in the various provinces of Canada. This subject will be up for
discussion, and I hope the members of the conference will think over
it and see if it is not possible for this conference to do what I, and
I think all of us, would consider a splendid piece of work, that we
should bring the provinces together in some way to consider this
question and, if possible, solve the problem along what seem to be
ideal and reasonable lines. However, I do not propose to say anything
further on that point. I will now call on Dr. Glen Hamilton, of
Winnipeg.



LICENSE INSPECTORS

Dr. HAMILTON: The subject that I have to present to you very briefly
is one to which I am sure a great many of you, if not all of you, have
given considerable study.

One of the greatest difficulties in the way of making certain and
secure the aim and purpose of medical licensure is that of protecting
the public against the presuming irregular. Our universities may
efficiently educate, and our colleges license, but these do not and
cannot protect an unsuspecting people, for whom the title "Doctor" or
practitioner is a sufficient and satisfying guarantee of ability to
treat.

All will agree with the opinion that much of our trouble with the
irregular practitioner is due to the fact of there being no official
whose duty it is to check up the licenses of those who practise
medicine or any form of healing.

It is a matter of history that the medical Acts were passed in order
to protect the public by licensing only those known to be
scientifically trained and efficient. The feature of the Acts which
assures to the public a properly qualified licensee is a valuable
safeguard, but there is no safeguard which assures to the public that
only those presuming to practise are so licensed.

A casual glance over the field of licensing in its application to many
activities in our provincial, municipal and civic affairs shows that
wherever license is issued, whether for the safeguarding of the
public, the raising of revenue, or for any other purpose, there is in
each case with the exception of the medical license, a close scrutiny
of those so licensed; moreover the party, group or department most
concerned in the license is the one usually assigned the duty of
supervising such licenses. As medical licensure is on behalf of the
public, the safeguarding of the public interest should be done by an
officer acting on behalf of the public.

In provincial affairs, such as the automobile, the license is issued
for two prime reasons, namely, revenue, and safety. The collection of
money and issue of renewal license is smartly looked after by the
provincial departments concerned with revenue and police order. In
licenses issued by the city, revenue and tabulation of police
information are reasons considered sufficient for a strict control.
Here, too, the collection of the fee and the issue of the license
annually are closely checked by a special official or department
concerned. In the matter of a medical license, the prime reason for
the issue of the same is educational efficiency in the interests of
the public safety. The educational feature is guaranteed by the
College of Physicians and Surgeons co-operating with the
university--but what about the public safety? Why is there no annual
check up of those practising medicine or healing of any kind, as there
is of those who drive automobiles, or perform other activities in
which the public safety is concerned?

When the College of Physicians and Surgeons Council has satisfied
itself as to the educational equipment of an applicant, it issues
license to practise. When the College of Physicians and Surgeons finds
it necessary to exercise disciplinary power over those whom it has
licensed, it is acting in accord with the clear intention of the Act;
but the College of Physicians and Surgeons Council clearly cannot be
called upon to exercise disciplinary effort upon all and sundry of the
quacks and fakirs attempting to delude the public in the matter of
treating disease. Surely here the question of public safety lies much
nearer the Police Department of the Attorney General, and in the
interests of public safety should be the particular charge of that
department. A special officer appointed to scrutinize licenses of
those who practise medicine or any form of healing would put an end to
very many impositions perpetrated upon the public for many years with
no authority to call them in question. It is true when the acts of
these irregulars become the concern of the criminal authorities, the
Attorney General's Department interposes, although its activities are
exercised from the standpoint of criminality rather than from the
standpoint as to whether the party under suspicion may or may not have
been guilty of fraud upon the public in an unlicensed presumption.

In conclusion I would suggest, that in the interests of the public
safety, the Attorney General's Department of each province should
appoint officers to see that only those licensed to do so are
permitted to practise medicine or any form of healing. The scrutiny of
licenses could be readily assigned as a duty on officials already
appointed and without extra expense.

The CHAIRMAN: Dr. Hamilton has brought up a very interesting point.
The whole subject, including the paper by Dr. MacCallum and the paper
which has just been read by Dr. Hamilton, is now open for discussion.

Dr. R. S. THORNTON (Dominion Medical Council): I rise for the purpose
of supplementing in one or two points the statement which has been
submitted by Dr. MacCallum.

Our Medical Council has been created since the 7th of November, 1912.
It came into existence as a result of the final revision of the Act
made in 1911, following a meeting of the Canadian Medical Association
in Winnipeg in that year at which a resolution was passed asking Dr.
Roddick to continue his efforts to get the law enacted. The reason why
I go back into that little point of history is to point out that when
the matter was under discussion in Winnipeg in 1911 at that meeting of
the Canadian Medical Association, there was not at that time a
Canadian medical man. We were provincial physicians only. There was no
such individual as a Canadian Physician, meaning by that a man who had
a standing which was nation-wide, and which would be recognized from
the Atlantic to the Pacific. While we met as a Canadian Medical
Association, there was not a Canadian medical man a member of that
association. To-day there are 1,300 men with the Canadian license, one
third of whom have obtained their Dominion diploma by reason of their
ten years' standing, and the other two thirds by reason of taking the
examination.

The point which was stressed at that time in the creation of the
Dominion Council is still a point which I think we want to stress at
this conference, namely, that of a national status for the practising
physician. By that I do not mean that the Dominion Council should
supersede or should in any way transgress upon the rights of the
provincial Medical Councils, but that all of us as medical men, in the
provincial Medical Councils, in the Dominion Council, and in the
associations, should continually aim not merely for the point of
co-ordination which we have been considering, but we should bear in
mind that what we want to establish is a national standard of medical
practice, and in whatever discussion may take place I would like to
have that viewpoint in the minds of this conference.

There have been many little difficulties in carrying the Act into
effect, and various questions arise at times between the Dominion
Council on the one hand, and the provincial councils on the other, or,
as it might happen, between provincial councils. But these have been
overcome. Remember that our council was just being established when
the war came. The war threw us out of four or five years of growth
right at the very time when we were getting into our stride. So we
would probably have had a much larger number than 1300 at the present
time if it had not been for the war. We have ironed out these little
difficulties that have arisen with us, but you will observe that it is
not for the Dominion Council in any way to propagate its desires or
wishes among the provincial councils. It would not be a proper thing
to do, in the first instance; it would very naturally and rightly be
resented in the second. So the Dominion Council has to wait for the
removal of some of these difficulties, but any suggestions which are
made from any outside body such as this conference in the way of
recommendations to provincial councils, the Dominion Council would
then be in a position to secure certain things being done which the
provincial council might not be able to undertake.

Just one other point in conclusion. The province of British Columbia
has accepted absolutely and entirely as the sole standard for
qualification in that province the certificate of the Medical Council
of Canada. They have no reciprocity with Great Britain; they have no
reciprocity degrees of their own. A few years ago they surrendered
their provincial examination, and accepted in place of it the license
of the Medical Council of Canada, and that is the only way a man can
go into the province of British Columbia and practise there to-day. An
agreement has been made whereby the fee is divided to the mutual
benefit of the Dominion and Provincial Councils, and to the benefit of
the physician who takes the examination and saves $50 in the process.
Is it possible that this conference might be able to help out an
extension of this process of co-operation? As I say, the Dominion
Medical Council cannot say to any province that they give up their
examinations. There are local conditions too, which may make it
difficult for them to be able to do that, but bit by bit, if each
province could attain to the position of British Columbia, then you
would have one standard from one end of the country to the other, and
you would have established a national status for the practising
physician in Canada.

The CHAIRMAN: We should like to hear from some members of the
provincial councils who know the difficulties in their respective
provinces. It is a very broad question, and I hope that this
discussion will go on, and that everyone will express his mind freely
and without any restraint. We want to know exactly what the objections
are, and what support may be given.

Dr. A. BAZIN (Montreal): If it is permissible I should like to read a
letter from Dr. F. W. Marlow, who was detained by illness from
attending this conference. He is chairman of the Committee of the
Canadian Medical Association which has been studying for three or four
years the question of higher degrees in Canada. No conclusion has been
arrived at as yet by the committee, but a great deal of study has been
given to the question. Dr. Marlow sends this communication:--

Toronto, December 17, 1924.

     Briefly, may I state, that after studying the matter of
     a college I have concluded as follows:--

     1. Majority of opinion throughout Canada is in favour
     of the ultimate establishment of a college.

     2. Its establishment would stimulate post-graduate
     work, by providing possible recognition in Fellowship
     diplomas. The qualification of specialists would, in a
     measure, conform to its requirements. The general
     standard of medical and surgical practice would be
     elevated.

     3. It would provide something distinctly Canadian for
     Canadians, and would soon be accorded due recognition
     throughout Canada and abroad.

     4. An affiliation with the Royal College of England and
     London might be arranged.

     5. No new organization is considered desirable or
     necessary.

     6. If ultimately formed it should be in connection with
     the already existing Dominion-wide licensing body,
     Canadian Medical Council, which body, in the face of
     great difficulties, surmounted various obstacles as
     between the Dominion and its provinces.

     7. It can only come as a matter of evolution. The
     process requires:--

     (a) Abolition of provincial licensing examinations.
     (b) One licensing body for Canada, namely, the Canadian
         Medical Council.
     (c) License of Canadian Medical Council to be recognized in
         all the provinces.
     (d) Intimate working relations between Provincial Medical
         Associations and Provincial Medical Councils.
     (e) Intimate working relations between the Canadian Medical
         Association and the Canadian Medical Council.
     (f) A united Canadian Medical Association and a general
         demand for a college.
     (g) Canadian Medical Council to become the College of Physicians
         and Surgeons of Canada. Licentiates to become members.
     (h) Establishment of Fellowship diplomas, with admission to
         Fellowship by examination only, except as provided for the
         admission to honorary Fellowship.
     (i) Legislation covering (g) and (h).
     (j) Selection of outstanding physicians and surgeons to conduct
         Fellowship examinations, until such time as there are
         sufficient Fellows in the college to do this work.

     These conclusions are hastily put down and follow the
     line of my verbal report at the Ottawa meeting.

     It would appear to me, that, an expression of opinion
     from the conference would be valuable, so that the
     committee may have some guidance in respect of further
     activity.

The CHAIRMAN: Was any action taken at that meeting by resolution or
otherwise?

Dr. ROUTLEY: Yes. The annual meeting referred the matter to this
conference, and Dr. Marlow, who was to be here but is ill, sends that
communication on as chairman of the committee.

The CHAIRMAN: You have heard, the purport of the communication from
Dr. Marlow, which has been sent on by him as chairman of that
committee to this conference. It implies much of the argument already
put forward as to the Dominion Medical Council controlling
examinations for the entire country.

Dr. H. W. HILL (London): I am not intending to discuss licensure, but
I wish to offer one bit of information to the conference which may be
of some importance in the future.

Dr. MacCallum referred to the discrepancies in the requirements of the
various councils of the various provinces. The universities conference
has a Medical Section, which has taken up the question of
discrepancies in the curriculum of the various universities, and
reports have come in from nearly all the universities. I have the
misfortune to be the secretary of that section and to have tabulated
the results. They are quite interesting. I cannot report them here,
but to illustrate just one point alone, and it is a very important
subject, the school which gives the most gives three times the number
of hours as the school which gives the least. I would lay before the
conference the fact that this report will come out at the next
universities conference, and it ought to contribute to the subject of
medical education so far as showing what the actual status in Canada
is.

Dr. G. R. CRUIKSHANK (Windsor): As a member of the Ontario Medical
Council I wish to state that anything that I say is not the voice of
the council, but my own voice. Naturally we cannot say that we bind
our councils, but this is a very important matter, and I am sure the
Ontario Medical Council is willing to do anything reasonable, and if
the universities will get together and submit something to us that is
reasonable it will certainty receive our approval. We are here to
protect the public, and all we ask is a reasonable knowledge of
medical matters. A university may be idealistic and go much further
than we do. In times past the Ontario Medical Council has done its
best to raise some of the universities up to the general level, but in
the last year or two the universities have taken such a spurt, that we
do not need any longer to spur them along, but rather wait.

I was going to hold back a resolution I have here till later because
five minutes is all I have and something may crop up later on which I
want to speak, but I think it may clarify the issue if I present it
now. I would move that the paper of Dr. MacCallum be referred to a
committee composed of representatives from the various councils and
the universities, with power to add to their number, for
consideration. I think probably if we have a committee of this kind it
can take Dr. MacCallum's address up clause by clause and have a report
to submit that would be a step in the right direction.

The CHAIRMAN: Do you propose that they should submit a report at a
future sitting of the present conference?

Dr. CRUIKSHANK: I move that the address of Dr. MacCallum be referred
to a committee composed of representatives of the universities and of
the councils for consideration, and to report to-morrow to this
meeting.

The CHAIRMAN: One thing occurs to me in connection with that. We are
unfortunate in not having representatives from the provincial councils
of the eastern provinces; there is no one here from Prince Edward
Island, New Brunswick or Nova Scotia, who is a member of the
Provincial Licensing Board. No one has responded to the roll call as
officially representing those bodies. If Dr. Cruikshank would be good
enough to write out his resolution, I can put it to the meeting later.
In the meantime we can refer it to the Resolutions Committee, of which
Dr. Connell is chairman. I am sure there is not a member present here
who has not some very definite ideas on the subject before us, and
before we get through I shall not be at all surprised if every
individual in this room wishes to get on his feet and express his
opinion. I hope there will be no time lost.

Dr. A. MacG. YOUNG (Saskatoon): I wish to congratulate Dr. MacCallum
on the paper he has just given us. We believe the subject which he has
introduced is of very great importance. He made one reference to
Saskatchewan regarding our relations with Great Britain which perhaps
requires an explanation.

At the last meeting of the legislature, we had inserted in our Act the
words, "after examination by said council." That is referring to the
Medical Council of Great Britain. We were quite of the opinion that
they did not conduct an examination, but had certain assessors or
inspectors, and we said that so far as we were concerned we would
accept that as coming within the meaning of our Act. In other words we
did not exclude British practitioners from reciprocity, but we were
not in favour of this method of interprovincial registration. That is
the situation.

In Saskatchewan we are very much in favour of one portal of entry into
the practice of medicine in Canada, and all we have done at any time
has been along that line. I might state that we were the first in
Canada who voluntarily did not hold provincial examinations. Then
certain difficulties arose with regard to drugless practitioners, and
a commission was appointed to inquire into the whole question. As a
result of the investigation by that commission, the matter of holding
examinations was turned over to the university. Again a means was
opened up whereby provincial examinations would be held. At the last
session of the legislature there was inserted in the Act these words,
"or if deemed advisable may accept the examiners of the Medical
Council of Canada appointed for a similar purpose." That means that if
the university desires, it may accept the appointment of the Medical
Council of Canada examiners. So we have left open the door again
whereby this may become the sole portal of entry.

We believe absolutely in a national system of examination in Canada.
Registration or license must be left to each province, but we believe
the proper ideal is to have Canadian practitioners, rather than
provincial practitioners, and our whole effort has been towards that
end, and we will heartily support anything which will have for its
effect the bringing of that into being.

The CHAIRMAN: As this discussion goes on it is getting more
interesting. We have heard from Dr. Young as Registrar of the Council,
and he has shown that so far as Saskatchewan is concerned there seems
to be a sentiment in favour of some general standard for the whole
Dominion. Whether or not that is to be the final opinion of this
conference is left to be seen, and therefore we will welcome any
direct criticism or any antagonism against that idea. You have already
heard my sentiments from the chair, and I would like to hear the
opposite side, because we should all approach this question with an
open mind. I think if the Registrars of any other councils would give
us some technical points it might be of value. I see Dr. Aikens, of
the Ontario Medical Council. Perhaps he might say something to us. It
has been suggested to the chair that I should proceed in this way.

Dr. H. W. AIKENS (Toronto): Five minutes, five hours, or five months
would not suffice to enable me to compass the whole situation so far
as licensure is concerned. If there are any difficulties in connection
with matriculation or enabling certificates that we have not met with
in our office already which call for solution, then I would say I
would acquiesce in what Shakespeare says: "There are more things in
heaven and earth than are dreamt of in our philosophy." We have had
all sorts of difficulties, and we are at a loss from day to day to
know how to proceed--difficulties which concern our council, concern
other councils, concern the Canadian Medical Council, concern the
British Council, and chiefly relating to the circumstances under which
we should be free to give a qualifying or enabling certificate to
those who come to us for them. It is a little difficult without
specifying to indicate what our troubles are.

Matriculation we must handle as something which concerns not ourselves
alone but other provinces, other countries under the British flag, and
foreign countries, and we sometimes feel that it might be a wise thing
to divide all those who come to us for the purpose of getting
standing into two classes: those who will be allowed to matriculate
with us, and those who will not. Those who will be allowed to
matriculate with us will be naturally those who belong to our own
province and have met all our requirements. To those who belong to
other provinces and to foreign states we would say: "We will let you
present your certificates for matriculation at the time you go up for
final examination before us or before the Canada Medical, and we will
say whether they are acceptable. If they are not acceptable, we will
not give you a certificate. If you have not a certificate you cannot
demand of us an enabling certificate; you will have to go to your own
province for it." In that way we would meet a good deal of adverse
criticism directed against our council on the ground that it has
issued enabling certificates which should have been issued by other
councils; but there are circumstances under which it is absolutely
impossible to refuse students who come to our office on the last day
before the one on which they must send in their certificate to the
Canada Medical at Ottawa, and who say, "I come from a far distant
province and want an enabling certificate." We say, "No, go to your
own province." "I cannot do it," he says, "it is too far away and I am
too late." Although we do not do so, we feel disposed to say, "Why did
not your university five or six years ago advise you of the fact that
at the end of your course you would have to have such a certificate,
and prepare you in that way to obtain it at that time." We have been
more than accommodating; we have been absolutely gracious with a great
many to whom we felt we should not issue such certificates. But we are
being pressed by our own graduates and our own licentiates, who say it
is not fair to allow what is going on to continue any longer, that
students should not be permitted, for instance, to go up for our
Ontario matriculation examination and pass in seven subjects and fail
in five, and then go to some neighbouring province and pass three or
four more papers with the university of that province, and then come
back to Ontario and ask to be allowed to go up for examination at the
same time that a man who has passed all his twelve papers set by the
Ontario Educational Department.

These are the difficulties we encounter every day, and personally I
should be delighted to think that someone here had enough grey matter
to tell us a solution of the problem, if for no other reason than to
relieve us of the responsibility of meeting these unfortunate students
whom we have to try and oblige, when we desire at the same time to
play the game.

Dr. R. H. ARTHUR (Sudbury): I think probably we are all agreed on one
thing, that is, that the ideal method of licensure in the Dominion
would be to have but one examination, and that in the hands of some
body that has power to govern the entrance to the medical profession
throughout the whole Dominion.

Unfortunately, I think, at the time of Confederation the whole field
of education was given to the provinces, each one to do as it saw fit,
and that has probably been the great stumbling block in the matter of,
I won't say medical education, but medical licensure. When the
Dominion Medical Council was born, it was born with handicap; that is,
they were only there on sufferance, and any province that did not
choose to come in did not have to. I believe eventually they are all
in now, but at the same time it does not give it the air of finality
and power that I have always felt it should have, and it has always
seemed to me, and I make the suggestion with great deference, not
claiming any grey matter at all, that if the Medical Council of every
province would signify their willingness to forego their examinations
and place them in the hands of the Dominion Council, provided the
Dominion Council would get legislation that would give them power to
control the whole matter of entrance to the medical profession by
examination, the present difficulties would be overcome. While the
provinces have control of the matter of education, it does seem to me
without any quibbling that it does not necessarily follow they have
control of the matter of examination, and if every one of the Medical
Councils of the various provinces would signify not only their
willingness but their desire for some such legislation along this
line, in the form of an amendment to the British North America Act,
that this power to control examinations, not necessarily education,
but to control the examinations for the whole Dominion, should be got.
If so, it would do away with the overlapping that now exists. It would
make one standard throughout the country and we would then be one step
further towards being a nation.

While these are my personal views, the body which I represent here I
am satisfied at the present time would not under existing
circumstances vote to forego their licensing power, but if they felt
there was a finality to it I think they would agree.

Dr. L. D. CARDER (Vancouver): Speaking on behalf of British Columbia,
we have felt very keenly that there should be one licensing body for
the Dominion of Canada. We, I think, were the first to delegate our
examining powers to that central body absolutely. We hold no
examinations; we delegate that to the Dominion Council, and we find it
works very well. We have no reason to be dissatisfied with it, and we
do not see any particular objection to the other provinces doing the
same thing. We think we made a real sacrifice in doing that, because
we do not have any twenty-five below zero weather out in British
Columbia, and I never heard of anybody leaving British Columbia to
practise in any other province, while others do leave other provinces
to practise in British Columbia.

Dr. W. H. HATTIE (Halifax): I certainly cannot speak in an official
capacity at all. I am not a member of the Provincial Medical Board,
but I am in such relationship to that board that I have some idea at
any rate as to the attitude which the board takes on the proposal that
the Medical Council should constitute a single portal of entry. As you
may know, sir, Nova Scotia has not gained anything through uniting
with the other provinces in Confederation, and we have learned to be
very conservative there; we are not anxious to lose anything more than
we have lost.

As far as our council in Nova Scotia is concerned we feel that the
Provincial Medical Board is very fair and has, I think, a very good
control of the situation. There is some dissatisfaction, but it is not
very marked. I think I am giving you the attitude of the Board when I
say they would hesitate very much indeed to depart from a procedure
which has been satisfactory, in favour of another method which might
not prove to be so satisfactory. As it is, the board has practically
absolute control. We are very differently situated in that respect
from the province of Saskatchewan. Dr. Young has told you that there
the examinations are held by the university. With us the examinations
are controlled absolutely by the board. We are possibly a little too
meticulous about requirements. I know it has happened on several
occasions that men whom we would not accept have been accepted by
other provinces, and they have ultimately been able to get
registration in Nova Scotia, either through the Medical Council of
Canada, or through the General Medical Council; but we have entered
into relationships with both the Medical Council of Canada and the
General Medical Council with eyes fully opened to the possibilities.
When in the first place we obtained reciprocal relations with the
General Medical Council, it was with full knowledge of the
possibilities that that would ultimately lead to an indirect system of
interprovincial reciprocity. We have entered into these relationships
with our eyes fully open, and we feel that we must abide by anything
that might develop from these relations, and, as I say, we have had to
admit men to registration who would not have been admitted had it not
been for these relationships. The instances have been few, and we do
not complain.

I do not like to introduce a discordant note, Mr. Chairman, but I
think perhaps it is just as well that all should know that the chances
are that the Provincial Medical Board of Nova Scotia would be rather
loath to depart from its present practice. I think perhaps after all
that is all I need say. There are arguments pro and con, but I do not
know that I can add very much to the discussion.

The CHAIRMAN: That is the kind of criticism we want to hear. I am a
Bluenose myself, and I know how difficult it is to get them into line,
but once in line they are the best crowd I know of to fight for an
ideal. We have not heard from Alberta yet.

Dr. G. R. JOHNSON (Calgary): I do not know that I can add very much to
the discussion. I think many of the problems have already been stated.
I thought at one time that Alberta had all the problems due to the
fact that it was a new province and a great many medical men were
coming in, not only from our own Canadian universities but from
foreign countries as well. I thought our problems there were more
acute than those anywhere else, but I find that that is not the case.

The general opinion in Alberta is in favour of, and I believe the
council would be quite willing to stand behind any movement which
would accept the Canadian Medical Council examination as being the one
entrance into the province. It is true that we would like to make sure
that all applications received were bona fide in every sense of the
term; that is, we would require from each man at least that he is a
reputable citizen, that he has a good preliminary education, that he
has taken a medical course and passed successfully. We accept the
certificate of the Canadian Medical Council, and of the General
Medical Council of Great Britain, but we would like to see one
nation-wide standard, so that a registrant of Alberta could practise
in any other part of the Dominion and the registrants of any other
provinces come to Alberta and practise without further examination and
without further test.

I will not mention any of the problems that we have had to meet in the
last three or four years, as they are very similar to the ones
mentioned by the Registrar of Ontario.

Dr. J. F. ARGUE (Ottawa): I want to look at this thing first of all
from the standpoint of the medical student. I think one of the things
we should consider here is whether there is not any possibility of the
student getting away from dual examinations in his final year. In the
majority of the provinces, in his final year he comes up for his
university examinations, and if he wants to qualify to practise in the
province he goes through another series of examinations. I think our
ideal should be some method, either under the Medical Council of
Canada or otherwise, if it ever comes to one licensing body for the
Dominion, by which assessors should be appointed who would co-ordinate
with the examinations that are held at the close of the University
term, and in that way the student would be freed from one extra set of
examinations.

There is another point. If we are to have any uniformity and prevent
men slipping through into one province after being denied in another,
we must have one standard matriculation. The universities of Canada
should get together and provide one standard matriculation, and if a
man passes that he should be able to go to the university. I think we
have reached that in Ontario during the last year. We have one
standard matriculation, and if a man wants to study medicine, law,
science or any other subject that is taught at the university, that
one examination qualifies him to enter the university.

Another point is that our provincial registrars or provincial medical
councils should not allow anyone to get in by the back door. If a man
is turned down by one province, if the registrar would take the
trouble to notify the Medical Council and the provincial licensing
bodies that this man had made application and that his qualifications
were not what they should be, the other provinces would be warned.
Probably most of you know that during the last session of the Ontario
Legislature we had a man made a doctor practically by Act of
Parliament. Things like that would be avoided. I do not hold the
medical schools free from responsibility for some of the trouble. I
can remember men of very meagre matriculation standards entering upon
the study of medicine, and being told that if they would matriculate
during their first or second year they could go on, and they would be
kept on until finally they got a license to practise. This is simply a
question of co-ordination, it seems to me, between the medical
schools, the provincial Medical Councils, and the Medical Council of
Canada. The ideal I have for the future is a license to practise
anywhere in Canada after passing one examination, and that examination
should be held during the time of the final examinations of the
student's medical college, and should be conducted by a combined board
appointed by the central licensing body and the university which the
student attends.

Dr. A. T. BAZIN (Montreal): I do not represent any school or any
licensing body, but I think Dr. Argue has struck a note which should
command our sympathy when he spoke from the viewpoint of the student.
I might cite one instance that occurred not so very long ago, where a
student going through the strain of his final year and examinations,
followed immediately afterwards by the strain of a provincial
examination, and immediately thereafter by the further strain of the
Dominion examination, committed suicide very shortly afterwards. There
was no reason for it that we could discover except that his mental
balance was upset due to the prolonged strain which he had undergone.
That perhaps is an extreme case, but it shows what occasionally may
happen.

There are other viewpoints that might be considered as affecting the
student. Why after submitting a youth to a very prolonged system of
education, with all the expense incident thereto, should he be
penalized by the collection of a fee here and a fee there all for the
gaining of one object? That applies not only to the licensing fees,
but also to the matriculation fees. Matriculation in certain
provinces, perhaps not in all, is by means of two paths: one the
presentation of credentials which admit him, and the other by passing
an examination. It is permissible to conceive that if a student
desires to pass an examination, that there are special expenses
incident to that examination which should be collected from the
applicant; but if a man has followed a more or less prolonged course
of preliminary instruction which necessarily involves expense, and
does not actually form a demand for further expenses on the part of
the provincial board in order to show his credentials, why should he
be mulcted the expense of an examination fee? So much for certain
points in regard to the student's viewpoint.

As I say, I am not representing anybody but the executive of the
Canadian Medical Association, and that Association felt that a
conference of this kind, without necessarily arriving at any very
definite conclusions, but simply talking back and forth, detailing the
difficulties that present themselves, would certainly be of value. We
have with us to-day one who has had a very extensive experience both
on a provincial board, that of the province of Quebec, and on the
Dominion Board, Dr. Normand, of Three Rivers. I am sure the conference
would be very glad to get the benefit of his experience. There are
many problems in the province of Quebec that are perhaps different
from the problems presented in the other provinces, and we all of us
in the province of Quebec appreciate the difficulties in relation to
other provinces, and I do not think there is anyone who can clarify
the situation better than Dr. Normand.

The CHAIRMAN: I am sure we shall all be delighted to hear from him if
he will be good enough to give us his views.

Dr. L. P. NORMAND (Three Rivers): My situation is very peculiar,
because I have not been appointed by the College of Physicians in the
province of Quebec to represent it at this meeting. I am here as a
representative of the Canadian Medical Council, but as my friend Dr.
Bazin says, I have been associated for a very long time with the
College of Physicians and Surgeons of the province of Quebec, having
been for over twenty-five years a member of the college and for seven
years president of that college.

The province of Quebec has been one of the first provinces of Canada
to exchange with the British license. Since 1889 we have had an
exchange of licenses between the province of Quebec and Great Britain,
without any question. In connection with the Canadian Medical Council
I was engaged for many years before 1912 studying the Roddick Bill,
and I was one of the representatives of my province on the board, when
that Act was finally drafted and put into effect.

The province of Quebec has never discussed the question of having one
Dominion license. Any man from any province, Ontario, or western or
eastern provinces, coming to the board of Quebec with a Dominion
license has always been accepted and a license granted. In the
province of Quebec we have two classes of students. We have those who
comply with the requirements of our board, who are what we call
regular students, and we have those who do not comply with our
requirements but who come before our board and ask for a license to
practise in the province of Quebec, but we refuse them. During the
last twelve years many of them have been going to the other provinces
and paying the sum of $25 or $50 to the registrar to be registered.
They pass an examination of the Dominion Council, and get a license
from the Dominion Board, and then come back to the province of Quebec
and force a license from us when they have not proved themselves
sufficiently qualified to be accepted by our own board in the first
place. But we are now refusing to grant them a license. For the last
three or four years we have decided not to license any man that we did
not believe sufficiently competent to get our license in Quebec, and
who simply went to some other province and then came back to us. In
1918, six years ago, Dr. Simard and myself asked for an amendment to
the regulations of the Dominion Board by which the Quebec man who
could not get a license from Quebec should not be accepted through any
examination of the Dominion Board until he had satisfied every
requirement in order to become a licensed doctor, or until he had got
a certificate from the registrar of the province of Quebec. I was
sorry to hear the other day that we have many men coming up before the
board of Quebec, and instituting law suits against our Board on the
ground that this amendment to the regulations of the Dominion board
has not been subjected to the Governor in Council at Ottawa and given
lawful effect. At the last session of the board of the province of
Quebec in September--I was not present--they decided to ask that at
its next meeting the Dominion Board find means to stop any incompetent
man from passing via the Dominion Board, and if that is not done, I am
sorry to tell you that the province of Quebec has decided to withdraw
from the Dominion Board, if we cannot stop these incompetent men from
forcing themselves on us.

I was very glad to hear representatives from other provinces tell you
this afternoon that British Columbia, for one, has decided to put
aside its own regulations and accept the examination of the Dominion
Board. I have heard other gentlemen say that in the near future all
provinces may accept the examination of the Dominion Board; but let me
tell you, although I am not speaking for the board of the province of
Quebec, I know French Canadians' ideas sufficiently well to be
confident that never will the province of Quebec give away this right;
never will it forego the regulations of its own board and accept only
one Dominion license for all Canada. It is only a dream to think that
such a thing will happen. Quebec will keep the same regulations, the
same laws for the people who are willing to come before the Quebec
Board, but we will always be very glad to help in trying to make the
Dominion Medical Board the best of all boards in Canada.

The CHAIRMAN: We are very much interested in hearing Dr. Normand. It
impresses me as an individual that he has made a splendid argument for
the ideals we are trying to forward. It seems to me that if we had
what has been suggested, examinations of the same standard throughout
Canada, it would not matter much whether the Quebec Board compelled
its students to take its examinations in Quebec or elsewhere. It seems
to me a uniform standard would solve a great many of the difficulties,
and I am sure our colleagues from Quebec would welcome a condition
which would permit a nation-wide scheme whereby that unification might
be obtained without in the slightest degree infringing on the rights
and privileges and ideals which our colleagues have in the province of
Quebec and in the other provinces. I hope that this discussion will go
on. This is the kind of thing we want to hear. We have just had a real
difficulty presented, and I am sure there are many others.

Dr. YOUNG (Saskatoon): Suppose a man domiciled in the province of
Saskatchewan and educated, we will say at McGill University in the
province of Quebec, receives an enabling certificate from the
registrar of Saskatchewan, and passes the examination of the Medical
Council of Canada, receives his diploma and goes to the province of
Quebec, will he be accepted in the province of Quebec for
registration?

Dr. NORMAND: I am very glad that Dr. Young has put a specific case. If
a man from Saskatchewan or any other province has received his
preliminary education in such a way as to get his B.A. or some other
degree, and is regularly admitted as a medical student of that
province, if he has complied with all the requirements of that
province, it does not matter if he has received his education in
Quebec or elsewhere, if he gets his license from Saskatchewan and is a
regular physician of the province, and then comes with a Dominion
license to the board of Quebec, he will be accepted. But we do not
want a man from Quebec who is not able to pass to get his B.A. or pass
his preliminary examination, a man born and educated in the province
of Quebec, to be allowed to practice in the province of Quebec when he
is incompetent to pass our examination, just by paying a fee of $25 or
$50 in Saskatchewan or any other province, and then come into Quebec
with a medical license. We will not accept that man, because if he is
incompetent to pass our own requirements he should not be allowed to
practice in our province, for he has not proved himself competent
simply by paying $25 or $50 in some other province. He is a man from
our own province, and we have a right to refuse him even though he has
a license from the Dominion Board, when he gets his license without
any examination, just by paying a fee.

Dr. YOUNG (Saskatoon): I have in mind a gentleman in Saskatchewan who
applied to me for an enabling certificate. I made full inquiry as to
his domicile, and I was perfectly satisfied that he was domiciled in
Saskatchewan. He complied with our preliminary requirements and
received an enabling certificate from me, and did not have to pay $25
for it, either. Then he went to the Medical Council of Canada and
passed their examination and received his diploma, and then went to
the province of Quebec, but for some reason of which I am not aware he
was refused. I understand that he went further. I have here a report
from the province of Quebec, and apparently this man went to a lawyer;
I presume that is one reason they keep lawyers, to keep men straight
in the law. Apparently this man had a lot of difficulty, and I was
wondering why that particular man had that difficulty, in view of what
Dr. Normand has just told us, because this man was domiciled in
Saskatchewan, and had complied with all the preliminary educational
requirements of that province, and received from the registrar of that
province an enabling certificate. He had met all our requirements as
to preliminary education, had received his diploma from the Dominion
Council and then went to the province of Quebec, but was not accepted
without first going to a lawyer. I believe eventually he may have been
accepted. I was wondering just what the regulation was with regard to
that very case.

Dr. NORMAND: I do not know just what particular case Dr. Young is
speaking of. I have not been a member of the executive for the last
five years, and I cannot say what the reasons were in this particular
case, but I know that before that we used to accept any man as long as
he was a regular doctor and had graduated in any other province, and
had received a license from the Dominion Board. Could Dr. Young give
me the name of the man?

Dr. YOUNG (Saskatoon): Harold J. Steed.

The CHAIRMAN: This is a little bit irregular if we are to proceed by
parliamentary rules. We cannot expect Dr. Normand to remember these
individual cases. He has given the general principles and perhaps
Professor MacCallum in replying will deal with some of these points in
connection with licensure.

Dr. J. C. SIMPSON (Montreal): I happen to have come in rather close
contact with students' problems in regard to education and licensure.
Dr. Aikens very aptly said in the course of his remarks, referring to
the student who comes at the last moment and asks for an enabling
certificate that the question might very well be asked, "Why did not
your university five years ago advise you that you would run up
against this difficulty?" That, of course, is a very just criticism to
make. It happens that in our own university less than fifty per cent
of our students belong to our own province; less than fifty per cent
are students of the province of Quebec. The majority of them come from
all the other provinces, from the United States and other countries.
We are therefore brought into contact with the problems of students
from all provinces. Certain of our students coming from other
provinces and receiving their education in the province of Quebec, and
living there five years, make contacts and for one reason or another
wish to get a license to practise in the province of Quebec, so we are
up against just such problems as Dr. Aikens has mentioned.

There are one or two practical points where I think great help could
be given by registrars of the other provinces to their own men. During
the last few years and particularly at the present time, we are taking
up with the individual students when they come to us this problem of
licensure which is five years away; we start with them when they enter
the school. We are advising them as the sure way of keeping clear, to
register with their own provincial council in their first year. We are
telling the men from the province of Quebec that the way to get a
license in the province of Quebec is to obey the regulations of the
Quebec College of Physicians and Surgeons. We are advising the men
from the other provinces to register with their home province. Now we
are up against this difficulty. We find that one province, the
province of Quebec, makes it obligatory on the student to register
when he begins his medical study. The others do not. Ontario this
year, and I think this is a splendid move, announced a policy of
encouraging medical students to register with them when they begin
their medical studies; they charge just a nominal fee for this
registration. I have found from actual experience in the last month or
two that some of our students who have tried to register in certain
other provinces have not been encouraged, and in one case a student
was told he could register but would have to pay $100. It seems to me
that is a thing that just needs to be brought to the attention of the
registrars of the different provinces. What are some of the
advantages? Just one or two I want to reiterate: First, that the
medical student from the beginning of his course is kept clear with
his home province; secondly, if that student later on is for any
reason influenced to practise in the province of Quebec, he has
established from the very beginning of his medical course the fact
that he does belong to the province of Alberta or Saskatchewan or
wherever he happens to come from.

Dr. J. S. POOLE (Neepawa): Dr. Thornton is a confrre of mine on the
College of Physicians and Surgeons of Manitoba, but he spoke for the
Canada medical. Speaking for the College of Physicians and Surgeons,
but presenting rather my own views, we as a council feel that the
Medical Council of Canada must either go forward or retreat. A number
of anomalies have been presented to-day which must be rectified. An
enabling certificate has been used by many men in a way in which it
was not supposed to be used. Men who are not able to get a certificate
from their own province go to another province, and it is to
accommodate those students that an enabling certificate is given.

I think I am speaking for our own college in Manitoba when I say that
if the rights of the provinces are safeguarded, if the Medical Council
in a round-table conference of representatives of the provincial
medical councils and of the universities can work out proper
regulations as to matriculation and medical examination, our province,
and in time I have no doubt the other provinces will get behind the
Medical Council of Canada and give us the one door of entry. I have no
doubt those Scotchmen in Nova Scotia will even see their way to come
in as well. It is not the use but the abuse of the system that Dr.
Normand is objecting to.

Dr. D. LOW (Regina): I cannot speak with authority for anybody in
Saskatchewan, but I think I can say something that will give you an
idea of the general attitude of the profession in Saskatchewan in
regard to this matter.

I think it was in 1920 that a representative went to the Vancouver
meeting carrying a resolution asking the Council of the Canadian
Medical Association to endeavour to have steps taken to establish a
College of Physicians and Surgeons in Canada along lines similar to
that in Great Britain, and if possible in conference with them. First
I should say that we in Saskatchewan have not got a teaching body in
medicine. Alberta, Manitoba and British Columbia have. We are the only
province, I think, that does not undertake to manufacture doctors. We
thought that in the working out of this resolution, it would come to
the knowledge of the heads of the leading teaching bodies in the
Dominion and those in close touch with the licensing process, and that
we could safely leave it to them to maintain in Canada what we contend
is as high a standard as is asked for anywhere of those who wish to
practise medicine. We felt these men in due time would evolve a
standard of requirements and education that would be satisfactory, and
possibly beyond the requirements of most of those who set the standard
for licensing at the present time.

I may say that the resolution was passed at the provincial meeting of
the association. Some thought it had not received sufficient
discussion, but the resolution was so acceptable to the association
that they did not think it necessary to discuss it. But to make sure
there would be no mistake, the resolution was brought up again next
year and reaffirmed, and every one who spoke expressed his hearty
concurrence in it. We still think that if our teachers, the men in the
universities, and those concerned with licensing in Canada, will get
together in the spirit that we know exists, notwithstanding any
disagreement that may appear on the top, we are confident that
ultimately a system of examinations will be evolved that will be
satisfactory even to Quebec.

Dealing with the question of what must be given up by the provinces,
it seems to me, and I think to a number of others in Saskatchewan,
that we do not have to give up anything in order to agree in this. We
only have to say: If the standard is set where we think it should be
set, and the applicant is shown to have a proper knowledge of medicine
according to the standards of to-day (some of us might not be able to
meet them), it will be acceptable.

The discussion to-day bears out what I have said. I do not think it is
well to have all the sugar at the top when there is some salt hidden
below. It reminds me of something Dr. Roddick said when he was
endeavouring to have the Dominion Council established. I happened to
have the honour of his acquaintance, and met him on one or two
occasions during that time, and he told me, "Oh, it's a hell of a job.
I get Quebec fixed up, and British Columbia breaks out. I get British
Columbia fixed up, and Ontario breaks out." I am sure, gentlemen, we
will get them all by and by. Notwithstanding the fact that we have a
great number of extreme progressives in our Dominion no one will deny
that we are a very conservative people. We do not like to take radical
jumps; we do not like to swallow anything holus-bolus, but to
thoroughly digest and assimilate it, and what Dr. Primrose has said
about Bluenoses will apply pretty well all across Canada. Once we are
satisfied a thing is right and really means a step forward, everybody
gets in line. There is the statement of a man who was concerned with
the formation of the Dominion Council, quite a prominent man in his
province; "It's a splendid idea," he said, "a lovely thing, and we all
like it; that is politically some of us do, but actually, you know, we
don't want it." This discussion shows we are in just the same position
we were in then, but notwithstanding all that, we have a Dominion
Council. There may be some difficulties before us, but they can all be
smoothed out. We have only to get together in a proper spirit to
adjust the little difficulties, matters of detail rather, and I am
satisfied that if we do that we shall achieve the ultimate result we
are all aiming at.

Dr. J. J. GUERIN (Montreal): The whole question, as I see it, is mixed
up with the Roddick legislation from its very inception. I was a
member of the Executive Council of the province of Quebec at that
time, and I may say that the province of Quebec is exceedingly jealous
and exceedingly conservative in so far as anything pertaining to the
Dominion is concerned. They view with a great deal of anxiety any
proposition that would militate in any way against the bill
instituting the College of Physicians and Surgeons of the province of
Quebec. They gave the College of Physicians and Surgeons certain
rights, after very mature deliberation and they would not hear of any
license that would deviate from the requirements enacted by that
legislation.

We have, according to our law in Quebec, a standard of matriculation,
and that is the rock on which the whole thing shatters--the
matriculation. Our standard of matriculation is a B.A. degree of a
university, and those who are not possessed of the B.A. have to pass
before the College of Physicians and Surgeons, through professors
chosen by them, an examination equivalent to the examination they
would have passed had they obtained the B.A. degree, and until a
student has got the B.A. degree or has passed an equivalent
examination he cannot be registered in the province of Quebec. It is
all very well for us to discuss the pros and cons. I believe myself
that the standard of medical education throughout the Dominion of
Canada is pretty well equalized, but it is to prevent the undesirable
element from getting into the profession that we enacted those laws.
We have had applications from all classes of people to study medicine,
and before those laws were enacted many undesirable people were
entering on the study of medicine, so it was finally decided that we
would establish a standard of preliminary education, and that standard
is established by the B.A. degree, or by a very severe examination
equivalent to the B.A. degree, and a student is not supposed to
commence his medical studies until he has satisfied the College of
Physicians and Surgeons that he comes up to that standard.

It is all very well to speak about the final examination. I have no
doubt but that many men are refused in the province of Quebec who are
the peers of their fellow-practitioners in other provinces, so far as
their medical training is concerned; but we are exceedingly
conservative in Quebec. We want the preliminary training; we want to
have men brought up in an atmosphere that will qualify them later on
to occupy the exalted position of physician in our province. I do not
know of any change in the British North America Act that could change
this state of things, because education is essentially one of the
prerogatives of the province, and the province, I may say, Mr.
Chairman, is so exceedingly careful lest there should be any
interference in the education of the youth that they would view with
great suspicion any enactment that might in any way militate against
the standard established to-day for the entry into the study of
medicine.

In my own university, the University of Montreal, we have a
matriculation examination; in McGill they have a matriculation
examination; many universities have a matriculation examination which
qualify the youth to study medicine in these institutions, but neither
matriculation nor examination by the University of Montreal, or McGill
or Laval or of anything you please in the province of Quebec, will
entitle a man to present himself for a license after five years unless
he has previously qualified himself as the legislature requires in
order to commence his study of medicine.

It is very well for us to discuss these questions and to listen to the
arguments that are being made, but the primary trouble is the
examination for the entry into the study of medicine, and unless you
can find some method of co-operation which I cannot see at the moment,
and I was very intimately concerned with the legislation in regard to
this bill from the very beginning, I cannot see how you could ever
pass any legislation over the head of the College of Physicians and
Surgeons for the province of Quebec, and what is more I cannot see how
the legislature could be convinced that it would be for the general
advantage that we should deviate from the state of things that now
exists. Our standard for the study of medicine is high; our standard
is one that we do not wish to lower; and notwithstanding anything we
may do, though I have no right or prerogative to speak for the College
of Physicians and Surgeons, being here simply representing the
University of Montreal--I have been on the board of the College of
Physicians and Surgeons for many years; I am not on it now--but I am
sure that if the representatives of the college were here they could
not tell you anything different from what I am telling you.

From the discussion that has taken place it seems to me that the whole
trouble arises over the preliminary education and examination for the
study of medicine, and unless that difficulty can be overcome in some
way that I cannot suggest, I think we will meet with failure in our
efforts to bring about an understanding whereby the license of the
Dominion Council would prevail in the province of Quebec.

Dr. J. C. CONNELL (Kingston): May I first express my great
satisfaction and pleasure that I have been permitted to attend this
first conference of the Medical Services in Canada. It realizes an
idea, a dream perhaps, that has been in my mind more or less for the
last twenty-five years, and I hope this will prove only the beginning
of a permanent organization which will continue from year to year and
contribute very greatly to the progress of the medical services and to
the welfare of the people of Canada generally. We did not secure the
Medical Act of Canada without dreaming about it for a long time. I was
a medical student when I first heard Dr. Roddick speak on the subject
of Dominion registration--I won't tell you just when that was, but it
was a long time ago--and I considered it a great honour when later on
I had the acquaintance and friendship of Sir Thomas Roddick. Certainly
he dreamed about that Act for a long time, and finally his dreams
came true. Even Quebec was reconciled and became a party to the
Medical Act of Canada as it now stands. Of course, the Act is full of
compromises, as is known to quite a number of gentlemen here who are
familiar with the details leading up to the final acceptance of the
Act. It is not a perfect Act by any means, but it has been working
twelve years, and I think we have no reason to be dissatisfied with
the results. There are now over 1,300 practitioners in Canada who have
the license of the Medical Council of Canada. That represents a large
body of medical opinion, and I think I can foresee in the next
generation of the medical profession in Canada, that those who hold
the license of the Medical Council of Canada will control medical
opinion in Canada. I am quite sure there will be no going back; there
will be progress, and continued progress all along the line. Of
course, there are difficulties. Some of them are inherent in the Act
itself. It has been suggested, for example, that the question of
preliminary education, curriculum, and so on, should be in the hands
of the Medical Council of Canada. There is no provision whatever for
that in the Act. I myself, after working with it for some time, feel
that that is not necessary, that we can work it out as it stands. That
is one of the suggestions that have been made.

We have also been informed to-day that the province of Quebec will
insist upon an amendment to the Act which will legalize what they have
been doing for the last few years. I should like to emphasize that the
Medical Act of Canada provides that a candidate must have either a
provincial license, or that he must comply with all the regulations
right up to the point of writing on the examinations of the provincial
board. Now for several years the province of Quebec has not issued
enabling certificates to such candidates. It will only issue
certificates to those who actually hold a license. It has withheld
that privilege, although that privilege is definitely provided for in
the Canada Medical Act, and we are told that Quebec will withdraw
unless that is legalized. Well, no amendment to the Medical Act of
Canada can be presented to the House of Commons until every provincial
council has consented; how are you going to get it? Not easily. I
think it will be a long time before there is any amendment submitted
to the House of Commons that will essentially change the provisions of
the Medical Act of Canada. Perhaps that is one of the weaknesses of
the Act; it may be it is one of its strengths. Personally I think it
can be worked out as the Act stands.

There are one or two other points on which I would like to say a word:
first of all, the reference made by Dr. Argue to dual examinations by
the council and the university and his suggestion of some system of
assessors. After my experience of quite a few years now in connection
with medical education, I am not in favour of such a system. I think
it is not unreasonable that a candidate who has spent his years in a
university and has now graduated should submit his qualifications for
review by outside examiners. So far as I am concerned, I would say to
any under-graduate who has come to the point of graduation, "It is
quite reasonable that you should submit yourself to a board of
examiners to see exactly where you stand." I think that is a very good
thing for the school, a very good thing for the candidate, and I would
be very sorry to see any departure from such a system. The system of
assessors is not workable in a practical way. I do not think it
amounts to anything. The other objection to it is this: We are likely
for some time to educate quite a number of foreigners, and if you have
a system of assessors practically every man who graduates from a
Canadian school will have a Canadian license. I do not think that is
good public policy; I do not think it is good from a professional
standpoint. Just on that point I would like to point out what a good
many of my provincial friends fail to see, that it is to the advantage
of the profession in any province that all the men who are educated in
that province should have a Dominion qualification rather than a
provincial one. He should have the whole of Canada for his field,
rather than be limited to one province. It is in the interests of the
profession in the province that that should be the case. I say that
because it applies particularly to my own province, and I have
difficulty sometimes in persuading my colleagues that that is really
the case.

In regard to the difficulty that Dr. Normand has raised with regard to
Quebec, it seems to me the remedy lies with Quebec itself; it is a
domestic problem. It appears there are two classes of students in
Quebec, regulars and irregulars. The regulars--Dr. Normand will
correct me if I misunderstood him--are those who have complied with
the preliminary requirements of the Medical Council of Quebec in
regard to matriculation. The irregulars are those who have not, and
who with incomplete matriculation are admitted to the medical schools
and receive a medical education. Why are they admitted? Is it not a
matter of accommodation between the medical schools of the province
and the Medical Council of Quebec? Should there be any irregulars?
There are no irregulars in Ontario.

Dr. J. C. SIMPSON (Montreal): I think you misunderstood the statement
of Dr. Normand. In his terminology irregulars are those men who do not
fulfil the requirements of the province of Quebec but who fulfil the
requirements of some other province. A man, for instance, who fulfils
the requirements of Ontario, let us say, may not be a regular student
from the point of view of the college of the province of Quebec,
because he may not have the B.A. degree, which Quebec requires.

Dr. J. C. CONNELL (Kingston): If he is a resident of the province of
Quebec, he is subject to the regulations of the council of the
province of Quebec, and if he wants to get an enabling certificate--

Dr. J. C. SIMPSON: A student who has complied with the matriculation
requirements for entrance to any university in Canada may still not be
in a position to proceed to his license in the province of Quebec.

Dr. J. C. CONNELL: I cannot see but that it is a domestic question for
Quebec, after all. If he wants to get an enabling certificate he
cannot get it if he is not domiciled or a resident, and no other
province will give him an enabling certificate.

Dr. J. C. SIMPSON: That is quite admitted.

Dr. J. C. CONNELL: No other province should give a man domiciled in
the province of Quebec an enabling certificate. He must get it at
home.

Dr. J. C. SIMPSON: That is obvious.

Dr. J. C. CONNELL: Then where are your regulations? There is no
difficulty except between the council of Quebec, and the colleges. I
may be dense, but I think after all it is a domestic question for
Quebec, and I think I can safely say that Quebec will not withdraw
from the Medical Council of Canada.

The CHAIRMAN: We have not heard from New Brunswick. I see my old
friend Dr. MacLaren, whom the conference would be glad to hear from.

Dr. MURRAY MACLAREN, M.P. (St. John, N.B.): I cannot speak for the
council of the province of New Brunswick because I am not a member of
it; I can only say something as an individual, and as a member of the
council of the Canadian Medical Association.

We all recognize the fact that the British North America Act provides
that education comes under the provinces. I think that also includes
examinations, for I take it that education includes everything
surrounding itself, and I think examinations would be included in the
interpretation of education. Consequently both examinations and
education are matters for the province to deal with. That being the
case and the profession being unhappy under these circumstances, has
led after many years to an attempt being made to arrive at some
central method of examination. But there must always be difficulty in
doing that. The British North America Act is there, and it is, I would
consider, permanent, and I would say that so far as the Dominion is
concerned we must always expect difficulty, and we are always limited
in our procedure. I think up to the present we have endeavoured, as it
were, to arrive at a method satisfactory to us and yet not in direct
conflict with what is laid down in the British North America Act. I do
not see any way of arriving at the object aimed at. I sympathize with
those who desire it and would desire it if it were possible, but I
have not any solution to offer. There may be, and I think there
probably will be some way found of meeting the difficulties in the
situation. Arriving at a uniform standard of matriculation and having
a uniform standard of medical education throughout the Dominion is an
entirely different thing from what is laid down in the British North
America Act. There is clearly no reason why the various provinces, the
various councils and the various universities should not among
themselves agree upon a standard. It is a matter then for the councils
and the universities, if they see fit, to grapple with the problem and
arrive at a common standard. They are very far from it now. It was
very interesting to note the disparities between the different
provinces which Professor MacCallum outlined this afternoon, but there
is no reason why an agreement should not be reached that would not in
any way contravene the provisions of the British North America Act.

After all, our primary object is to elevate the medical status in the
Dominion of Canada. That is the essential thing and to me is far more
important than the question of one board of examination. All these
other matters are, of course, important, but the primary thing is to
arrive at as high a standard of matriculation and of education as we
can reasonably expect and ask for. If we advance, we will advance, I
believe, step by step. If we secure first a uniform matriculation,
there will be here and there an improvement in matriculation
requirements, because I am satisfied that those who have now a good
standard will not be prepared to accept anything less. If we secure
that first, an improvement in matriculation and through the curriculum
of medical education, we will have accomplished a substantial good,
and I think it may lead the way to something further in the way of
Dominion registration. The whole scheme of registration will then be
brought to a level throughout the Dominion, and by that time it may be
there will be some method found of securing one examination.

British Columbia, it seems to me, has taken a wise course in handing
over its examinations to the Dominion Board. There is nothing to
prevent any other province from following its example, but no province
need do so unless it chooses; and I take it there are several
provinces that will not be prepared to do so. But even a few following
that course will help in the formation of public opinion on this
matter. I think the greatest good we can look forward to in the
meantime, because it is possible, because it is reasonable, because it
is desirable, is the obtaining of a uniform standard regarding
entrance to the study of medicine, and in the subsequent course of
medical education, that is, in the curriculum.

Dr. MCGILL: I wish to clarify one point about which there has been
some misunderstanding, at least in my mind, and that is with regard to
what is meant by an assessor. If it means a person who merely visits
during an examination, without participating in it, then I would agree
with Dr. Connell that it would be practically a useless procedure, but
on the other hand, if in this country some system such as that adopted
in Great Britain could be introduced, whereby the assessor is also a
co-examiner, the system would be an admirable one when it is
introduced to bring about reasonable uniformity in instruction, and
there should be no great difficulty in working out some such scheme.
One should remember, however, and I think the committee should
remember, that such a scheme is necessarily expensive. It is expensive
in Great Britain for the General Medical Council, and would be much
more so here where the distances are so much greater. With regard to
that examination, I may say I have had some personal experience,
having been a co-examiner in the University of Aberdeen, for two years
before I came to this country, and I know the influence of this system
of co-examiners was very markedly felt in the standards that the local
university authorities felt they had to maintain. It brought about a
correlation of teaching which I think is what we are all aiming at in
this country.

The CHAIRMAN: If there is no further discussion I will call upon Dr.
MacCallum to reply.

Dr. JAS. M. MACCALLUM (Toronto): Others I am sure have succeeded very
much better than I have in explaining the difficulties we had with
matriculation, but I tried to make you understand that there were
different ideals of education, different ideas about it, and I refused
to say which was the best. When you tackle that job you have a very
difficult thing to deal with, but do not forget, it is not merely a
question of Quebec. We all have provincial pride. We in Ontario have,
as I think you all know, but the fact is that the standard of
matriculation can be improved in various places. It will be improved,
and that is my object in bringing the matter before you. We cannot do
it ourselves, but reports will be made to the various Councils
represented here, and I have no doubt it will lead to improvement.

I said I was a man of peace, and yet I may say I regret very much
there was no gentleman here who would get up and break a spear on
behalf of British reciprocity. Some of my friends say I love a fight.
Candidly I confess I do, but I do not see why something has not been
said on that question. I would ask Dr. Carder this. He tells us they
have accepted the Medical Council of Canada examination as their own.
Now in the event of that becoming the practice in all of the
provinces, or in the event, which will happen long before that, of the
license of the Canada Medical Council becoming Dominion-wide, has
British Columbia got any objection to our also having British
reciprocity? What will be the attitude of British Columbia?

Dr. L. D. CARDER (Vancouver): They would not do it.

Dr. MACCALLUM: All right; that settles that for all time, gentlemen. I
knew that long ago. I thought you might just as well recognize the
fact that these problems are complicated by political considerations.
I am not going to say what they are, but just buttonhole Carder
outside. He did not tell me, but I got it from another source.

Dr. Normand told you Quebec was going to withdraw. I have had later
advices. The last advice I got was that Dr. Normand was suffering from
nightmare. Every once in a while he falls to sleep and is wakened by
some such nightmare. I am quite convinced had Dr. Normand, the Nestor
of the Quebec Medical Council, been present at that council, he would
never for one moment have joined in it. Dr. Normand, like myself, is a
man of peace. Like myself, so my friends tell me, he is a man of
consideration and courtesy. This is all a misunderstanding, gentlemen.
I am not going to get up here for one moment and contend anything
else. Dr. Normand and I may possibly go over to Hull, and in a quiet
chat get a great many things cleared up. I had taken the trouble to
read the proceedings of the Quebec Medical Council, and there seems to
have been in this account of that nightmare some sort of an idea that
the other provinces were trying to force Quebec. Now I know Dr.
Normand will never think that for one moment. It is all a
misunderstanding. The College of Physicians and Surgeons of Quebec has
no quarrel with the Canada Medical Council. The Canada Medical Council
is placed in a most invidious position. The province says: This man
was born in this province; he matriculated here; his domicile is
here; he lives here; this is his home; he belongs to us. Surely Dr.
Normand would not be so discourteous; I am sure he would not be
lacking in the courtesy so characteristic of all the French-speaking
people, as to say, "We demand that man." That is where the whole
trouble is. The Dominion Medical Council cannot interfere. What right
has it to say to my quiet and serene friend there, Dr. Aikens, "You
cannot give a certificate to this man?" He says, "This man is mine."
Saskatchewan says, "He is not your man, he is ours." Quebec says,
"That man belongs to us." I hope that will show to Quebec that we
really are at one and I have not any doubt that Dr. Normand will join
the league.

Dr. G. R. CRUIKSHANK (Windsor): I am sure we are all agreed that this
has been a most profitable discussion. We have touched on some knotty
problems, but the end is not yet. It won't do to get drawn into a
controversy in this discussion, or then nothing will be done. I move,
seconded by Dr. Poole, that Dr. MacCallum's paper be referred to a
committee composed of representatives from the universities and
licensing bodies for consideration and report to this conference
to-morrow, the committee to be named by the chair.

The CHAIRMAN: What is your pleasure? Shall the motion carry?

The motion was agreed to.

The CHAIRMAN: Then I nominate the committee as follows:--

Dr. D. S. MacKay (chairman)
Dr. W. H. Hattie
Dr. J. C. Simpson
Dr. L. P. Normand
Dr. Duncan Graham
Dr. P. S. McKibbon
Dr. W. T. Connell
Dr. W. A. Laidlaw
Dr. W. A. Rehfuss
Dr. G. R. Cruikshank
Dr. J. S. Poole
Dr. G. R. Johnson
Dr. A. M. Young
Dr. L. D. Carder
Dr. R. H. Arthur
Dr. J. M. MacCallum
Dr. R. S. Thornton
Dr. J. J. Guerin

May I ask every member of this committee to be present to meet Dr.
MacKay in the Tudor room of the Chateau promptly at eight o'clock
to-night. Is there any further business? If not, we will now adjourn.

The conference adjourned.




=FRIDAY MORNING SITTING=


The conference met, Dr. Primrose in the chair.

The CHAIRMAN: I shall first of all call upon Dr. Seymour, Deputy Minister
of Health of Saskatchewan, to read to the conference his address on public
health work in that province.



HEALTH WORK IN SASKATCHEWAN

Dr. M. M. SEYMOUR, Deputy Minister, Department of Public Health,
Province of Saskatchewan: It is almost two decades since the province
of Saskatchewan was constituted, but in order to trace the groundwork
of public health activities initiated by the early pioneers, it is
essential to give credit and honour to those who legislated and
administered the affairs of what was then a part of that large area
known as the Northwest Territories.

As remote as 1898 we find a Public Health Ordinance in force for the
prevention of contagious diseases, with provisions for appointing
medical officers of health and sanitary inspectors in cities and
towns. Although, at this early period of western civilization, the
cities in what is now the province of Saskatchewan, had not attained
to any great importance in population, we find that they, with several
of the more populous towns, had complied with the law in having the
services of medical health officers. In common with all newly-settled
sections of land recently opened for homesteaders, little attention
was paid to affairs affecting the general health. The natural freedom
from law and order found all settlers who entered the virgin prairies
become almost licensed to neglect or pay attention even to the
rudiments necessary to healthy life. The well-balanced discipline of
the members of the Royal Northwest Mounted Police was employed to meet
and advise settlers that all matters of law for the order, health, and
general wellbeing of residents must be respected, and to this
splendidly equipped and judicial force much credit is due for the
administration of early health measures.

The Public Health Ordinance, amended in 1902, was adopted at the first
session of the legislature of the province of Saskatchewan in 1905,
and was further amended in 1907 and continued to be the health law
until December, 1908.

Early in 1906 the Government appointed Dr. M. M. Seymour as Provincial
Medical Health Officer, who, for three years, was the only official,
and who, with occasional help from the Royal Northwest Mounted Police,
carried out such preventive measures as were necessary in controlling
outbreaks of disease of a communicable nature. At this period, when
settlers were flocking in from all quarters, such diseases as smallpox
and typhoid fever were introduced, becoming endemic, owing to the then
practice of settling in communities. Many of the outbreaks reached
epidemic proportions, showing the necessity for a more organized and
delegated method of control by health districts, instructed,
supervised and made responsible to a central governing authority for
all affairs affecting the people's health.

Up to this stage the administration of health matters was under the
Department of Agriculture, and the correspondence of the period shows
the amount of work required of the deputy minister and the provincial
medical health officer in attending to all matters relating to the
public health and welfare of residents.

With the passing by the legislature in 1909 of the first Public Health
Act, being chapter 8 of the Revised Statutes of Saskatchewan, a new
and improved method of public health administration was inaugurated, a
permanent bureau was created under one of the ministers of the
Government, with the chief officer called the Commissioner of Public
Health to perform the duties prescribed by the Act, and such other
duties as might be assigned to him by the Lieutenant-Governor in
Council under any other Act.

A Council of Public Health was established to act with the
commissioner in considering and revising rules and regulations made
under the provisions of the Act and to report thereon to the
Lieutenant-Governor in Council. The commissioner immediately set about
to the collecting of a staff of permanent officials as a nucleus
around which centre would collect all matters relating to the public
health, requiring legal, technical and executive decision. Early in
1910 the following officials were appointed, namely: T. Aird Murray,
C.E., Consulting Engineer and Assistant Commissioner of Health;
Medical Inspector and Provincial Sanitary Engineer in the person of
Thomas Watson, a member of the Royal Sanitary Institute.

The appointment of a consulting engineer to this new province proved
to be a wise and advanced step in the work of prevention of disease,
as the provision of means for sewage disposal and the preserving of
safe water supplies to the larger centres of population was of the
utmost importance in a prairie province like Saskatchewan. The new
Public Health Act provided that before any scheme for establishing a
water supply or sewage disposal works could be undertaken, it was
first necessary to obtain from the commissioner a certificate to the
effect that the plans and specifications had been approved of. This
was made mandatory by the inclusion in the Act that no by-law for
raising money for such a construction could be submitted to the
electors without the preamble to the by-law stating that the proposed
work had received the approval of the Commissioner of Public Health.
This type of advanced public health legislation was very favourably
commented upon at a conference held in Ottawa, called by the public
health section of the Conservation Committee in 1910. At this early
period, sewage disposal plants were designed and constructed in
Regina, Moose Jaw, Swift Current, Yorkton and Maple Creek, most of
which were completed and in operation in the year 1910.

The Public Health Act, in defining the functions of the commissioner,
specified matters for which rules and regulations could be made for
the guidance of all whose duties it would be to carry out health
provisions. Regulations dealing with contagious and infectious
diseases, prevention and removal of nuisances, dairy and milk
supplies, tenement houses, hotels and restaurants, were treated and
passed as being the essential matters requiring early attention.

As a preparatory step towards efficient administration, it was
imperative to organize the province into health districts in order to
utilize local governing bodies and make them responsible to the Bureau
of Public Health for carrying out the regulations dealing with
sanitary and health affairs. Although in every city and many towns
there existed health boards, in the numerous rural municipalities and
villages no such provision obtained. Therefore, it was necessary to
create all organized centres as health districts. This was easily
accomplished by making every municipal board a unit of the bureau with
a qualified medical practitioner as medical health officer.

With the distribution to health units of copies of the Public Health
Act and Regulations, together with the powers and responsibilities
they directly implied, the councils of health districts especially,
and also the general public, became interested, with the result that
the correspondence on all subjects relating to health became
voluminous. This desire to acquire information was met as far as
possible by the commissioner and other officials of the bureau, by
visiting centres and holding public meetings to educate not only
members of health boards but also the general public on ways and means
of co-operating with their local health authorities in efforts to
carry out the provisions of the regulations. Year by year has shown
that the regulations issued by the bureau have engaged the attention
of the local health board, as well as interested residents to give
personal attention to matters affecting community life, until the
Bureau became the clearing-house for all complaints relating to
hygiene.

In 1923 the Public Health Act was amended, creating the Department of
Public Health, with Hon. J. M. Uhrich as the first Minister of Public
Health. The responsibility for the administration of the activities
of the Department of Public Health in Saskatchewan is vested in the
Minister of Public Health, and he has under his jurisdiction the
following Acts:--

(1) The Public Health Act;
(2) The Vital Statistics Act;
(3) The Union Hospital Act;
(4) An Act to Regulate Public Aid to Hospitals;
(5) The Venereal Disease Act.

The Council of Public Health, created by previous legislation, was
continued under the new Public Health Act. It consists of the deputy
minister, as ex-officio chairman, three duly qualified medical
practitioners, one qualified Veterinary Surgeon, and at this session
the Act has been amended by adding a civil engineer to the Council of
Public Health. This council is required to meet at least once a year
to consider and review all orders, rules and regulations, and to make
a report to the minister, with such suggestions and recommendations as
may be deemed necessary in the interests of public health. This
Council may also consider matters referred to it by the minister and
submit a report upon the same to the Lieutenant-Governor in Council.
The members of the Council are appointed to hold office for two years
and receive remuneration from public funds.

The members of the Council of Public Health at the present time are,
in addition to the Deputy Minister, Dr. T. W. Walker of Saskatoon,
President-Elect of the Saskatchewan Medical Association; Dr. T. M.
Leask of Moose Jaw, President of the Saskatchewan Medical Association
for the year 1924; Dr. W. A. Thomson, former President of the
Saskatchewan Medical Association; and Dr. Chasmer, Secretary-Treasurer
of the Saskatchewan Veterinary Association.

The provisions regarding health districts and boards of health, as
well as requiring health districts to appoint legally qualified
medical men as health officers, are being continued in the new Public
Health Act. The power is also given for the appointment of sanitary
officials. In order to provide for the increased work of the
Department of Public Health, it has been divided into the following
divisions:--

(1) Administration;
(2) Child Welfare and Hospital Management;
(3) Communicable Disease;
(4) Sanitation and Hospital Organization;
(5) Venereal Disease Control;
(6) Vital Statistics;
(7) Laboratory.


ADMINISTRATION

The administration under the minister has full responsibility
regarding all matters pertaining to the department and formulates the
general policies and suggestions in connection with the various
divisions. The department operates the general supervision of all
boards of health of the province, as well as the carrying into effect
of the Health Act and Regulations. Public health propaganda and
publicity work receives a lot of attention from the department.


CHILD WELFARE AND HOSPITAL MANAGEMENT

The Division of Child Welfare and Hospital Management, which is
presided over by a physician, has the supervision of the organization
and holding of child welfare conferences and baby clinics, home
nursing, maternity grants, and the relief of destitutes, who are for
certain reasons unable to obtain aid from any municipality.

Within the last few years all parts of Saskatchewan have been well
covered by baby clinics, special attention being given to outlying
districts far from qualified medical assistance. This work has been
very much appreciated, with the result that a number of districts now
have child welfare clinics held regularly under the supervision of the
local physician. Children of pre-school age are given a thorough
physical examination, parents are advised as to defects, if found, and
are advised to see their physicians regarding the same. The importance
and necessity of an examination by a medical man, at least once a
year, is strongly recommended to the parents. The growth of this work
may be judged by the fact that the number of children examined has
grown from two hundred and ninety-two (292) in 1906 to three thousand
four hundred (3,400) in 1924. It may be noted that the latter figure
does not include the number examined in connection with local clinics,
of which there are now a number being held regularly. Films, pictures,
posters and exhibits are made use of for the spreading of baby
welfare, and information is given at fairs and other community
gatherings.

In addition to these clinics, three nurses are employed to give
further instructions in the care of children, one nurse devoting her
time among the new Canadians. This work is meeting with great success,
and through the enthusiastic co-operation of women's organizations,
the number of women reached is growing rapidly. The course includes
instructions in the general care of children, first aid, and what to
do before the doctor arrives.


MATERNITY GRANTS

The province of Saskatchewan makes a grant of twenty-five dollars
($25) to assist any expectant mother who lives where there is no
medical attendance readily available to obtain the required medical
aid. This sum is usually divided by making a grant of ten dollars
($10) at once to the mother for obtaining the necessaries for the
event, and fifteen dollars ($15) is paid to the doctor who attends
her. This sum of $25, however, may be paid entirely to the physician,
or may be paid to the hospital that the mother goes to, upon her
request. That this grant has fulfilled, to a great extent, its
purpose, may be judged from the following figures:--

          Number of mothers
    Year  receiving the grant

    1920       17
    1921      125
    1922      253
    1923      286
    1924      427


HOSPITALS

Upon the formation of the province of Saskatchewan in 1905, there were
six hospitals received financial aid from the public funds:--

Regina--Victoria Hospital.
Prince Albert--Victoria Hospital.
Yorkton--Queen Victoria Cottage Hospital.
Moosomin--General Hospital.
Battleford--Victorian Order.
Indian Head--Victorian Order.


UNION MUNICIPAL HOSPITALS

In order to ensure better hospital care for the rural districts of the
province, and especially to provide for maternity and emergency cases,
in the year 1917 an Act was passed providing for the formation of
rural municipal hospitals by which two or more municipalities could
combine to form a hospital district. By this means it is possible to
raise money to build and equip a hospital, and this union hospital
plan has worked very satisfactorily.

There are at present forty-three (43) hospitals receiving aid in the
province, not including ten (10) Red Cross Nursing Outposts.
Saskatchewan is now fairly well equipped with hospital facilities.
Fifty-six per cent (56%) of the total bed capacity is available in the
cities, while forty-four per cent (44%) serve the rural districts and
the population of the smaller centres. For the treatment of tubercular
cases there is one bed now available for every nineteen hundred
(1,900) of the population, while isolation accommodation is at the
ratio of one bed for every thirty-three hundred (3,300) of the
population. The sum of three hundred and twenty-thousand dollars
($320,000) was voted to the aid of hospitals last year from public
funds. The per capita investments in hospital buildings and equipment
in the province now amounts to five dollars and ten cents ($5.10). In
September, 1923, the hospital regulations, which have been enforced
for a great many years, were amended for the purpose of assisting the
hospitals in obtaining for their patients the best possible service.

The Department of Public Health, which administers the Hospital Act,
makes it clear that the responsibility for the management and control
of the hospital, as well as the results obtained in so far as the
patients are concerned, rests with the Board of Management. It is
pointed out that the board has a duty to perform in seeing that the
hospital is properly staffed and furnished with the necessary X-ray
and laboratory facilities. Among the regulations are included:--

(1) The interpretation of practising medicine in hospitals, which is
limited to those registered under the Medical Profession Act.

(2) All plans and specifications of the building or addition to
hospitals, or alterations in hospitals, shall, before such work is
begun, be submitted to the Minister of Public Health for approval.

(3) Provision shall be made for at least eight hundred (800) cubic
feet of space for each patient, and twenty-four hundred (2,400) cubic
feet of air per hour, with at least one window for every two beds.

(4) Fire protection must be provided.

(5) City hospitals are required to have an Advisory Medical Board of
three doctors.

(6) Each hospital is required to have a medical staff, which staff is
to meet monthly for the purpose of reviewing and analyzing the
clinical experiences of the staff, discussing cases ending fatally or
unimproved, and any notifications or applications which may occur in
the hospital.

(7) A report of the meeting is to be sent to the minister.

(8) Hospitals are required to make provision for the care and
treatment of maternity cases, as well as for cases of tuberculosis, to
the extent of one-tenth of their authorized bed capacity.

(9) Case records are required to be written up for every patient
admitted to the hospital, as soon as possible after the admission.
Where no case record has been written up, the hospital is to note this
fact in red ink on the form which is sent to the Department every six
months.

(10) Anaesthetics are to be administered in the operating room, and by
a physician, unless permission is otherwise given by the
superintendent.

(11) Two qualified practitioners are required to be present at major
operations, except in cases of emergency, to be approved of by the
superintendent.

(12) Nurses and employees shall show proof of vaccination against
smallpox, and shall take typhoid vaccine every two years. Those
showing a positive Schick test shall be given toxin-anti-toxin. Those
giving positive Dick test shall be immunized against scarlet fever.

In the training school for nurses provision is made for nurses
receiving at least three months in a sanatorium. In the year 1923 the
hospitals had two thousand two hundred and fifty-three (2,253) beds,
and treated thirty-two thousand six hundred and sixty-three (32,663)
patients, of which three thousand four hundred and forty-eight (3,448)
were emergency cases. In 1912 only one birth in twenty was attended in
hospitals; in 1923 one out of every six births took place in the
hospital. Five hundred and thirty-one thousand and seven (531,007)
hospital days were accounted for, which was an average of 12.7 days
for each patient. During the year twelve thousand four hundred and
thirty-six (12,436) operations were performed, with two hundred and
eight (208) deaths following. Infections developing in hospitals were:
Medical, 22; surgical, 22; obstetrical, 16. The average cost per
patient per day for maintenance was three dollars and nineteen cents
($3.19).

In the year 1909 an active anti-tuberculosis campaign was started by
the author. The Anti-Tuberculosis League was established, with the
result that to-day Saskatchewan has a first-class, modern, up-to-date
institution for the treatment of tuberculosis. Another similar
institution will be opened in the beginning of the year 1925,
providing accommodation then for over four hundred (400) patients.


DIVISION OF COMMUNICABLE DISEASE

The Division of Communicable Disease, under the direction of a
physician, includes:--

(1) Epidemiology and statistics;
(2) Distribution of vaccines and sera;
(3) Supervision of trachoma;
(4) Supervision of tuberculosis;
(5) Care of the dead.

This division co-operates with local health authorities and physicians
generally, in the carrying out of the regulations for the control of
communicable diseases, as well as distributing propaganda and
literature regarding the same.

There are forty-four (44) diseases classified as communicable, which
the law requires to be reported to the local health officer, within
twenty-four hours. This officer in turn submits a report to the
division, weekly, of all cases he has had reported, or has knowledge
of. Cases of tuberculosis not receiving sanatorium treatment are
visited by a nurse of the Department, who, in co-operation with the
attending physician, gives instructions in the care and preventive
measures relating to the disease. A full-time nurse is also employed
regarding cases of trachoma. This nurse acts under the direction of
the division Director, and co-operates in the closest possible way
with the local physician.

It is found that approximately 49.4 per cent of deaths from diphtheria
occur in children under six years of age, and 44 per cent occur
between the ages of six and sixteen. A special effort for the locating
of this disease in children up to the age of fourteen is made by the
use of the Schick test and anti-toxin. Vaccines and sera are
distributed free and doctors in hospitals, during the year 1923,
distributed a sufficient amount of toxin and anti-toxin to immunize
thirty-three thousand one hundred and fifty-nine (33,159) persons at a
cost of six thousand two hundred and ninety dollars and twenty cents
($6,290.20). Smallpox vaccine was issued sufficient to vaccinate
nearly twenty thousand (20,000) people. Sixteen thousand five hundred
and seventy-three dollars ($16,573) was expended in vaccines and sera
in this year.

The following figures are of extreme importance, showing the rapid
increase in the death rate from cancer. These rates are per 100,000
population:--

    1914   18.0
    1915   18.4
    1916   27.8
    1917   28.8
    1918   29.6
    1919   28.5
    1920   30.1
    1921   39.3
    1922   42.2
    1923   42.6

Last year there was one more death reported from cancer than from
tuberculosis.

I wish to acknowledge the very great assistance which has been
received from the Dominion Council of Health in improving the
legislation and regulations regarding health matters, thereby making
them, in so far as possible, uniform with the Health Acts and
Regulations of the other provinces of the Dominion.

Much help has also been received from the Federal Department of
Health. The literature sent from the Department, as well as the
advice, counsel and visits of officials have been of very great aid.


DIVISION OF VENEREAL DISEASE

The division for the examination and treatment of venereal diseases
operates three full-time dispensaries and clinics in the larger
cities, and two part-time clinics in the smaller ones. Since the
beginning of this work in 1920 the number of patients receiving
treatment has increased from two hundred and seventy-eight (278) in
1920 to one thousand four hundred and thirty-one (1,431) at the end of
1923. Venereal diseases are classed as communicable, and every person
so infected is required to report either to a registered medical
practitioner or a public health dispensary, and undergo a course of
treatment for the cure and prevention of the spread of the infection.
Physicians giving treatment for these diseases, syphilis and
gonorrhoea, are required to report all such cases with particulars,
within three (3) days of the first visit of the patient. For this
purpose all registered medical practitioners are supplied with
suitable forms for so reporting. These forms do not require the
sending in of the name of the patient as long as the patient continues
treatment, which he is required to do by law. Prisoners at the two
provincial jails are examined, and, where necessary, receive
treatment, the cost being borne by the Department of Public Health.
Neo-arsphenamine and mercury are supplied free to physicians for the
treatment of patients who are not able to pay for the same, or who are
unable to report at a dispensary. These dispensaries are located in
the largest office buildings in each city and everything is arranged
so as to minimize undue publicity, which might otherwise be attracted.

Follow-up work is done as far as is possible, by the two nurses
employed, male and female. Sources of infection are strongly
emphasized and attempts are made to clear this up. Educational work in
connection with syphilis and gonorrhoea occupies a very important
place in the work of this division. First-class wax models,
illustrating various stages of syphilis and gonorrhoea, are used, and
exhibited at fairs and exhibitions, and frequent public addresses are
made relating to these diseases, by the deputy minister. Pamphlets,
etc., are distributed, so that thousands of people are being reached
through these different agencies. As a result of a recent survey
undertaken by the division, it was found that only nine per cent (9
per cent) of those attending might have been able to pay something for
treatment.

I might mention that one hundred and five (105) patients received
treatment at the Regina dispensary on one day recently; five of these
patients being children suffering from hereditary syphilis, the
remaining hundred being about equally divided between syphilis and
gonorrhoea in men and women.

Upon the termination of the Great War, health representatives of the
different provinces were invited to come to Ottawa to confer with the
federal authorities as to what measures could be taken for the
prevention and treatment of syphilis and gonorrhoea.

Conditions arising out of the Great War gave much publicity to the
fact that these diseases were common in civil life, as was shown by
the statement that for every six cases of syphilis and gonorrhoea
among the soldiers of the United States Army, five of them had the
disease when they entered the army.

At the Ottawa conference it was stated that there was a sufficient
amount of these diseases in Canada, in addition to any that might be
brought back by returning soldiers, to justify these diseases being
dealt with as a national problem, assistance for which should be
supplied to the provinces from federal sources. This principle was
acknowledged and agreed to at the time, and the sum of two hundred
thousand dollars ($200,000) was voted by the Federal House to be
divided among the different provinces, upon the basis of population,
and that each province would furnish an equal amount to that given by
the Dominion, and that provision would be made by each province to
provide such facilities for the continuance and treatment of syphilis
and gonorrhoea as would be approved of by the Federal Department of
Health.

This the provinces have done, and having seen how these diseases are
being dealt with in some of the principal centres of the United States
and Europe, and hearing what is being done in Canada, through being a
member of the Dominion Council of Health, I must decidedly state that
the measures being carried out at the present time in the different
provinces of Canada, regarding syphilis and gonorrhoea, are the best
being done anywhere.

All interested in this question were very much disappointed this year
when it was learned that a reduction of twenty-five per cent (25%) had
been made in the Dominion grant, especially so after a deputation from
the Federal Council of Health had received the most positive assurance
that the best would be done to prevent any reduction being made. I
heartily approve of the recommendation made in the very able address
of the chairman of this conference, that a resolution be sent urging
that the grant be continued.


DIVISION OF SANITATION

The Division of Sanitation, under the direction of a civil engineer,
gives information concerning the organization of Union Hospital
districts, prepares plans and specifications for the construction of
up-to-date hospital buildings, and co-operates with municipal boards
of health for the prevention of diseases caused by pollution of air,
water, milk and food. Public water supplies, sewage and sewage
drainage systems are under constant observation, and new installations
or extensions to existing systems cannot be undertaken until the plans
and specifications have been approved of by the department. It might
be noted that the sum of two hundred and sixty-four thousand four
hundred and sixty-eight dollars ($264,468) was expended by
municipalities during 1923 for the development of the water and sewage
works, this sum being more than three times the amount spent in any
previous year, which would indicate a tendency towards more active
development in municipal sanitary works.

There was in Saskatchewan last year some four hundred and fifty-six
thousand (456,000) dairy cattle. The authorities have been shown that
about eighteen per cent (18 per cent) of these are tuberculous. It has
also been shown that twenty-five per cent (25%) of the deaths from
this disease in children are caused by bovine tuberculosis. Seventy
per cent (70%) of all milk sold in the cities of Saskatchewan is now
pasteurized. Four years ago this process was a commercial one which
offered practically no protection from the disease. To-day the city
pasteurization plants are all under careful bacteriological
supervision, and ninety-eight per cent (98%) of the total bacteria has
been eliminated, thus ensuring almost complete protection from milk
bovine diseases.

This division devotes a lot of attention to giving advice towards
private sources of water supply. For sanitary purposes, the province
is divided into four districts under the supervision of a sanitary
officer, who devotes his whole time of visiting, inspecting, giving
advice and instructions to medical officials, regarding the
responsibility and the protection of the health of their respective
communities. This work is helping to raise the health standards of the
smaller urbane centres, and having also a marked effect in improving
the health ensurement of the people in the rural districts. Slaughter
houses receive attention, as well as do summer resorts, and
considerable amount of time is devoted to the organization and
consideration of Union Hospitals throughout the province.


LABORATORY DIVISION

The Laboratory Division of the Department of Public Health is
maintained for the benefit of the public, and the assistance of the
medical profession and the hospitals of the province. All work is done
free of charge. The work of this division is increasing very rapidly.
In the year 1923 over seventeen thousand (17,000) examinations were
made. Culture media, containers for different specimens are supplied
to doctors, hospitals and any one requiring same. Twenty thousand
(20,000) of these were distributed during the past year. The scope of
examinations included five thousand three hundred (5,300) examinations
for syphilis and gonnorhoea, four thousand (4,000) for other
communicable diseases, and in addition, over four thousand (4,000)
examinations for the Liquor Commission, and other departments. The
director also performs autopsies and attends inquests when required.


DIVISION OF VITAL STATISTICS

The Division of Vital Statistics compiles records of births,
marriages, dissolution of marriages, and deaths occurring within the
province. It also classifies and tabulates these statistics, in order
to provide some satisfactory means to show the result of public health
activities. It is the channel whereby the efforts of the other
divisions may be traced year by year. Thus the Health Department is
enabled to set a goal of attainment, and the degree of approach to
that goal may be taken as a measure of success of the work done.

Each municipality in the province is considered as a registration
division, although any such district may be enlarged or diminished at
the discretion of the Lieutenant-Governor in Council. The
Secretary-Treasurers of the towns, villages or rural municipalities
constitute the local registrars. City registrars are appointed usually
from members of the Health Department. In unorganized territories the
Lieutenant-Governor in Council may appoint any person to act in that
capacity.

In conclusion it can be claimed that some results have been obtained
in health work in the province of Saskatchewan.

Beginning with one official, and with an appropriation in 1906 of
twenty-seven thousand dollars ($27,000) for all health work, including
aid to hospitals, the sum a year ago had been increased to five
hundred and forty thousand dollars ($540,000).

In 1905 the six hospitals with their equipment were valued at
$63,084.53.

In 1924 the forty-three (43) hospitals with their equipment have a
valuation of $700,000.

In 1905 one thousand and seventy-eight (1,078) patients received
twenty-one thousand, three hundred and sixty-nine (21,369) days'
treatment.

In 1924 thirty-two thousand seven hundred and sixty-three (32,763)
patients received five hundred and thirty-one thousand five hundred
(531,500) days' treatment.

From a hospital bed capacity of about seventy-five (75) in 1905 it has
been increased to two thousand three hundred and fifty-three (2,353)
in 1924, or one hospital bed for every three hundred (300) of the
population.

For the treatment of tuberculosis seven hundred (700) beds are now
available in Saskatchewan, and between two and three million dollars
have been spent in providing up-to-date sanatoria.

In the year 1912 one birth in every twenty (20) took place in
hospitals.

In the year 1923 one birth in every six (6) took place in hospitals.

The report of the Registrar-General of Great Britain recently
published stated that the general death rate of Saskatchewan of 7.4
was the lowest of any portion of the British Empire.

The Dominion Bureau of Statistics, commenting on the mortality rate of
Saskatchewan, stated it was not only the lowest of any of the
provinces of Canada, but the lowest for any country in which vital
statistics are available.

For these results credit is due to the splendid work done by medical
officers of health in the cities, towns and rural districts, as well
as to the assistance received from the members of the medical
profession.

Last year I had the honour of being named by the Federal Government to
represent Canada upon the Interchange of Health Officials of the
Health Section of the League of Nations. There were twenty-four (24)
delegates, representing eighteen (18) different countries. We met in
Washington, spent four months making a thorough survey of conditions
in the United States, after which we went to Europe and spent a few
months in looking over health conditions there, having a final
conference in Geneva.

Time does not permit me to go into details regarding this trip. I
must, however, say that from what I have seen on this side of the
water and in Europe, it is not at all necessary to go outside of
Canada to see the most up-to-date health work being done at the
present day.

The Chairman: We are all interested in the address which we have heard
from Dr. Seymour, and it might be just as well before any discussion
is had on his paper that we first hear from Dr. Jost. Both addresses
might then be discussed at the same time.



THE NOTIFICATION OF DISEASES

Dr. A. C. JOST (Halifax): The paper which I shall offer to the
conference has at least the merit of brevity. Necessarily it was
written from the point of view of the province of Nova Scotia, so that
ladies and gentlemen will bear in mind that the illustrations are of
course Nova Scotian.

"No Health Department, federal or local, can effectively prevent or
control a disease, without knowing when where or under what
circumstances cases are occurring". This is the heading which for many
years has stood at the top of the page commencing the reports on the
disease prevelance in the United States Weekly Public Health Reports.
The motto is something more than a justification of the elaborate and
valuable portion of the report which follows, if indeed any dictum so
obvious requires justification.


THE NEED

The knowledge sought after is vital to the organization whose duty is
the control of disease. It is essential for the local board or unit,
whose duty is that of self-protection against the individuals who may
have been in actual contact with the infection. Little less important
is it for the larger--the provincial or state--organization, whose
responsibility is in the larger area made up a number of local
subdivisions; for though the central organization must go to the areas
not infected, the information is vital, that in one or more of the
units making up the whole there are present diseases which it would be
well for the remainder to prevent gaining a foothold. And finally,
since disease recognizes no political or state boundaries, since these
are days of rapid travel and constant intercourse between countries
not nationally connected, it is most advisable that the larger areas
be able to acquaint themselves of the presence of disease in the
countries surrounding them. Each of these statements may be regarded
as a truism, so far at least as infections are concerned, a truism
which requires no elaboration or excuse.

Furthermore, the motto outlines for us a synopsis of the information
it is most desired to collect. When has the disease occurred? This is
a matter of the most vital importance. Was it present at the time the
report was being made or has it burnt itself out? Is the information
being sent at a time when there is possible the institution of
measures to prevent spread, or have already the seeds of contagion
been scattered far and wide? Control necessitates the early and active
commencement of suitable protective measures. It is not historical
data which it is desired to collect merely as a matter of interest and
record; it is rather the information on which instant action is to be
taken, if life is to be saved, or if the community is to be protected.
It must therefore be obtainable at the earliest date after
recognition, if it is to be of value, for otherwise exposures may have
been made, a short incubation period may have been passed, and already
an outbreak have so far gained headway that speedy arrest or control
is impossible. Exact information of the "when, where and under what
conditions" the disease is occurring is therefore essential.

On these points there is practical unanimity of opinion, concurred in
by every organization formed for public health protection. In respect
to other information, or programme of effort, there may be differences
of opinion, but of the fact that a health organization or department
is seriously hampered or hopelessly crippled if it cannot secure this
so needed information there is no difference of opinion. As well
expect the banker to devise an adequate banking system without a
knowledge of the monetary demands of a country or his facilities for
meeting them, as to expect a health organization to protect community
or country without a knowledge of the conditions against which it must
be prepared to guard. "You do not know where you are going, but be on
your way" are as faulty instructions to the mariner leaving port as,
"You do not know what amount of disease is present, but function" is
to a health organization.


DIFFICULTIES OF COLLECTION

But it is doubtful if any health organization has yet devised a means
of procuring the information it requires, in a way which is
satisfactory to itself, or which justifies the opinion that the
figures it presents are really representative of the health conditions
of the community in which it is interested. One must admit that there
are a certain number of cases of almost any infectious disease the
recognition of which is an impossibility or which do not at any time
in their courses come under the observation of a person or
organization who might be supposed to be interested in them for the
purpose of reporting. There are the mild or ambulent cases of the
infections, large numbers of which at no time come under the notice of
any controlling agency. There are certain infections in which the
almost universal procedure is to arrange for their care in the home,
no physician being called except for the purpose of diagnosis with
respect to the initial case occurring in the home or the community.
These are well known facts, so well known as to admit of no denial nor
while the disease itself preserves its usual characteristics or while
society is constituted as it is can the difficulty be surmounted. But
letting these cases go, admitting that these must remain, to prevent
such accuracy as would delight the heart of a statistician, there are
I believe few health authorities who have devised any scheme or who
have succeeded in so carrying out or perfecting any scheme devised by
others that they will accept without a well marked degree of hesitancy
the numerical data of disease prevalence which may from time to time
be secured.


METHODS

In all the schemes for the collection of the information sought after
there is a quite marked similarity of procedure. In order the better
to secure the reports, in order to have more than one route by which
the necessary information may pass, practically all regulations
provide for the dual responsibility of both physician and householder,
with respect to reporting, once an infectious disease has been
recognized. Furthermore, there is quite marked unanimity in there
being made provision for the disease being recorded, not to one
individual or organization only, but to both a medical health officer,
if one be appointed, and to the local board of health. The report once
received by the medical health officer, the route is a well marked
one, the report going thence to the central authority for noting and
tabulation. There is too, practical unanimity in the provision that,
after the occurrence in the household of the initial case, with each
separate or additional case, in the event of the disease having
spread, the same procedure must be followed. Not however in all the
regulations is the time the same in which any or all of the diseases
must be reported. With respect to our own law for instance, while for
some a time limit of twenty-four hours has been set, in other diseases
one of a longer time is permissible.

These provisions apply to the reporting of the disease at its initial
onset. In order to be assured that no cases have been missed by this
procedure, endeavour has been made to procure information from
altogether different sources (as for example the death reports),
information by which it may be determined if diseases on the
notifiable list have gone on to death, not having been reported.
Checking up the mortality lists, a note is made of all deaths
occurring from such. The medical health officer or the physician in
attendance is then requested to examine his records, for the purpose
of ascertaining that the necessary reporting had been carried out in
these particular cases. This procedure is the one on which most
reliance is placed in the state of New York.

These then are the various steps of the process, advised and followed
out in practically all instances. They are simple, checked whenever
possible, and provision is made by passage along an alternate route if
for one reason or another one has not functioned. This provision
applies especially however to the first steps in the process, where
suppression is the most urgent, and where it is necessary that the
board of health as well as the medical health officer must be made
aware of the emergency, in order that measures may immediately be
taken to safeguard other members of the community. The objection to it
all is that only in a very moderate number of cases do the results
obtained merit the opinion that there has not been somewhere along the
route a very serious breaking down. As has been stated, many cases are
not reported at all, and many more are reported to the medical health
officer or to the local board of health and disappear before another
point in their destination has been reached.


NOVA SCOTIA'S EXPERIENCE

While it may be asserted that some progress has been achieved towards
accuracy in the years which have elapsed since the attempt was first
made to collect data, this province cannot be said to have progressed
so far towards a satisfactory result as have others of the Dominion.
It is somewhat difficult to determine how far short we are falling. If
we take the number of deaths caused by certain of the notifiable
diseases in the course of the year, a computation may be made showing
approximately the total number of cases which have been present if the
ordinary case fatality was met with. An attempt has been made along
this line and the results are herewith presented:--


======================================================================
                       |         |                 |Probable|  Cases
        Disease        |  Deaths |     Average     | number |reported
                       |1922-1923|    Mortality    |of cases|1922-1923
                       |         |                 | present|
-----------------------+---------+-----------------+--------+---------
Diptheria              |    25   |       16%       |    160 |    187
                       |         |   1 out of 6    |        |
Cerebro-spinal         |    12   |       25%       |     50 |     17
  meningitis           |         |   1 out of 4    |        |
Pneumonia all forms    |   819   |       10%       |  8,000 |    344
Measles                |    49   |        1%       |  4,900 |  1,570
                       |         |   1 out of 100  |        |
Scarlet fever          |    14   |     2 to 8%     |150-700 |    641
                       |         |1 out of 12 to 50|        |
Tuberculosis all forms |   651   |       14%       |  4,500 |    347
                       |         | 1 d. to 7 cases |        |
Typhoid fever          |    21   |       10%       |    200 |    113
Whooping cough         |    60   |        1%       |  6,000 |    716
----------------------------------------------------------------------


These are, it must be admitted, perilously of the nature of guesses,
but they indicate, respecting some of the diseases at least, how far
we are from getting the reports we should have. Apparently, and this
is something which is quite commonly conceded to be the case, the
presence of diphtheria is made known to the medical health officer and
by him to the department, with a quite commendable degree of accuracy.
Possibly the same may be said of scarlet fever, since the wide range
observable in the fatality rate may be sufficient to explain the
discrepancy. We ought to have as great accuracy in respect to typhoid
fever, but whether we have it or not cannot be stated. But there is
such a difference in respect of the other diseases between the number
of cases reported and the number we believe to have been present that
the conclusion is obvious that but a small portion of the reports find
their way to the department.


IS MORE ACCURATE REPORTING POSSIBLE?

The question will at once be asked, if some diseases are being
reported with a fair degree of accuracy, why are not all? Does not the
success with respect to some indicate that there is a possibility of
success with respect to all? Is it that the pressure of public opinion
is more urgent and will not permit laxity, or is it that the natural
dread inspired by some disease encourages their being brought into the
limelight? If the latter is the case why cannot this attitude of mind
be encouraged in respect to all diseases? Should any disease be played
as a favourite? Should any be protected by having conjured up for its
benefit the shelter of professional inertia or secrecy, and permitted
to continue its ravages? The medical profession should lead, not
follow public opinion in this respect.


THE PAYMENT OF FEES

Shall a fee be asked for in connection with the collection of reports?
There is no question which in any group of physicians will more
quickly precipitate an argument. In favour of it are those whose
opinion is that there are now too many demands being made on a
physician for which little compensation is provided. This service is
largely, it is claimed, a service in which the public only benefits.
If the public are to benefit it is but fair that the information,
being valuable, shall be paid for, at least to the extent of
reimbursing the physician the amount of his outlay. But has the
physician no responsibility as a member of his community or of society
as a whole? Is he not protecting himself and his own family when he
protects the community? How many physicians are there who could enjoy
their present standing if society, through government, municipal,
provincial or federal aid or some organization had not provided the
hospitals, schools or colleges where his education was obtained, or
had not protected him from opposition even to the extent of placing
themselves liable to the criticism of having established a closed
profession? In Utah this protection of the state may be withdrawn and
the practitioner's name be removed from among those eligible to
practise in the state if reports of notifiable diseases are not
communicated to the proper authorities. So here at least is one
community which is disposed to question the assumption that there is
no community responsibility from which a physician may not escape.


RESULS OBTAINED FROM REPORTING ON PAYMENT BASIS

Has the payment of a fee been productive of more accurate returns?
This is very questionable. There are countries where this system is in
vogue and apparently is meeting with favour, and where there is a
disposition to think that the results obtained justify the expense.
There are others where payment is provided for, and presumably the
fees collected in some cases, but which countries by no means
favourably impress one as being among those whose records are of
value. There is at least one where for years provision for the fee has
been on the statute books but where within the past five years no
instance of its collection has been known. In the state last referred
to the health authorities attach no significance to this provision,
but are apparently satisfied with the results obtained, to all intents
on a purely voluntary basis. Only one conclusion seems possible, that
success in the collection of the statistics does not depend wholly on
the provision or otherwise of a fee.


WHO SHALL PAY THE FEE?

And who shall pay the fee, if a fee is to be charged? Is it to be a
provincial responsibility? Has any organization of medical men
sufficient influence with their provincial governments to induce them
to accept the expenditure? If not the provincial organization, can
they do this with the municipal authorities? Of all the ways in which
the small amount of money which it is possible to obtain for health
purposes can be spent, does this method of spending it offer the
prospect of the most satisfactory returns? In the province of Nova
Scotia the Health Act specifically states that certain diseases must
be reported. Can it be represented to the government or the
municipality that the legislation now on the statute books has been
unfair in its demands on the medical profession and that the
profession has thereby suffered and will continue to suffer until some
other provision has been made? Remember that it is the medical
profession as a whole on whom the burden of establishing proof of this
must fall. No matter how anxious a health department may be to bring
about a change it must have the support of the whole profession behind
it if these demands for payment are to meet with a favourable result.


THE PRESENT URGENCY

This matter is being brought before you because about this time it is
forcing itself on the attention of all the provincial health
departments. The nearly national status which the Dominion now has as
a signatory participant in the League of Nations compact has brought
added duties and responsibilities. One of these is that Canadian
statistics of the presence of disease shall be prepared and forwarded
for publication with those of the other signatory powers. A duty has
thus been imposed on the Federal Health Department or the Census
Bureau which these departments unaided cannot perform. Only through
the assistance they are given by the provincial departments can the
scheme be carried out, or can the results obtained be other than a
commentary on lack of provincial organization or support. It cannot be
considered that this article in any way fully covers the ground. If it
has had the effect of bringing this important matter before you in
some of its most striking aspects it shall have served its purpose.

The CHAIRMAN: The papers which we have had from Drs. Seymour and Jost
are now open for discussion.

Dr. H. W. HILL (London, Ont.): Dr. Seymour spoke of a Minister and a
Deputy Minister of Health and he also referred to a Commissioner.
Perhaps it would be well if he would explain the respective functions
of these various officers. I do not know whether I was right in
gathering that the Health Department of the province of Saskatchewan
administers certain hospitals. If that is the case, I might ask Dr.
Seymour to what extent the department is engaged in this work. To my
mind the fundamental distinction between the practising medical
profession and boards of health is the fact that heretofore boards of
health have been supposed not to do any therapeutics. I wonder what
has been done in Saskatchewan in this respect? With regard to the
excellent paper which we have had from Dr. Jost concerning the
reporting of communicable diseases, it seems to me that men who are
engaged in public health affairs should realize unreservedly that it
is altogether unfair to charge the physician, who does not report all
cases that occur, with the responsibility of any neglect in this
matter. It must be borne in mind that the physician fails to have any
cognizance of an enormous number of cases, and we shall never properly
control communicable diseases so long as health departments depend
entirely upon the reporting of these diseases by physicians. I am sure
that the physician does not see 40 per cent of the total number, and
we are trying too often to control the spread of communicable diseases
on a 40 per cent basis. This of course is impossible. We have made an
intensive investigation in the city of London in connection with 8,000
school children and the figures disclose an astounding state of
affairs in comparison with the records of the health department, which
do not begin to touch the actual numbers of communicable diseases that
exist. When we remember that 74 per cent of the population who die
between the ages of one and thirty-nine succumb to infectious diseases
of one kind or another, we can easily realize that the problem of
controlling communicable diseases is one in regard to which boards of
health have so far merely scratched the surface. This is true of
medicine in general, because 60 to 70 per cent of the population
require medical attention and of this number only some 20 per cent
receive it. The possibilities have not yet been exploited, either from
the therapeutic or the public health standpoint. The whole thing
remains to be done on an enormous scale which would stagger most of
us, particularly when we realize what has to be done in both these
directions. For myself I am convinced that until the board of health
discovers cases of infection and reports back what it finds we shall
never get anywhere; certainly I do not think that any progress will be
made merely by trusting to what the members of the medical profession
may report to us, no matter how conscientiously they may do so.

Dr. J. W. S. MCCULLOUGH (Toronto): The question of reporting
communicable diseases is one that is constantly coming up and in my
opinion the duty which now devolves on the medical profession in
connection with the reporting of these diseases is a proper one to
which they should respond. On the other hand, however, seeing that the
measure is something which is intended to benefit the general public,
I think it is only fair that the public should be expected to pay for
the service they receive. In England the physician is paid 2s. 6d. for
reporting communicable cases, and this system has worked well there. I
think the point has been well taken by Dr. Hill, that even if some
enactment had the effect of increasing the number of reports made by
physicians there would still be a large proportion of communicable
diseases in Canada which would remain unreported, inasmuch as a
considerable percentage of these cases are not attended by doctors.
This I think will be admitted readily enough. If we could improve the
situation to the extent of having the physicians report all cases with
which they have to do, so much would be gained. It is important that
reports of this kind should be given to the health authorities, for
only by knowing of the existence of tuberculosis, for example, can the
problem in relation to that disease be adequately dealt with. The same
is true in regard to other infectious diseases. In the obtaining of
reports of communicable diseases I do not think that any measure will
give altogether satisfactory results. In this matter the solution is
to be found in a full-time organization, with well-trained nurses
going into the houses of people from day to day. They can find out
what cases of communicable disease exist and report them. I am
strongly of the view that physicians should be paid for these reports,
and in my opinion the local unit of government and not the central
government should be held liable in this regard.

Dr. H. L. YOUNG (Victoria, B.C.): We came here--at least I did--fully
expecting that there would be a rather intimate discussion of that
aspect of the question touching the relationships of the health
authorities to the medical profession and the public. Speaking as a
health officer, I think there is a feeling of hostility on the part of
the medical profession towards the health authorities, but I want to
qualify that statement at once to the extent of expressing my
agreement with Dr. Amyot who yesterday said that the opposition came
rather from a clamorous minority and not from the profession as a
whole. The profession as a whole is, I think, satisfied to lend its
influence and power to the advancement not only of the interests of
the profession itself but as well of those of the community at large.
Since the war there has been a material change in the relations
between the public on the one hand and the medical profession and
governments on the other. In all these questions we must remember that
three elements are involved--the profession, the public and the
government. Ultimately, the views of any one of these must prevail
where the majority exists, and the people are conscious of the fact
that there is something radically wanting in the attitude towards
themselves of both the profession and governments. They are demanding
more and more that something shall be done in regard to diseases that
can be controlled and they are appealing to the profession to whom
they have been accustomed to look for guidance in emergency. They are
determined that the government shall give them such protection for
themselves and their families as they feel that they are entitled to.
The public consciousness is becoming alive not only to its rights but
as well to its power, and it is for the profession to see to it that
nothing shall be done which will endanger its own interests. The
government looks at these questions not from the humanitarian but from
the economic point of view. Let us not forget that. If we consult the
budgets of the different provinces over a period of years, we shall
find that in the last ten years the votes for charities and hospitals
have more than doubled, from the point of view of maintenance alone.
In British Columbia during the last ten years we have doubled our
expenditure, and we are spending this year upwards of $1,500,000 for
the maintenance of our institutions. This does not include an enormous
expenditure in the way of capital charges. Governments are becoming
seriously alarmed and are determined to see that diseases shall be
controlled as far as possible in order that the taxpayers may be
relieved of the burden which they are at present bearing for the
upkeep of these institutions. The hospitals are obliged to carry an
accommodation for thirty per cent more than they should have to take
care of. Proper preventive measures are being demanded by the people,
and governments are supporting this demand. We have now reached the
stage where preventive methods are encroaching on curative methods,
and if the medical profession does not take proper steps to meet the
situation they may find the people demanding something which they do
not understand, which has not been thoroughly worked out, and which
will end detrimentally to the profession itself. At present the public
have enormous organizations--this is especially so in the United
States--which are reaching out and extending their energies, and they
are demanding more and more that proper measures be adopted to
safeguard the health of the people. There are a great many fanatics
who expect to cure all the ills of the world by means of legislation.
We have these people on the one hand. On the other hand, we have in
the profession the ultra-conservative element who are content to go
along following the traditions of the past, giving their services
freely wherever they can, but accomplishing little in the way of
prevention. Between these two extremes the public health authorities
are rapidly having to assume a position of control, restraining the
one and trying to stimulate the other.

Now, in years gone by we have been wont to look upon the sick person
as an individual who had been visited by Providence and who might look
after himself if he was able to pay, but who, in any case, was usually
taken care of by the profession. Since the war we have been gradually
coming to the view that the individual must be considered from a
different standpoint; he is not to be regarded merely as an individual
but rather as a member of the community, and his case must be treated
from the point of view of the public welfare. It seems to me that
unless the profession itself takes matters in hand, the public will
force something upon the government which will be unsatisfactory both
to themselves and to the profession. The profession, recognizing that
governments respect it and are asking for its advice, will do well to
come forward and take the initiative in this forward movement with a
view to preventing chaos and to advancing the general welfare of the
public. In British Columbia we have tried to provide some measure of
co-operation, and in regard to this Dr. MacDermot will have something
to say. The public health officers, let me say, are not the
originators of the present forward movement; it is due to the
awakening consciousness of the public, and it is a mistake for the
profession to assume any attitude of antagonism to the health
authorities.

The CHAIRMAN: The present conference affords a splendid opportunity
for experts to get together, and the subjects which are being
discussed this morning are undoubtedly of sufficient interest to
elicit further discussion. I might call upon Dr. Laidlaw, of Edmonton,
who no doubt has something of interest to contribute to the subject.

Dr. W. A. LAIDLAW (Edmonton, Alberta): There is no question as to the
need of these reports being made by physicians; such a need is I think
apparent to all. The experience of the province of Alberta, based on
morbidity and mortality statistics, is somewhat similar to that of
Nova Scotia. Diseases of any severe type are well reported;
practically all cases of smallpox for example are notified. The people
themselves have a dread of smallpox and they will report, and see that
their neighbours report, every occurrence that takes place. In regard
to the milder diseases, however, no reports come from the country
districts. In the municipalities and cities where there are full-time
officers and an organized staff we get fairly complete reports, but in
a province like Alberta, where the municipal unit comprises some nine
townships, or eighteen square miles, where there is not the means of
providing an organized staff or a medical officer we are not getting
the reports that we should. We get no reports from the small
municipalities except where the disease is severe, and often we get
such reports after the damage is done. The solution lies in grouping
together all these small municipalities into one unit large enough in
population to pay a full-time staff. Dr. McCullough will, I think,
bring that question up later. Our population in that province is, I
think, about 600,000. The forms for reporting these diseases should I
think be concise and simple, and the Department of Public Health
through the local boards should be charged with the onus of following
up and getting the information from the physicians. In Maryland there
is a follow-up system, a form being sent every week to physicians on
which they state the number of diseases that have occurred of which
they have cognizance. This system, I believe, is proving valuable. As
regards the question of fees, I agree it is the duty of the provincial
or local boards to pay for the reports which the doctors send in. In
the last analysis we can get no reports unless we are assured of the
hearty co-operation of the medical profession, and it does seem to me
that the boards should pay for these reports.

Dr. G. G. MELVIN (Fredericton, N.B.): I should like to make just a few
remarks touching Dr. Jost's paper. No doubt members of conference will
understand that we in New Brunswick are late comers in the field of
public health, having passed the present Health Act only in 1918. In
the province of New Brunswick we do not place the whole burden of
reporting communicable diseases on the medical man. True, we do place
upon the medical man the responsibility of reporting communicable
diseases whenever it is possible for him to do so, in other words, in
all those cases in which his attendance is required. I hardly think
that anyone would be so unreasonable as to suppose that the
responsibility of reporting communicable diseases should be placed
upon a physician in any case in which he is not interested and in
regard to which he can therefore have no knowledge. In New Brunswick,
however, we put upon the lay population some share of responsibility;
we place upon the householder the burden of reporting what he suspects
to be a communicable disease when any such occurs in his household.
Every householder suspecting a disease of a communicable nature is
expected to report it to the local health authority, and it then
becomes the bounden duty of that authority--and there is one such
authority in each county--to transmit the information to the central
departmental authority. The matter is then investigated, and as
matters work out in New Brunswick we are generally able to investigate
these cases of supposed contagious disease through our own officers.
We have adopted in New Brunswick the principle of all-time medical
officers, and I may say that this is by no means a dead letter.
Scarcely a week passes but I have had investigated cases of suspected
communicable diseases to which no doctor had been called. Some of
these upon investigation have proved negative, but that does not
discourage us. Others have been positive and by such means we have
been able more than once to check what was apparently the beginning of
an epidemic. I thought it worth while to call the attention of
conference to this point, as it agrees to some degree with Dr. Hill's
view that the public health authorities should investigate these cases
themselves and report back to the physician in order to relieve the
medical profession of the necessity of reporting their own cases. It
would cost an enormous amount of money to investigate every single
case, and in any event a good many of the diseases would not reach us.
As I say, we are laying upon the lay population themselves as well as
on the medical profession the responsibility of reporting communicable
diseases; that is to say, we expect the householder to report such
cases as he suspects himself. We do not of course hold him responsible
if, acting upon a suspicion which afterwards proves to be ill-founded,
we find that the disease which he thought to exist does not really
exist at all. We cannot blame him for a false diagnosis, but we
expect him to report whenever he has reasonable grounds on which to
base a suspicion. The population of New Brunswick, I may say for the
information of gentlemen who may desire to know, is about 400,000.

Dr. >H. W. MCGILL (Calgary, Alberta): I desire to say a word in behalf
of the man in private practice. I am afraid the private practitioner
has been put in a false position this morning, and Dr. Young, I have
no doubt quite unintentionally, helped to do that. I do not think
there is a clamorous minority among the profession opposed to public
health matters. The duty of the state is clearly defined, and Dr. Hill
a moment ago referred to the responsibilities which should fall
respectively to the country and to the individual. The field of
prevention is one of the duties that appertain to the state, but how
far the public health bodies and the state should go in adopting
remedial measures is a question which is giving the profession some
concern. The public child welfare movements, public health units, and
so forth, are ideal, and necessary and good in their way, but to what
extent should they adopt remedial measures? In the matter of
infectious diseases, that might be desirable, but certainly preventive
health measures form part of the scope of the state. I would refer
particularly to one such measure, which I regard as one of the most
efficient of the preventive means which we have adopted. I mean
vaccination. In many parts of the country vaccination is more or less
neglected, and in this connection there is room for greater attention
on the part of public health bodies. I rose, mainly for the purpose of
putting myself on record in regard to the suggestion that private
practitioners are opposed to measures of public health. I do not think
that this is the case at all, nor do I think that any such inference
can be substantiated for a moment.

Dr. GEORGE YOUNG (Toronto): The thought occurs to me, Mr. Chairman,
that possibly there is a danger of paternalism in the public being
treated as children, without any sense of responsibility on their part
to the state. It seems to me that governments do not pay enough
attention to the education of the individual regarding his duties to
the state, and in my opinion the regulations in the province of New
Brunswick have a good deal to be said in their favour.

Dr. R. E. WODEHOUSE (Ottawa): In Manchester the wage earner is
reimbursed for any loss suffered as a result of quarantine and it is
claimed that satisfactory results are obtained through this system.
The authorities get to know of cases of infection, inasmuch as the
householder has no fear of reporting the disease; he knows that he
will not suffer any financial loss. Where this is not done there is
naturally a reluctance on the part of people to report diseases. We
must have the co-operation of the people in the reporting of diseases
and in Los Angeles, in the case of the plague, those who are affected
hesitate to report.

The CHAIRMAN: If there is no further discussion, Dr. Jost and Dr.
Seymour will close the discussion.

Dr. JOST: Referring to Dr. Hill's comment, I have no doubt whatever
that he is perfectly right; a great deal of the responsibility rests
with the householder, and that I think is practically universally
recognized with all health organizations. Not only is the physician
supposed to report any case with which he is dealing, but the
householder as well is expected to play his part. I drew attention in
my paper to the fact that there were several channels through which
this information might eventually pass on its way to the central
authority. One difficulty which we have had to contend against is
this: we are not getting any reports from the doctors in a good many
cases, and if we do not get them from the doctors how can we in reason
take the matter up with the householder? Undoubtedly a great many
doctors do everything they possibly can; we have proof of that in our
own experience in the province of Nova Scotia. Some of our physicians
report, but unfortunately there are many cases that are not reported,
and if the doctors do not report it is impossible to do anything with
the householder. My paper dealt with the pros and cons, the various
arguments for and against, the practice, and I mentioned the fact of
pay. I referred to one state in which, although there was provision
for pay the physicians never requested it. Our own experience in
Canada is not very favourable so far as the value of payment for
reports is concerned. I believe that some years ago in British
Columbia there was offered for reports on tuberculosis a fee as high
as a dollar, and if I mistake not, Dr. Young will bear me out that the
results were not very satisfactory. Even after that offer was made
there was no improvement. The same thing has been true in a great many
states in the American union. Some states adopted the practice of
paying a fee and eventually, struck the provision off the statute
books. So far as this particular question of a fee is concerned my own
opinion has not crystallized; I am doubtful whether by such a
provision you could get better results. I do not think there is much
more I can add at the present moment by way of closing the discussion
on my own paper.

Dr. SEYMOUR: Replying to a question asked by Dr. Hill regarding the
respective positions of Minister of Health and Commissioner, I may say
that by the enactment of certain amendments to the Public Health Act
in 1923 a minister of health was provided for and the position of
commissioner was done away with. There are no hospitals in
Saskatchewan administered by the Government. A grant of fifty cents
per day is made to hospitals for both pay and non-pay patients and one
dollar a day is paid to the sanitoria for tuberculous cases. The
Department of Health takes a special interest in hospitals and
provides regulations for the reason that the administration of the
Hospitals Act comes under the Minister of Public Health; and when the
question of providing aid for hospitals was under consideration, and
the sum of $320,000 was asked for in that province, some of the
members of the legislative assembly wanted to know what was being done
with a view to ensuring that the money was spent to the best
advantage. The minister replied that the amounts were carefully
checked and that every effort was made to see that the best possible
treatment was given patients. The Department of Health is trying to
make good that statement and the regulations provide that the best
possible work shall be done in the hospitals and necessary facilities
afforded. The clinics are for inspection and diagnostic purposes only;
no treatment is made in connection with any of the clinics. The nurses
are distinctly instructed that their work is merely that of inspection
and that examinations should be made by medical men alone. We try to
differentiate between these two.

With respect to the reporting of diseases, I am in accord with remarks
made by Dr. McCullough, that the profession should not be asked to do
this extra work without remuneration. The onus of reporting is placed
on the householder in practically all health acts of the province.
That however does not amount to anything; the householder does not
report and no effort is made to make it compulsory. It is a mistake to
assume, as I think some may assume, that Dr. Hill was in favour of
householders reporting.

We have done away with terminal disinfecting; we rely more on bedside
disinfection. I believe that public health education carried on by men
like Dr. Amyot and Dr. Hill in Canada has done an immense amount of
good, and we are trying to have our health regulations based on the
definite information they supply us. I may observe that we do not
quarantine now for smallpox. The patient is isolated and if any
objection is raised to vaccination we keep him isolated long enough to
ensure the public safety, or until he sees the wisdom of being
vaccinated. I think it is unfair to lock up a whole family because of
the illness of one member. This year we supplied anti-toxin free and a
sufficient quantity of material to deal with 40,000 cases of different
kinds, while sufficient smallpox material was provided for 20,000
persons. There is a large amount of trachoma in the province of
Saskatchewan and we have provided the services of nurses to care for
these cases under the direct supervision of a local medical attendant.
By employing full time nurses for trachoma we have secured good
results. In conclusion, I may say that the Department of Health does
not do any therapeutic work.

The CHAIRMAN: I have now pleasure in calling upon Dr. McCullough to
address the conference on the subject he has undertaken,



"THE GREATEST PUBLIC HEALTH NEED OF CANADA"

Dr. JOHN W. S. MCCULLOUGH, M.D., D.P.H. (Chief officer of Health,
Department of Health, Ontario): Before I begin the discussion of the
subject on which I have undertaken to address the conference, I beg to
be allowed to congratulate the executive committee on the success that
has so far attended this gathering. It is a rare opportunity to public
health men to be able to meet and discuss such problems as have so far
come before this conference, with the general profession and I am sure
that the committee having this matter in charge have discharged their
duties well and to the satisfaction of all who are present. The
subject of my address, as the chairman has announced, is "The Greatest
Public Health Need of Canada," and that your suspense may be relieved
at once I shall say that the greatest need of public health in Canada
is a full time local health organization.

In my opinion the most pressing public health need in Canada to-day is
the establishment at the earliest possible date of some system of full
time local health organization. Most of the provinces have excellent
government organizations, supported as a rule by active voluntary
associations, but in the municipalities, particularly in the rural
areas and small towns, the machinery for carrying on public health
work is not as effective as one would desire. A study of the municipal
health organizations of the United States, Great Britain and Canada
shows that outside of the large cities there is no completely
satisfactory organization for carrying on public health work in an
efficient and economical way. The part time health officer in these
countries, with some notable exceptions, has proved a failure as might
be expected. The business in life of the practising physician is the
practice of his profession. The work of the part time medical officer
of health necessarily interferes with and injures the professional
work of the practising physician and consequently both suffer. I have
in mind two small cities in Ontario close together, each with a
population of about 30,000. The people in each of these cities are of
much the same character. Both of these cities are largely industrial
and are smart up-to-date places, from a business point of view. The
assessed values and the debenture debts are much the same. The one has
had a full time health organization for about five years. This city
has pasteurized milk, medical inspection of schools, ante-natal
clinics, tuberculosis clinics, and public health nurses, and spends on
public health work upwards of $20,000 a year. The latter has always
had a part time medical officer of health. There, loose milk is sold,
there are no clinics, no medical inspection and no public health
nurses. The yearly public health expenditure is $6,500. But in the
former the infant mortality rate has dropped in five years from 101
per thousand births to 38, in the latter, this rate has actually
increased in late years and is now 71 per thousand births.

In the care of tuberculosis, most of the provinces of Canada show a
remarkable decrease in mortality in the last twenty years, but the
public expense in the care of existing cases shows that a great deal
requires to be done to lessen the financial burden in this regard. For
example, let me point out that in Ontario, the institutional care of
some 3,000 tuberculous cases last year cost the provincial government
$315,290. This represents about one-third of the actual cost of
maintenance of these cases, and takes no account of interest on
investment, nor cost of administration. In addition, the last report
of the Mother's Allowance Board (1923) shows that there was paid in
allowances on account of tuberculosis $214,578. This sum is 13 per
cent of all disbursements made by that body. Thus it will be seen that
the large sum of about one and a half millions of dollars is spent by
the public of Ontario on the care of the indigent tuberculous. This
bill will gradually increase from year to year unless satisfactory
means are provided whereby the infection may be controlled.

The cardinal principle in the control of tuberculosis is the discovery
and treatment of early cases and segregation of advanced ones. This is
a task beyond the power of any provincial government and must, to be
effective and economical, be the duty of competent local authorities.
The part time system provides no satisfactory solution of this, or
indeed of any public health problem. On the other hand, the experience
of full time health organizations shows that under such control public
health work is advanced in a remarkable degree. Public utilities such
as pure water, sewage disposal, satisfactory disposal of waste and
garbage, and clean milk are soon provided; the infant mortality, the
tuberculosis and typhoid mortality are rapidly diminished; inspection
of school children is satisfactorily carried on and the entire
community under such control benefits to a large degree both
physically and financially. In provinces where the rural areas are
divided into small municipalities like townships, and in the small
towns, such units are financially unable to bear the burden of a full
time health service. Under such circumstances the logical course is to
consolidate a number of such units for public health work, taking for
this purpose the county or part of a county with its small urban
municipalities. This is exactly what is being done in Great Britain
and in the United States. In England the consolidated communities are
called combined areas. In the United States the county is the usual
unit. In the former country considerable advance has been made in this
direction, and in the United States the number of counties organized
in this manner has increased from four in 1914 to over 250. By means
of an organization of this kind direct results have been obtained in
connection with the control of the smallpox situation. There was a
smallpox outbreak in the Essex border cities last winter which was
confined to this area and only 67 cases were reported. You may form
some opinion as to the nature of the outbreak when I say that of the
67 cases, 32 died, and of the latter none had ever been vaccinated.
While I am on the subject of smallpox, I should like to emphasize the
great value of vaccination in this particular instance. On the
occasion of which I speak the medical men and the population of the
particular city concerned got together; about 98 per cent of the
population were vaccinated in two or three weeks and the result was
that the total cases were but 67. This could not have been
accomplished if the seven municipalities combined had each a part time
health officer.

Reference has been made to the question how far remedial measures
should extend on the part of a department of health. In my opinion the
Department of Health should confine its attention to communicable
diseases, while the treatment of all other diseases should be in the
hands of practising physicians.

More is necessary for the successful operation of a county or combined
area scheme than a full time properly qualified medical officer,
although this attainment is a long step in advance. There must be a
satisfactory budget for expenses so that public health nurses may be
employed in the follow-up work of medical inspection of schools and
general community service. Sanitary inspectors are needed for the
supervision of milk supplies and for other purposes, and certain
clerical assistance is necessary. The basis for the determination of a
budget is usually placed at 71 cents per head of population. In order
that the county or "combined area" may be assured of the proper
qualifications of the medical officer of health, the central
authority should contribute towards his salary and make the
qualifications of the medical officer of health a condition of such
contribution, and further, some security of tenure in his office
should be guaranteed. In England the Ministry of Health pays one-half
the salary of full time medical officers of health.

There is little hope of any but the larger cities voluntarily adopting
a plan of this kind. Where the scheme of municipal health organization
is in operation, as it is in Ontario, the local authorities are
apparently satisfied with it for the reason that they know of nothing
better. They regard the quarantine of communicable disease as the
beginning and end of the duties of the medical officer of health. The
only way to instruct local governments in the value of a competent
health organization is by practical demonstration extending over a
period of three or five years in suitable counties or combined areas.
Ordinarily such demonstrations for a chiefly rural area will cost
$10,000 a year. The funds might be secured from the joint contribution
of central government, local area and perhaps some private source.
There is nothing like successful demonstration of work of the kind to
convince the public of its value.

Whether or not these remarks apply with equal force to provinces other
than Ontario, other members of the Conference will be more competent
to say, but there is no doubt that in respect to my own province, the
weakest spot in our public health organization is the part time plan,
and our greatest need is to have that plan replaced by a full time
service. The matter is brought to the attention of this Conference for
the reason that in the inauguration of such a plan enabling
legislation is required to consolidate municipal units into county or
combined areas for public health purposes. This being done, public
opinion and the assistance of the medical profession are necessary in
its successful operation. It is hoped therefore that the conference
will fully discuss this question, and if the subject meets with the
approval of the members that they will give it their valued
assistance. As a further example of the value of a full time health
organization it is of interest to point out that the advance report of
the results of the work of the Massachusetts Health Commission in
Halifax, Nova Scotia, shows that the death rate of that city has
dropped in five years from 20.01 per thousand in 1919 to 11.7 per
thousand in 1923, and that the work of the commission has resulted in
the saving of 550 baby lives and 1,700 adult lives in the five year
period. In Ontario last year, through the co-operation of the Canadian
Anti-Tuberculosis Society and the Red Cross, the Department of Health
was able to carry on a survey. I need not burden you with the results
of that survey, but they amply show the great need that exists in
urban and rural areas for proper surveys to discover defects among
children. We carried on the work among pre-school and school children
and were splendidly assisted by the local practitioners. I trust that
the conference will discuss this question and that we shall have the
views of gentlemen upon it.

Dr. J. G. FITZGERALD (Toronto): This interesting and significant
contribution does not inaugurate any fundamentally new principle, nor
does it propose anything radical. For over 80 years local medical
officers of health and health authorities have been co-operating in
the larger communities. The first full time local authority was
appointed eighty years ago, and since then there has been a rapid
extension, so that the application of this principle is now general
throughout the world. It was in Liverpool that this radical movement
was inaugurated and now in all countries it is regarded as essential
and is accepted as a matter of course. What Dr. McCullough in essence
advocates is its extension to less populous and smaller communities,
either in the shape of counties or in the form of combined areas. The
extension of the principle has taken two forms: in the United Kingdom
there is what is known as the combined area while in the United States
the country is divided for this purpose into counties. It was in 1908
in Jefferson county, Kentucky, that a full time service was
inaugurated and last year in the United States there were 230 such
county services. That gives an idea of the rapid extension of the
movement there. Since 1911, under the direction of the Minister of
Health, of the Scottish Board of Health, and of the Health Department
of Northern Ireland, there has been a similar extension of the
movement in the British Isles. The most important consideration, and
the one to which I would especially direct the attention of the
conference, is the question of ways and means. There are many other
important aspects of the problem, and while I do not think we should
consider the question of policy, as to what the department should
undertake it does seem to me that the matter of ways and means is of
vital importance. Dr. McCullough intimated at the close of his address
that in some countries the central authority contributed a
considerable part of the cost of maintenance. That is true in the
United Kingdom; there the local authority contributes a small
proportion of the cost while the contribution of the central authority
is substantial. In the United States the federal service, the state
health department and the local county each contribute, in addition to
what is received from the Rockefeller Foundation, which is the
successor to the Rockefeller Sanitary Commission. In 1923, through the
co-operative support of this one voluntary agency alone there was
contributed the sum of $216,000 in twenty-two states. Three other
countries besides the United States benefited from that institution,
Canada being one of the three. The province of New Brunswick was
assisted to some extent. It is interesting to know that in the new
countries of Europe, in Jugo-Slavia and in Czecho-Slovakia, this
method is spreading; these countries are being now aided by more than
one body. The same is true in South America, notably in Brazil. The
question of ways and means is a very important aspect of the subject,
and until there is some definite assurance that there will be an
adequate financial support to warrant the inauguration and to ensure
the proper maintenance of this work, we cannot hope for the best
results. There is a conspicuously successful example in the Essex
Board of Municipalities: in my humble opinion the work there has been
extraordinarily successful.

Dr. MELVIN: I shall offer just a few observations upon Dr.
McCullough's interesting paper. Had I discussed this subject six years
ago, at the inauguration of our present health system in New
Brunswick, I would have said that all time medical health officers
were absolutely essential. Members of the conference will pardon me if
I refer for a moment or two to our little province; I know it is
obscure, especially to people in the West. However, I may observe that
we have put into practice and have continued in operation the
principle of all time medical health officers. While I am in agreement
with Dr. McCullough as to the superiority of the system of all time
medical health officers, at the same time I have one or two
reservations to make. The word reservations, by the way, has come very
much into use of late years; but that is by the way. The all time
medical health officer is certainly the ideal condition; a trained all
time medical officer is of considerable advantage. And by "trained" I
mean a man who is educated in the science and art of public health
work. There can be no question, therefore, of the superiority of that
system. But in the province of New Brunswick--and this is what I meant
when I said that I had a reservation to make--we have found that all
time medical health officers are not very easily had; by reason of the
necessity of paying an adequate salary to an all time man we have been
able to secure few such officials. That is the only fly in the
ointment. If we had financial aid enough to increase the pay by 50 per
cent there would be no obstacle at all in the way of having all time
medical officers in New Brunswick, but owing to financial restrictions
we have rather too few medical health officers in that province to
cover the districts which they are supposed to take care of. We have
three officers, each of whom has a territory of about six thousand
square miles to cover, that is to say, three or four counties. I must
say on behalf of these men that their work is a great success; their
duties are efficiently discharged and they are performing a great
service to the community. They are indeed the standby, the
corner-stone of our health system, and they are by far the most
important officers we have on our staff. The point I want to emphasize
in this matter is this: in public health promptness is
everything--promptness in responding to complaints of every kind where
contagious diseases appear. One can understand that other things being
equal, the more promptly a complaint is responded to the more
efficient will be the administration of public health. Indeed,
promptness is of such importance that it is hard for one to
overestimate it. The only point in favour of part time officers is the
relatively greater number of these officers who may be obtained, with
a consequent added promptness with which complaints may be taken up.
On the other hand, however, part time medical officers are almost of
necessity untrained men, inasmuch as you cannot expect to get a man
skilled in public health to undertake this work on such a basis. You
cannot expect a man to go to the expense of properly fitting himself
for the discharge of the duties involved in public health
administration if you are to pay him $500 or even $1,000 a year. I say
therefore that part time medical men are almost necessarily untrained,
and this of course is a great disadvantage. I thought I would bring
this point to the attention of the conference, but I do not want to be
misunderstood at all. I am heartily in favour of Dr. McCullough's
proposition, but it seems to me that medical health officers should be
not only trained men but all time men as well. We have a system of
public school inspection in which we have medical school inspectors
who partly make up for the paucity of the district medical officers.
They are all time men, and in addition to that fact they have had the
benefit of a short course--the only instance in Canada of a short
course in training in medical school inspection. This helps to a
considerable degree so far as our province is concerned in
supplementing the duties of the district medical health officers. In
conclusion, let me once more express my hearty approval of the
principle contained in Dr. McCullough's paper.

Dr. A. H. WRIGHT (Toronto): I want to say just a word or two in regard
to Dr. McCullough's paper, and I am entirely in accord with him. That,
I suppose, is an old story with me, so far as my relations with him
are concerned. I cannot add much to what he has said in reference to
the two cities which he mentioned as spending $20,000 and $6,000
respectively. His mention of that fact however, brought to my mind a
paper read in Detroit at the last meeting of the American Public
Health Association by Dr. Rumsden, of the United States Health
Department, at Washington. He put the matter on a business basis,
which is something that is not altogether new. Dr. McCullough's paper
also put it on a business basis to a certain extent. But Dr. Rumsden
went rather farther back; he did not take the father or the mother of
the family but he went to the central power: he went back to the
government and through the government to the taxpayer. His paper was
published in the December number of the _Journal_ and it is an
admirable one which I can recommend to any member of the conference.
He said that to withhold one dollar on the ground of economy and to
lose one hundred dollars in consequence was not good business, and he
gave certain figures to substantiate the position he took. The last
appropriation by Congress, he pointed out, was $3,400,000,000; and as
he stated, the taxpayer has a right to know what becomes of that
money. He looks around and finds that so much is given to agriculture,
so much to stock-raising, so much is devoted to roads, so much to
harbours, and a large sum is spent in the enforcement of a prohibition
act which is not enforced. In short, the taxpayer finds that money is
wasted on every hand, and when he sees so much disease around him he
naturally asks himself how much, either directly or indirectly is
spent on the prevention of disease. As this doctor asked, would it be
too much to ask that five per cent be spent on the public health?
Perhaps five per cent might be a great deal; but there is not spent
five per cent. Would one per cent be reasonable? That might be fair;
but they do not even give one per cent to public health, or even
one-half of one per cent. No, according to the figures they spend just
two-tenths of one per cent of the whole appropriation for the purpose
of safeguarding the public health.

I think that Dr. McCullough has the right idea; and when he gets hold
of a good idea it is hard to knock it out of his head. Now, what is
the best way of dealing with this subject? Dr. McCullough, I think,
has put the matter in a way that will be effective. But a great deal
depends of course on the way in which you put things, and the
important thing is that we should get on the right path. Once we are
sure that we are in the right direction we may safely go ahead. I am
strongly tempted to tell an old story, and although members of the
Conference may be quite familiar with it I think I shall venture it.
Two Cockneys were discussing politics and one of them wanted to know
what was meant by the slogan, "One man, one vote". "Well," said the
other, "it means just what it says--one man, one vote." But the first
fellow would not be put off in this way; he could not understand the
significance of this political phrase. "What does one man, one vote
mean, though?" he asked. "Well," the other fellow replied, "it means
one vote to one man". His friend still could not understand it and the
other fellow to make it plain said, "One vote, one man. One vote means
simply this--one bloody man, one bloody vote". "Oh," exclaimed the
other fellow, "I understand what it means now, but why the bloody 'ell
didn't you tell me that in the first place?".

Dr. MCCULLOUGH: It is impossible for a man to carry on intensive
health work in six counties, and it is just a question whether he can
do so in one county. All I am suggesting is that there should be a
suitable area, from the point of view of extent of territory as well
as from the financial standpoint, so that one organization can
satisfactorily do the work there. I do not think it would be in the
interest of public health, however, that any scheme of this kind
should be foisted on the public too rapidly; I should prefer to see it
introduced gradually and with the consent of the public. And there is
no better way to begin than by establishing in a province like Ontario
a few demonstration areas where an organization may be started and
this work carried on for three or five years so that the people might
see the value of it. Our people are intelligent enough to appreciate
the value of an organization of this kind and I am sure that they
would adopt it after adequate demonstration.

Dr. BLACKADER (Montreal): This is an all-Canadian conference,
embracing as it does representatives from Halifax to Vancouver, and I
think it would be well if the proceedings were placed before the
general profession of Canada through the medium of our _Journal_. I
would suggest therefore the advisability of having all addresses
edited as far as possible by the speakers themselves. The whole
February number might be devoted to the report of the proceedings of
this conference, and if this were done it would be wise I think to
have the speeches edited in the way I have suggested. The January
number is already in the press, but if all those who have spoken will
kindly edit their papers and their speeches we can have the February
number of the _Journal_ carry a complete report of the conference for
the benefit of every member of the profession.

The CHAIRMAN: It is exceedingly important that the proceedings of the
conference be reported in detail for the information of the entire
profession in the Dominion, and undoubtedly the proper channel for
this would be the _Journal_.




=FRIDAY AFTERNOON SITTING=


The conference resumed, Dr. Primrose in the chair.

The CHAIRMAN: I call upon Dr. MacDermot to address the conference on
the subject of



HEALTH INSURANCE

Dr. J. H. MACDERMOT (Vancouver, B.C.): I do not know how much of what
I am about to say is old ground, because I do not know just what has
been done in other provinces in this regard, but I thought that the
best way in which one might deal with a subject of this kind would be
to treat it rather on the assumption that nobody had ever heard
anything of health insurance.

In British Columbia we have been conducting a somewhat intensive study
of the question. By health insurance I mean any plan or scheme whereby
a certain group in society, roughly determined by earning power, is
insured against the cost of sickness, wholly or in part. A specimen of
such a plan is the National Health Insurance of Great Britain,
commonly known as the Panel system. The history of our connection with
the problem is briefly as follows:

Some eight or nine years ago the Government of British Columbia
appointed a commission to go into the question of workmen's
compensation for industrial accidents. Prior to that time industrial
companies or other employers of labour insured themselves against
accident to their workmen. When a workman was hurt he usually had to
employ a lawyer to fight his claim for damages, or accept a sum which
was often unfair. His fight, be it noted, was with the insurance
company, not with his employer. He had no wage allowance coming in
whilst he was ill, and often he had to wait a long time for his money.
The legal fees were high, and very often the final result was that the
workman obtained very little.

The attitude of the employer towards an injured workman was hostile.
What about the doctor? He usually did his work for little or nothing
unless he protected himself very carefully, and on the whole this
class of work was exceedingly ill-paid and unsatisfactory to the
medical man. In the first bill drafted no mention was made of medical
aid at all. When the commission held its sessions the Vancouver
Medical Association appointed a committee which met the commission and
gave evidence. This committee also approached Labour, through its
leaders, and urged on them the necessity for a medical aid clause from
the point of view of the workman. Together we were successful in
having such a clause added.

Next came the question of medical fees and method of administration.
At first, there can be no doubt, the commission had at least a bias
towards salaried medical men, from the standpoint of economy, both
from money and trouble, as it appeared to them. We were able to
persuade them that the principles of free choice of doctor, and
payment of the latter, by a schedule of fees were fairer and more
satisfactory than the other. As a result we obtained our present
Workmen's Compensation Act, which works on the whole very well and
with satisfaction to all those who are party to it. The workman gets
all that is his due without deduction; he gets allowances for the time
he is away from work, and his bills are paid. The doctor is fairly
paid for his work, and except for minor details I think it is fair to
say that we have little or no criticism of the act. The employer's
attitude towards the injured workman is entirely changed. He works now
with the workman and for him, to secure as good a settlement as can be
obtained.

Great strides have been made in the direction of safety appliances,
etc., designed to prevent accidents.

This is all a matter of economic efficiency; everybody concerned, the
Government, the employer of labour and the workman has realized that
the prevention of accidents saves money. They have realized too that
by giving prompt and adequate care to the injured man, they save money
and save the human material of industry. The workman is satisfied that
he and his family will be able to get three meals a day even when the
breadwinner is hurt. It is a sound piece of legislation and is well
administered. Our experiences in this regard taught us several
lessons, and other provinces will no doubt have seen the same thing.

We learnt first as regards the Government, that we cannot expect,
indeed we have no right to expect, the Government to look after our
interests. It is true, as we know, that the surest way to secure a
good and efficient act is to have competent medical aid, and that this
can only be secured from adequately paid medical men. But we must
remember that the government is always subject to tremendous pressure
from two sides, first, from those who want the legislation which will
protect them, and secondly, from those who have to pay for it. The
burden of financing these acts is a heavy one. In the end, we believe,
it is lighter than the original burden of cost attached to the old
methods; but it is difficult to convince those who have to pay that
this is so. Under this dual pressure the Government seeks escape and
finds it naturally in keeping the medical fees that have to be paid
down as low as possible. The moral is that we must fight our own
battle. We must be ready and organized to meet any such situation.
That is the first and perhaps the greatest lesson we learnt.

Next, we learnt that we must educate our own members. One cannot
accuse labour of greed and selfishness, nor can we accuse the
Government of meanness any more justly than we can some of our own
members. The medical man is willing to be exploited and to do any
amount of work for nothing; but when it comes to making an arrangement
whereby he can be sure of being paid he wants the earth; at least,
some of them do. This is one point that has to be noted.

Next, as regards labour. We learnt that labour is our best ally and
that we should keep it so. Labour's interests in this matter are ours
and we should realize this fact and work with labour.

Lastly, we found that this method of dealing with industrial accidents
is an extremely good one and very satisfactory in every way to the
workman, for the reason that the evils outlined above have been mainly
removed, and for us, because we receive fair remuneration for this
class of work. Next came the question of sickness. The V.M.A. took
this up next and spent some time deliberating on it. Our trouble was
that we had no facts to work on, and the conclusions we drew were
hypothetical only and subject to attack for that reason. We felt that
something ought to be done but we had not the basic facts at our
disposal on which to base any conclusion. Accordingly we decided to
call in outside help and pay for it. Two years ago the British
Columbia Medical Association set aside a sum to be devoted to this
purpose and employed a statistician to go into the whole matter and
dig out the facts of the case. He spent some four months over this
task and accumulated a great deal of material which I shall present to
you in a brief digest. The following questions present themselves for
answer:

1. Is there any demand for health insurance, and from whom?

2. Is there any need for health insurance? And why is our present
system not adequate?

3. What form should health insurance take? What would be the
advantages of it and the dangers?

4. What will it cost?

5. How will this cost be distributed?

6. How would it be administered?

6a. How would it affect the medical profession?

7. What attitude should the medical profession take?

8. How can the interests of the medical profession be safeguarded?

Questions 1 and 2 may be considered together: 1. Is there any demand
for it, and 2. is there any need for it?

Our researches into the economic conditions of British Columbia
revealed the following facts:

The average income of the industrial worker in British Columbia is
$1,000 a year or a little less.

The average duration of illness for each individual is about seven
days yearly.

The average working man's family in British Columbia has about one
week's supply of money in case of illness attacking the wage earner;
when this is spent they must run into debt.

Less than five per cent of the working population has any insurance of
any kind against illness, accident or death. This includes lodge or
club insurance, or benefit from fraternal organizations, as well as
ordinary sickness and accident insurance. Speaking to a statistician
of the Sun Life Company yesterday, I was informed that only about four
per cent of the population at large carries life insurance.

The cost of insurance is prohibitive to the working man.

Sickness means to the working man loss of earning power, absorption of
his savings, incurring of medical bills, and hardship to his family.
It means more; it means that he cannot get adequate medical attention,
and therefore he does not recover as quickly as he should. A working
man with pneumonia needs hospital care, trained nursing and skilled
medical attention just as much as does a millionaire; but unless he
becomes a charity patient how can he afford it?

Sickness and poverty react on one another, and the worry, insufficient
food and so on aggravate the sickness.

He does not seek medical attention as early as he should for himself
or his family. Much avoidable illness is thereby caused.

Our inquiry covered most of the states of the union, many of which
have been studying this question closely. Summarizing their replies we
found that they tallied quite closely with ours, their time loss
varying from six to nine days yearly. The Metropolitan Life has also
conducted an investigation with approximately the same results. In
British Columbia the economic loss to industry from sickness, in wages
alone, was placed at $4,165,000. To this must be added medical and
hospital care. This has been worked out on various bases, but the
smallest estimate is somewhere over $2,000,000. This when added to the
wage loss is rather more than three times the cost of industrial
accidents alone. It is the consensus of opinion, we find, that this
ratio of three to one is correct, and we will do well to bear it in
mind.

Another great disadvantage of our present system is the impossibility
of preventing sickness, especially amongst children and women. Except
for a small amount done through voluntary subscription and in free
clinics, preventive medicine is almost an impossibility, though we
admit its necessity and would gladly practise it. Labour, as a section
of society, recognizes all these things and is pressing for relief. It
is labour that is hardest hit. They have adopted health insurance as a
plank in their platform. The demand is there, and the facts I have
cited seem to show that the need exists. And I have of course only
dealt briefly with the matter. A very much stronger case could be made
out, and it seems to be the uniform opinion of all the states who have
gone into the question that under our present system of treatment of
the sick there is a great and unnecessary loss of life, of time (that
is, wage earning time and wages) and of health apart from life.

It is coming to be recognized that sickness affects a whole community,
not merely the sufferer, and that this is true not only of infectious
disease but of any sickness. It constitutes a definite loss and in one
way or another the whole community pays for it.

Before leaving Vancouver, I had an interview with Mr. E. S. H. Winn,
Chairman of the Workmen's Compensation Board, who has authorized me to
quote him in several references which I may make. He is also Chairman
of the Mother's Pension Board. His work in these two capacities has
given him an unusual opportunity to observe industrial conditions. I
asked him if he felt there was any need for a system of health
insurance and he stated most emphatically that it is one of our
greatest needs to-day. The question, "Who should be beneficiaries?" he
answered by saying that he would place the upper limit of income at
$3,000 annually. This may appear high to many of you and we had
arrived at a somewhat lower figure; but a great many authorities on
the subject state that there should be no upper limit. Three thousand
annually would include all wage earners, including railway engineers
and conductors.

As to the method of administration of such a scheme, it might I think
be done only in certain ways:--

1. By a voluntary organization, somewhat similar to club and contract
practice, only on a larger scale and with larger fees.

2. By a compulsory scheme under which every member of the class
affected must pay.

Again, it may involve only medical aid; or on the other hand sick
benefits may be added.

Lastly, as to the payment of medical men and their employment. It may
be done by a capitation fee (the Panel system) or patients may be
given free choice of a physician, who will then be paid according to a
fee schedule for the work done. As regards the voluntary scheme, we do
not think that anything can be said in its favour. It would not work.
The only people the act was designed to help, the shiftless and
improvident ones, would refuse to take advantage of it. The five per
cent who now take out insurance in one form or another would be the
only ones who would join. It would cost at least twice as much as a
compulsory scheme. During our investigations we found that the
insurance companies insuring against sickness return less than fifty
per cent in the form of paid claims. This does not of course mean that
they make fifty per cent profit, but their cost of operation is from
twenty-eight to thirty-five per cent of the premiums. The cost of the
Medical Association in British Columbia (that is to say, the cost of
administration) is less than four per cent of the total cost.

There are many other objections; and all the states consulted agree
that any scheme instituted must be compulsory and must function
through an extra-political board.

As regards sick benefits, there can be no question that unless these
were included the act would only be partially adequate. If it is true
that the average working man's family is only one or two weeks ahead
of the wolf, sick benefits are necessary. It was the opinion of Mr.
Winn that these might be left out at first and added afterwards, but
he expressed himself as being of the opinion that they were an
integral part of any complete scheme.

We come now to the question of the method of payment of doctors. We
came to a unanimous conclusion, so far as our various committees were
concerned, that we should utterly reject the Panel system or any
system involving salaried medical men except in cases such as X-ray or
other laboratory workers. We regard the Panel system as pernicious. It
introduces the element of speculation into the relations between
doctor and patient, which is so demoralizing and leads to such
unsatisfactory results in contract and lodge practice with certain
exceptions.

There is a continual struggle between the doctor and the source of his
salary, the commission governing the administration of the act. The
competitive element in the practice of medicine, which is so valuable
and salutary is removed when the practicing physician is paid a
salary. The only room for competition left in such a case is the
possession of the job itself. There are other undesirable features of
the Panel system but they are merely a matter of cost.

The question of cost must come next. The cost, apart from sick
benefits would amount to about three cents a day to the workman
himself. For his wife and family it would be increased in proportion
but not equally. It is suggested by many who have gone deeply into the
subject that there should be no distinction between single and married
men but that they should pay equally. The estimates of cost vary to a
considerable extent in various localities, but Mr. Winn, who has
access to accurate figures in affairs relating to the Workmen's
Compensation Act, estimates that the proportion of cost would work out
somewhat as follows:--

    Wage-earner $1      }
    Government 50 cents } Monthly.
    Employer $1         }

Making a total of $2.50 in all. This is very nearly our estimate,
though we allowed a little more. Three dollars would pretty nearly
cover medical aid and sick benefits.

What should be the attitude of the medical profession towards health
insurance? In the first place, the medical profession should conduct
an organized and thorough investigation into this whole matter. If one
talks to twenty medical men about health insurance, one is apt to get
twenty different opinions, varying with the status and special
interests of each man, but utterly useless because they do not know
the facts. And without a thorough knowledge of these one cannot work
out any plan.

May I quote from Dr. Cabot, of Boston, who wrote about this matter
some years ago:--

     "When sickness insurance gets a footing in the country
     I hope that it will be planned and led by those who
     know most about it, namely, the physicians themselves.
     Nothing would be worse for the reputation and dignity
     of the profession than to become engaged, like the
     English medical profession, in an unseemly scuffle with
     the government, to lose in the fight, and finally to be
     dragged, kicking and struggling into the enemy's camp
     and forced to do what they had previously angrily
     refused. Let us make our experiments and gain
     competence before the state tries to take over so
     difficult and dangerous a task."

This seems to sum up what our attitude should be, and it sums it up in
my opinion fairly well. We should study the problem thoroughly and
have every man in the profession acquainted with the facts, and be
ready to take a definite stand when the question is mooted, as it
certainly will be.

In British Columbia we have prepared a brief summary of the facts as
far as we have ascertained them and are sending this to every member
of the profession. We contemplate having a round table conference with
representatives of labour and getting their views. I would repeat here
that medicine has no better friend than labour in this connection.
Their interests are ours, and it is just as important for them that
any system of medical aid shall be planned along the right lines as it
is for us. To this end, I should like to see this matter taken up by
the Canadian Medical Association with a central committee and by every
province with local committees. I have not dwelt much on the side that
concerns us, but is it not true that there is room for improvement in
our present system or for a change of some kind?

The really enormous amount of work done for nothing or for trifling
fees, the fact that we are handicapped in our work at every turn
because our patients simply cannot afford the tests and special
examinations that they should have; the huge free clinics in every
city, composed of people who could pay a little but who cannot
possibly afford regular fees; the impossibility of doing preventive
work--all these arise out of our present system of practice.
Undoubtedly too the prevalence of quackery is due to our present
system, and nobody can suppose that any intelligent commission
administering an act would allow patients to go to practitioners of
cult medicine; this would be not from any love of us particularly but
from simple economic reasons.

Again, we know that certain evils have crept into the practice of
medicine. Over specialization, and specialization by men who are not
fit to be called specialists, would be checked, because results are
tabulated, and results count. The medical man who lets himself slump,
who gets rustier and rustier, could not get by under any system that
kept comparative records. The operation of the Workmen's Compensation
Act has shown that men are on their mettle, are kept up to the mark,
are checked up sharply if they do bad work; and again, cheap contract
work and lodge practice would be eliminated.

Lastly, there is considerable economic gain from such a scheme.
Certainty of payment, of fair fees for work done, would be a
tremendous boon to a profession which has suffered too much from
uncertainty in these things. I am not claiming that such an act would
immediately bring about a complete surcease of all our troubles. There
are several problems that arise.

First, the difficulty of preventing some men from getting more than
their fair share--and this has been a real problem with the Workmen's
Compensation Act. Perhaps limitation of quota might help here.

Next, the young man beginning practice: how can we help him?

Then there is the specialist, the legitimate specialist, not the
college bred one, who needs elimination rather than help. We must be
very careful not to remove incentive and not to try for a standardized
product. Our experience of the Workmen's Compensation Act shows that
this is not a very serious problem. Besides, there will always be
private practice.

Then there is the problem of the indigent. Mr. Winn suggested in this
regard that some scheme might be formed whereby people out of work
might be carried for three months. Again what about such matters as
venereal disease, and diseases requiring institutional treatment? Then
we must remember that if we adopt any such scheme we must to some
extent surrender our independence. Therefore, we must make very sure
of our ground before we do endorse any scheme of the kind. We must
prepare ourselves before the scheme is put into operation. We must
also be prepared at any time in the near future to be called upon to
implement some sort of health insurance scheme.

Mr. Winn, whom I have quoted, was some two or three years ago
appointed chairman of a commission to inquire into health insurance in
British Columbia. The report of this commission has not yet been made
public, but from conversation with Mr. Winn, I do not think there is
any doubt that he personally thinks health insurance should be
inaugurated, that it should be administered by an extra political
commission, as is workmen's compensation; that patients should have
free choice of a physician; that medical and hospital care should be
paid for by our present method, that is to say, for work done
according to a schedule of fees; and that all treatment should be
provided for. Sanitorium and institutional treatment, he thinks,
should be left as they are, under salaried medical officials, and he
is most probably right in this.

We in British Columbia do not think that the medical profession should
strive to inaugurate any scheme, but that we should educate ourselves
thoroughly about it and remain receptive, but ready to meet any
situation that may arise.

The first essential for this is complete organization of the
profession. We found this in the Compensation Act matter; our
salvation lay in the fact that we were at that time thoroughly
organized. Every man in the province was lined up and we spoke as one
voice. In England, on the other hand the profession was caught
napping, and we know the result. We have no fear, so far as we are
concerned, of a fair and reasonable Health Insurance Act. I am quite
sure that many men would welcome it. There are endless details to be
worked out, but our clear duty at present is, first, to organize;
secondly, to study the question; thirdly, to meet those other
interests that are involved--labour, the government, the employer--and
obtain their views and impress ours upon them. Our first duty is to
the sick. If we can devise, or help to devise any plan which will
improve health conditions there is no section of the profession that
will hesitate, so soon as it realizes the facts of the case.

We owe a duty too, to ourselves, not to allow ourselves to be
exploited or to be forced into a humiliating condition of
underpayment, of scrambling for positions, of incompetent and skimped
work. This is not only for our sakes, but because such a state of
affairs is utterly injurious to the very people it is designed to
serve. By maintaining our right to adequate payment for honest work we
shall be showing our honesty and our sincerity as workmen.

I am presenting herewith the report of our committee brought
up-to-date showing figures and statistics as regards the financial
effect of illness on the working man, and going into the question of
costs.

The CHAIRMAN: This is one of the most important questions that have
come before the conference and we are indebted to Dr. MacDermot for
the splendid paper which we have heard and which seems to me to be the
logical and analytical type of address which calls for careful study.
Dr. MacDermot's paper is now open for discussion.

Dr. GEORGE YOUNG (Toronto): The question which Dr. MacDermot has so
ably discussed in the address we have just heard is one of
considerable importance to the medical profession in this country. It
seems to me that the profession should wake up to the importance of
this matter, for it would be rather a serious thing for us in Canada
if we were faced with the same difficulty that confronted the medical
profession in the Old Country in 1911 when Lloyd George launched on
the public, complete in all its details, a bill which proved
altogether intolerable to the profession. At that time the medical
profession in Great Britain was not organized to deal with the matter
and it cost them some $300,000--to say nothing of the money that came
in from outside sources--to make the details of the bill such as would
be at all tolerable to the medical fraternity. It seems to me that now
that this question is in the air and that labour is behind it in
certain provinces the matter is one of some importance. We should
carefully study it, we should get at the facts as far as we possibly
can, and altogether make ourselves acquainted with the details of the
subject, so that in the event of legislation being mooted we should be
able to protect ourselves as well as the public against any
ill-considered measure that might be undesirable, either from our own
point of view or from the standpoint of the community at large. The
matter, I think, is one for the association to deal with.

The SECRETARY: Might I ask Dr. MacDermot whether the British Columbia
Association proposes to acquaint the other eight provinces with the
work which has been done in that province in connection with the study
of this problem.

Dr. MACDERMOT: I suppose that, as this matter is one for the
association, it is possible that this conference might, through the
Resolutions Committee recommend that the association take up the
subject.

The CHAIRMAN: It might be well for the conference to appoint a
committee to go into the subject and report to the next conference and
then to the Association. Having heard Dr. MacDermot's address, I am of
the opinion that the matter should go to the Association eventually.

Dr. GEORGE YOUNG: Perhaps that would be the best course to adopt. I
would move that the chairman be empowered to appoint a committee to
study the matter, in the light of the remarks which we have heard,
and that the said committee report to the conference.

Dr. LOW: I second that motion.

The CHAIRMAN: I shall ask Dr. MacDermot to close the discussion.

Dr. MACDERMOT: I am not quite clear as to just what scope the Dominion
would have as a whole in a question of this kind. The matter, I am
inclined to think, is rather of a provincial character and it will
probably be for each province to inaugurate its own system. Later on
there might be national co-ordination of provincial activities. As
regards Dr. Routley's question, I may undertake to say that British
Columbia will be glad to inform any of the other provinces as to just
what has been done; we will furnish the facts.

The CHAIRMAN: It has been moved by Dr. Young, of Toronto, and seconded
by Dr. Low, of Regina, that this matter be referred to the Executive
Committee of the Canadian Medical Association. Is it the pleasure of
the meeting to adopt the motion?

Motion agreed to.

The SECRETARY: I have a few announcements to make. Members of the
conference will be interested to know that seventy-three delegates
have registered on the present occasion, which is about twenty-three
more than we expected. This evening, following the dinner at the
Chateau Laurier, I should like to have the pleasure of meeting the
members of conference representing the four western provinces, of
Manitoba, Saskatchewan, Alberta and British Columbia. As members of
conference know, the next annual meeting of the association is to be
held in Regina during the week of June 22 next. It is well known that
the western provinces are behind that annual meeting and intend to
lend their co-operation to the end that the gathering may be a
successful one. Last November a year ago I had the pleasure of meeting
representatives of the four western provinces in conference and
following that very excellent meeting there was prepared for the
ensuing year a programme which was quite beneficial to the provinces
concerned. It seems an opportune time, now that so many are gathered
together here that we should get together for the purposes of an
informal round table talk on plans for next year. If the eastern
provinces desire to inaugurate a co-operative movement the Secretary
will be charmed to meet a delegation from those provinces at any time
to discuss a scheme similar to that which has worked so successfully
in the West.

The CHAIRMAN: I shall now call upon Dr. MacMurchy, of Ottawa, to
address the conference on the subject which she has undertaken to
discuss.



MATERNAL MORTALITY

Dr. HELEN MACMURCHY, Department of Health, Ottawa: A memorandum upon
the present state of affairs in regard to maternal mortality in Canada
was prepared by direction of the Deputy Minister of Health and laid
before the Dominion Council of Health on December 16, 1924.

At the request of the Council the following summary of this memorandum
has been made for the conference on the Medical Services in Canada.


DEBATE IN THE HOUSE OF COMMONS

In the course of a debate upon another subject in the House of Commons
on July 17, 1924,[3] Mr. Davies, M.P. for North Battleford, made a
reference to maternal mortality, quoting from the pamphlet "Issued by
the Meeting Lake Development Association. Representing Rural
Municipalities Numbers 466, 467, 497, 498."

[Footnote 3: Canada, House of Commons Debates. Official Report. Vol.
59, No. 93, page 4914. Thursday, July 17, 1924.]

The following is the paragraph in which the quotation made by Mr.
Davies occurs:--

     "There is no doctor living in this whole area. The
     nearest doctors available in cases of great need live
     in the towns along the lines of railway to the south
     and west a distance of 30 to 70 miles. The same applies
     to hospital provision. With an estimated population
     within the four municipal areas of 4,500 it is easy to
     imagine the amount of distress and suffering that
     exists through lack of medical attention. Owing to the
     costs of obtaining medical advice, in most cases
     running from $30 to $70 a visit, it is only in extreme
     cases that medical aid is brought in and when this
     occurs in the winter months the suffering is increased
     tenfold. During the last five years there have been
     over 800 births in these four municipal areas and out
     of these only 60, or approximately 7 per cent, had
     medical attention. In many of our little cemeteries
     there is a mound that covers the remains of some
     pioneer mother who has paid a penalty that would have
     been avoided had medical aid been obtainable."

A letter was addressed to the Minister of Health by Mrs. J. A. Wilson
of Rockcliffe, President of the Local Council of Women, Ottawa, April
8, 1924, making enquiry as to how many women are confined without
medical attendance in Canada.

At the Annual Meeting of the National Council of Women of Canada, a
resolution was passed, referring to the statement that twenty-four
mothers died in childbirth every week in Canada in 1922 and inquiring
whether these mothers were given sufficient or any medical and nursing
care.

Many letters in regard to maternal mortality and maternal welfare have
been received by the Division of Child Welfare in the Department of
Health of Canada since 1920. A few extracts are here given:--

     "We are a farming community of about three hundred
     people, have no resident doctor, neither have we a
     nurse. Our nearest doctor is three and a half miles
     distant, and he is the only one within a radius of
     fifteen miles. We country people need help for our farm
     women at childbirth...."

     "I hope some day we'll see every mother cared for as
     good as we care for our thoroughbred stock at least. It
     seems a pity that at this most important event we do
     not know that mothers have everything easy and
     comfortable. Wouldn't it be worth Canada's best efforts
     to make sure Canada's rural mothers fared well at the
     time their children were born? I think it would, and
     any one who cared enough would work with that result in
     view. We Canadian women must pull together for the
     benefit of women all over Canada especially farm
     women...."

     "If you could see the conditions here with regard to
     mothers and children it would make your heart ache.
     Expectant mothers performing tasks fit for men's
     strength and then when their hour comes often having to
     go through the ordeal without any assistance except
     that of a neighbouring woman and sometimes not even
     that; poor, ignorant, faithful, hard-working
     women--used worse than dumb beasts. They certainly need
     some person to befriend them and teach them. I often
     wish I had the power to rouse the women of Canada to an
     understanding of what these poor women and babies have
     to endure and I am sure they would devise means to help
     them. I have tried to do a little and it seems such a
     little for them. But I have determined that every baby
     arriving in my district shall have something more than
     a flour sack to wear...."

     "We have so many new babies and unfortunately so many
     deaths. Last week a mother died having her eighth baby
     in ten years and now we are faced with the problem of
     looking after these poor children--so thin and pale--it
     makes my heart ache to go into the house and the
     hardest part is this, Doctor, she wanted to die--so
     tired and worn out and weary...."

     "Perhaps the day will come when people will look back
     and wonder why mothers have been held so cheap. It
     seems to me that the present day could solve the
     problem in such a way that no woman would have to take
     the risks of twenty years ago. I know two neighbours
     about to be confined. Both have already large families,
     neither one expects to have a doctor as they feel the
     expense will be hard to bear even if one decides to
     take the cold fifteen-mile-drive in winter. Each has
     lost her mother within the last three years. I can't
     refuse them help yet I do not feel equal to the task,
     deeply as I sympathize with their need. They might get
     assistance if they claimed to be paupers. But being
     self-respecting, hard-working young Canadians trying to
     make a home and raise a family they and their families
     have to face danger. This is the normal state of
     affairs all through Western Canada except close in to
     towns or cities. Even if limited means is not the
     difficulty, few mothers care to go far from their dear
     ones in times of sickness...."

The questions raised by the foregoing may be summarized as follows:--

  I. What is our maternal mortality in Canada?

 II. How does it compare with the maternal mortality of other countries?

III. Is it excessive?

 IV. What proportion of births occur with no medical or nursing care for
     mother and child?

  V. Are medical fees too high?

 VI. What recent enquiries or investigations have been made into maternal
     mortality and related subjects, such as puerperal sepsis, and with
     what results?


I.--WHAT IS OUR MATERNAL MORTALITY?

The figures quoted above are in accordance with those reported by the
Dominion Bureau of Statistics for the year 1922.

The total number of deaths in childbirth was 1,248, which is at the
rate of 24 every week, or 3.4 every day.

The maternal mortality rate per 1,000 living births was 4.9 for all
the provinces of Canada, including the figures supplied by the
provincial authorities in Quebec and transmitted by the Dominion
Bureau of Statistics.

For the eight provinces of Canada which form the Registration Area the
maternal mortality rate was 5.5 per 1,000 living births.

The following table gives the rate for each province:--


DOMINION BUREAU OF STATISTICS
==========================================================================
                    |      Population     |   Births        |  Birth-Rate
                    |---------------------+--------+--------+-------------
                    |  Total   |  Total   | Total  | Total  | Rate | Rate
                    |population|population| No. of | No. of | per  | per
     Provinces      |  Census, |estimated,| Births,| Births,|1,000,|1,000,
                    |   1921   |  1922    |  1921  |  1922  | 1921 | 1922
--------------------+----------+----------+--------+--------+------+------
Alberta             |  588,454 |  611,281 | 16,561 | 16,163 |  28.1| 26.4
British Columbia    |  524,582 |  539,036 | 10,653 | 10,166 |  20.3| 18.9
Manitoba            |  610,118 |  626,436 | 18,478 | 17,679 |  30.3| 28.2
New Brunswick       |  387,876 |  392,381 | 11,465 | 11,564 |  29.6| 29.5
Nova Scotia         |  523,837 |  528,207 | 13,021 | 12,693 |  24.9| 24.0
Ontario             |2,933,662 |2,981,182 | 74,152 | 71,430 |  25.3| 24.0
Prince Edward Island|  88,615  |   88,307 |  2,156 |  2,160 |  24.3| 24.5
Saskatchewan        |  757,510 |  785,832 | 22,493 | 22,339 |  29.7| 28.4
Quebec[4]           |2,361,199 |2,402,287 | 88,749 | 88,377 |  37.6| 36.7
                    |----------+----------+--------+--------+------+------
    CANADA          |8,775,853 |8,954,949 |257,728 |252,571 |  29.4| 28.2
--------------------------------------------------------------------------

===============================================================================
                    |       Infant Mortality      |   Maternal Mortality
                    |-----------------------------+----------------------------
                    |                             | Total | Total |      |
                    |Deaths |Deaths | Rate |Rate  |No. of |No. of | Rate | Rate
                    | under | under |  per | per  |Mater- |Mater- | per  | per
     Provinces      |1 year,|1 year,|1,000,|1,000,| nal   | nal   |1,000,|1,000,
                    | 1921  | 1922  | 1921 | 1922 |Deaths |Deaths |Births|Births
                    |       |       |      |      |in C.B.|in C.B.| 1921 | 1922
                    |       |       |      |      | 1921  | 1922  |      |
--------------------+-------+-------+------+------+-------+-------+------+------
Alberta             | 1,391 | 1,475 | 84.0 |  91.3|   111 |   111 |  6.7 |  6.9
British Columbia    |   602 |   692 | 56.5 |  68.1|    51 |    63 |  4.8 |  6.2
Manitoba            | 1,533 | 1,669 | 83.0 |  94.4|    81 |    99 |  4.4 |  5.6
New Brunswick       | 1,299 | 1,194 |113.3 | 103.3|    47 |    59 |  4.1 |  5.1
Nova Scotia         | 1,311 | 1,239 |100.7 |  97.6|    56 |    70 |  4.3 |  5.5
Ontario             | 6,763 | 5,921 | 91.2 |  82.9|   387 |   370 |  5.2 |  5.2
Prince Edward Island|   180 |   153 | 83.5 |  70.8|     7 |     8 |  3.2 |  3.7
Saskatchewan        | 1,814 | 1,913 | 80.6 |  85.6|   128 |   127 |  5.7 |  5.7
Quebec              |11,387 |11,297 |128.0 | 127.8|   338 |   341 |  3.8 |  4.1
                    |-------+-------+------+------+-------+-------+------+------
    CANADA          |26,280 |25,553 |102.0 | 101.2| 1,206 | 1,248 |  3.85|  4.9
-------------------------------------------------------------------------------

[Footnote 4: These figures are supplied by the Provincial Bureau of
Health, Province of Quebec.]

DEATHS IN CHILDBIRTH--RURAL AND URBAN

At the request of the department the following table has been prepared
by the Dominion Bureau of Statistics. It is noted that in every
province, such urban death-rate is considerably in excess of such
rural death-rate. All villages under 1,000 population are classified
as rural.

In England and Wales the rural maternal mortality is the greater.


MATERNAL MORTALITY RATES BY RURAL AND URBAN FOR THE REGISTRATION
                          AREA, 1922
================================================================================
                |        Rural       |         Urban       |       Total
                |--------------------+---------------------+--------------------
     Province   |      |      | Rate |       |      | Rate |       |      |Rate
                |      |Mater-|  per |       |Mater-|  per |       |Mater-| per
                |Births|  nal |1,000 | Births|  nal |1,000 | Births|  nal |1,000
                |      |Deaths|living|       |Deaths|living|       |Deaths|living
                |      |      |Births|       |      |Births|       |      |Births
----------------+------+------+------+-------+------+------+-------+------+------
Prince Edward   |      |      |      |       |      |      |       |      |
  Island        | 1,751|    5 |  2.9 |   409 |    3 |  7.3 |  2,160|    8 |  3.7
Nova Scotia     | 6,914|   36 |  5.2 | 5,779 |   34 |  5.9 | 12,693|   70 |  5.5
New Brunswick   | 7,874|   25 |  3.2 | 3,690 |   34 |  9.2 | 11,564|   59 |  5.1
Ontario         |29,343|  121 |  4.1 |42,087 |  249 |  5.9 | 71,430|  370 |  5.2
Manitoba        | 9,554|   42 |  4.4 | 8,125 |   57 |  7.0 | 17,679|   99 |  5.6
Saskatchewan    |17,497|   74 |  4.2 | 4,842 |   53 | 10.9 | 22,339|  127 |  5.7
Alberta         | 9,483|   60 |  6.3 | 6,670 |   51 |  7.6 | 16,163|  111 |  6.9
British Columbia| 3,217|   16 |  5.0 | 6,949 |   47 |  6.8 | 10,166|   63 |  6.2
                |------+------+------+-------+------+------+-------+------+------
    Total       |85,637|  379 |  4.4 |78,557 |  528 |  6.7 |164,194|  907 |  5.5
---------------------------------------------------------------------------------


It is, however, probable that our maternal mortality is larger than
these figures indicate. An important inquiry further referred to below
on maternal mortality in Ontario, by the Provincial Department of
Health, under the direction of Dr. J. W. S. McCullough, Deputy
Minister, and Dr. W. J. Bell, Pediatrician to the department, shows
that in 1921 there were approximately 483 deaths in childbirth in
Ontario instead of 387 and 465 in 1922 instead of 370, or an increase
of about 25 per cent in the above figures.


SIGNIFICANCE

No words are needed to express the national importance of this
subject. The death of the mother means often the death of the
children.

Research studies in maternal mortality now in progress in the Vital
Statistics Division of the New York State Department of Health show
that for every 1,000 women who die in the state from causes connected
with childbirth, 500 of their babies die within the first year of
life. These studies throw light upon the problem of the motherless
child. The statistics show that each mother who dies from a cause
connected with childbirth leaves on the average two or three living
children. Careful inquiries made by the division have brought out the
fact that in the opinion of the attending physicians from one-third to
one-half of these mothers were neglected or given poor care at some
time before their confinement.--(_Health News_, New York State
Department of Health, Albany, February 4, 1924).

[Illustration:

Deaths under one
year per 1,000
births.

Deaths under
one month.

Deaths of babies
who survive one
month, and die in
the next eleven
months of the
first year.

From Report of Sir F. Truby King, M.D., Director of Child Welfare,
Department of Health, New Zealand, 1921-22]


INFANT MORTALITY

We cannot hope for much improvement in the infant mortality rate shown
in the above tables until we give the mother better care.

The great reduction in infant mortality which has taken place since
1900 in England and Wales, Canada, New Zealand, the United States and
other countries has almost all been in the second to the twelfth
months of the first year of the baby's life. This is shown in the
accompanying graph from page 3 of the Annual Report of the Director of
Child Welfare in New Zealand, Dr. F. Truby King, 1921-22.

It is the same in other countries. The child dies in its first month
because the mother did not receive proper pre-natal care.

Make Canada safe for the mother and she will make Canada safe for the
baby.


II.--MATERNAL MORTALITY IN CANADA AND OTHER COUNTRIES


=============================================================
     |                                  |Number of| Rate    |
Year |         Country                  | Maternal|per 1,000|
     |                                  | Deaths  | Births  |
-----+----------------------------------+---------+---------|
1922 | Denmark                          |    146  |  2.0    |
1922 | Netherlands                      |    454  |  2.5    |
1918 | Sweden                           |    304  |  2.5    |
1916 | Italy                            |  2,351  |  2.6    |
1920 | Switzerland                      |    235  |  2.9    |
1923 | England and Wales                |  2,892  |  3.8    |
1922 | Australia                        |    621  |  4.5    |
1923 | Spain                            |  3,010  |  4.6    |
1923 | Irish Free State                 |    297  |  4.8    |
1923 | North Ireland                    |    148  |  4.9    |
1920 | Germany                          |  7,865  |  4.9    |
1922 | New Zealand                      |    149  |  5.1    |
1922 | Belgium                          |    827  |  5.4    |
1922 | Canada (Registration Area)       |    907  |  5.5    |
1916 | France                           |  1,895  |  6.0    |
1923 | Newfoundland                     |     46  |  6.2    |
1923 | Scotland                         |    718  |  6.4    |
1922 | United States (Registration Area)| 14,657  |  6.6    |
------------------------------------------------------------|


III.--IS IT EXCESSIVE?

It has always been recognized that maternal mortality in childbirth is
preventable.

In spite of this fact, maternal mortality has not declined or has
declined very slowly.

In England and Wales[5] the maternal mortality rate in 1900 was 4.81
per 1,000 living births and in 1922 it was 3.58.

"The high child-bed mortality in England is one of the darkest blots
on our health record; it can be removed only on condition that mothers
and those who attend them understand the character of the risks
involved."--(_London Times_, 2.7.24.)

Maternal mortality in Canada in 1922 was 45 per cent higher than in
England.

"Lying-in is neither a disease nor an accident, and any fatality
attending it is not to be counted as so much per cent of inevitable
loss. On the contrary, a death in child-bed is almost a subject for an
inquest. It is nothing short of a calamity which it is right we should
all know about, to avoid it in the future."--(_Florence Nightingale_.)

[Footnote 5: Annual Report of Sir George Newman, Chief Medical Officer
to the Ministry of Health for 1923, page 95.]

"The case stands strongly against us--the mother in the prime of
life--the most valuable citizen in the community--dying often from a
preventable disease."--(_Prof. W. W. Chipman_, McGill University,
Montreal.)

What should we regard as a satisfactory maternal mortality rate? Major
Moss, R.A.M.C., stated at the discussion of this subject at the
British Medical Association meeting, Section of Obstetrics and
Gynaecology, 1924, that he had found it to be not over one in 2,000
with ante-natal care.


NOT ONE MOTHER DIED IN TEN YEARS

From 1894 to 1903--not one baby died in Villiers-le-Duc in France, not
one mother died in childbirth and only one stillbirth occurred.

The Mayor, a doctor, was M. Morel.

The same thing once happened in Quebec, in a rural parish, through the
exertions of the cur, the parish priest. Not one mother died in
childbirth in that parish for a whole year. I saw the reference
probably in "The Canadian Journal of Medicine and Surgery," perhaps
about 1904, but I have been unable to find it again.

At the meeting of the Academy of Medicine, Toronto, December 5, 1922,
Dr. C. J. Hastings, Medical Officer of Health, stated that the number
of deaths in Toronto in 1921 of women between the ages of 15 to 45 was
610. Of these 14.3 per cent died of diseases of pregnancy, 50 per cent
being septic cases. The other chief causes are in percentages--Cardiac,
12.1; tuberculosis, 12.1; cancer, 8.4; pneumonia, 7.0, etc.

Prof. W. B. Hendry stated that from 1914 to 1922 there were cared for
in the Burnside Maternity Department of Toronto General Hospital 6,982
maternity cases, of whom 86 died--a mortality rate of 12.4 per 1,000.


PRE-NATAL CARE

The good results of pre-natal care are shown by figures quoted by Dr.
J. W. S. McCullough and others in 1920, from the records of the
Burnside Maternity Department of Toronto General Hospital.

MATERNAL MORTALITY PER 1,000 LIVING BIRTHS

Maternity patients in public wards, not supervised   35
Maternity patients in semi-private wards              8
Maternity patients in public wards, supervised        4


HELP NEEDED IN THE HOME

Information received by the department seems to show that, in addition
to the great need of better medical and nursing care, ante-natal,
obstetrical and post-natal, the difficulty, often the impossibility,
of getting any help in the house even during the first ten days after
the birth of the baby is a cause of maternal morbidity and mortality
in Canada.

At the request of certain provincial authorities an outline has been
drafted intended to assist in organizing "Home Helps" for mothers.
This help is necessary for the home and the children, even if the
mother goes to the hospital at this time, and it is also necessary for
a short time after she returns from the hospital.


RURAL ANTE-NATAL CARE

Dr. E. K. MacKenzie, Tain, Rossshire, who travels 11,200 miles and has
3,700 visits and 2,400 consultations per year, states that since 1915
he has had 680 confinements, 224 primiparae, with 11 stillbirths and
no maternal deaths and no puerperal fever.

He says, "The contention that in general practice there is no time for
ante-natal care is baseless, as I have also found the statement that
patients resent such attention."

"Ante-natal care not only removes the anxieties of my practice but
simplifies my procedure and in the end makes my actual work less."

Dr. Janet Campbell says that without pre-natal care "a comparatively
simple event becomes one of dangerous urgency."--(Discussion at
British Medical Association, Section of Obstetrics, B.M.J., 16.8.24.)

It was in 1900 that the late Prof. J. W. Ballantyne, of Edinburgh,
proposed that ante-natal care should form a special and separate
department of the work of a maternity hospital. The first ante-natal
hospital ward was established by Dr. Ballantyne in the Maternity
Department of the Edinburgh Royal Infirmary in 1901.

"The advocacy of Ballantyne and his tardy followers has not been in
vain. The profession has at last universally acknowledged the urgency
of the teaching and practice of preventive midwifery."--(_British
Medical Journal_, 16-8-24.)

"England was fortunate in having as the father of English midwifery,
Harvey, who introduced into that branch of medicine the wide view, the
scientific spirit, and the conservative practice which have been its
characteristics. It was Harvey's inculcation of patience and
gentleness in imitation of nature, adopted by Smellie and Hunter,
which made such a strong impression on Boer, the founder of the great
Viennese School of Midwifery, who, after studying in France and
England, adopted the British practice 'having learnt in France what
Art, in England what Nature, could do.'"--(Page 1056, _The Lancet_,
November 22, 1924. The Lloyd Roberts lecture on The Renaissance of
Midwifery, by Herbert R. Spencer, M.D., B.S., London, F.R.C.P.,
Obstetric Physician to University College Hospital.)


IV.--WHAT PROPORTION OF BIRTHS OCCUR WITH NO MEDICAL OR NURSING CARE
FOR MOTHER AND CHILD?

The most complete statistics received are those from the Province of
Saskatchewan:--

Total births for 1922                                                  22,815
Total births attended by a physician, 15,001, or                  66 per cent
Total births attended by a nurse only, 182, or                     1    "
Total births attended by neither physician nor nurse, 7,632, or   33    "

It is stated that in other provinces the number of mothers who receive
no medical care at childbirth varies from 10 per cent to 50 per cent.

In the United States Registration Area the corresponding figure is
said to be 30 per cent.

An inquiry into the matter of Medical Service was begun in Ontario on
April 3, 1924, and is now almost complete.

The following is the form of the inquiry.

Secretary,
Local Board of Health.
_Re Medical and Hospital Services_

     DEAR SIR,--The Minister of Health and the Provincial
     Board of Health desire to obtain accurate information
     as to the distribution of legally qualified medical
     practitioners and of hospitals in the province of
     Ontario. The questionnaire on the reverse side of this
     letter is sent to you with the request that you will be
     good enough to furnish the information asked for. When
     the facts are known it will then be possible to
     determine just what districts or municipalities need
     further medical assistance or hospital accommodation.

     It is suggested that you confer with the local
     authorities and others interested in your municipality
     in order that the information furnished may be as
     accurate as possible.

     Please complete the questionnaire and forward it to the
     Chief Officer of Health, Spadina House, Toronto, before
     May 15, 1924.

JOHN W. MCCULLOUGH,
_Chief Officer of Health_.



QUESTIONNAIRE
RE MEDICAL AND HOSPITAL SERVICES

Municipality......................................County....................................

1. Population of municipality (1921 census).................................................

2. Names (of legally qualified medical practitioners in the municipality) Addresses.........

............................................................................................

............................................................................................

3. Is there, in your opinion, any lack of medical service to the people in the municipality?

............................................................................................

4. (a) Number of hospitals in the municipality (give names)..........................

............................................................................................

(b) Number of hospital beds..........................................................

(c) How are hospitals operated and maintained?.......................................

(d) Is there enough hospital accommodation in the municipality?......................

(e) If not, how many more beds are required?.........................................

Date ............................

.................................
Secretary, Local Board of Health.


If there should not be enough room under any of the sections a separate sheet may
be used.


    NUMBER OF HOSPITALS IN CANADA

    Prince Edward Island   3
    New Brunswick         16
    Nova Scotia           25
    Quebec                18
    Ontario              150
    Manitoba              47
    Saskatchewan          60
    Alberta               60
    British Columbia     100
                        ----
        Total            479


    RED CROSS NURSING OUTPOSTS, NURSING STATIONS AND HOSPITALS

    Prince Edward Island   1
    New Brunswick          0
    Nova Scotia            1
    Quebec                 0
    Ontario                9
    Manitoba               8
    Saskatchewan           9
    Alberta                2
    British Columbia       0
                        ----
        Total             30
                        ----
        Total            509


V.--ARE MEDICAL FEES TOO HIGH?

From the point of view of the patient there is some reason to think
that this may sometimes be the case.

A good many letters have been received on this subject, such as the
following:--

     "Do you know the terrible rates the doctors can charge
     here and sometimes do charge as high as $65 to go a few
     miles out in the country to a common maternity case
     (not more than seven or eight miles). Is it any wonder
     people take long chances these hard times? Of course we
     have some splendid big doctors who can see farther than
     their pocket, but don't you think their charges should
     be fixed a great deal lower than they are?"


VI.--WHAT RECENT INQUIRIES OR INVESTIGATIONS HAVE BEEN MADE INTO
MATERNAL MORTALITY AND RELATED SUBJECTS, SUCH AS PUERPERAL
SEPSIS, AND WITH WHAT RESULTS?

There is a great change, especially in the last three years, in the
general attitude in regard to maternal mortality.

At the Eighty-eighth Annual Meeting, British Medical Association,
1920, Section of Obstetrics and Gynaecology, Herbert Williamson, M.B.,
F.R.C.P.,

President, the following were the introductory remarks by the president:--

     "Our meeting this year is one of peculiar importance,
     for we see on the horizon the dawn of a new era in
     obstetrics. We have realized that in the interests of
     the State--nay, in the interests of humanity itself--it
     is desirable to amend and to amplify the training of
     those who are to succeed us in the practice of
     obstetrics. The State is awakening also to the fact
     that in the past it has failed to discharge its debt to
     the mothers of the race and has grossly neglected the
     things which make for their safety and happiness; there
     is to-day a sincere desire to correct these errors, and
     the questions involved are receiving an earnest and
     disinterested consideration such as has never been
     accorded them before.

     "We have come to realize more and more that obstetrics
     is essentially a branch of preventive medicine. I do
     not think it is speaking too strongly to say that it is
     the most important branch of preventive medicine. The
     dangers of childbirth are to a great extent
     preventable, and the more clearly this idea is grasped
     and acted upon by the medical profession and the
     general public the lower will be puerperal mortality
     and morbidity."


MATERNAL MORTAILITY IN NEW ZEALAND

A report by the Special Committee set up by the New Zealand Board of
Health, July 27, 1921, appeared on October 7, 1921. The Committee, who
had the assistance of Dr. Jellett and others, made twelve
recommendations which are of great value.


MATERNAL MORTALITY IN ENGLAND

In the reports of Sir George Newman, especially in "Recent Advances in
Medical Education in England" much attention is devoted to the
prevention of maternal mortality. The following reference is made to
Prof. B. P. Watson's paper in the British Medical Journal of October
21, 1922:--

     "Professor Watson, of Edinburgh, has rightly pointed
     out that if we in Britain are to keep abreast with
     other nations in regard to obstetrics and gynaecology
     we must be prepared to give a fuller and more intensive
     training in midwifery to our medical students. Such
     training cannot be given by making attendance on a
     certain number of confinements at the patient's house
     the chief feature. Clinical medicine and surgery could
     never be taught in such a way, nor can clinical
     obstetrics. What is necessary, as Professor Watson
     claims, is more intensive training, so that the student
     may concentrate his study and live, as it were, in its
     atmosphere, seeing all the work of a maternity
     hospital, an ante-natal clinic, the technique of the
     labour room, the care of the newly-born infant, and the
     aftercare of both mother and child. This is what he
     says:--

         'Ante-natal care implies a thorough general examination
         of the patient as early in pregnancy as possible, and a
         special examination to make sure that she has the
         physical configuration necessary for a normal labour.
         It implies a careful watch on the patient at regular
         intervals throughout the pregnancy, and the immediate
         institution of appropriate treatment whenever the least
         departure from normal is detected....

         'The problem which faces us is to convince women
         generally of the necessity for ante-natal care. This,
         as I have said before, can only be done by the efforts
         and example of the whole body of medical practitioners.
         An isolated ante-natal clinic here and there will
         benefit the community which it serves, and public
         opinion will be educated to a certain extent, but it
         will not be until the consulting-room of every
         practitioner is an ante-natal clinic for his district
         that the maximum of benefit will be obtained'."

Sir George Newman adds:--

     "The most significant educational advance which has
     recently occurred is, however, instruction in regard to
     the application of the principles of preventive
     medicine to obstetrics in four respects, namely,
     ante-natal work, the conduct of labour, the prevention
     of congenital syphilis and the care of the infant. The
     two last subjects are referred to elsewhere in the
     present report."


ONTARIO

_Special Investigation._

A special investigation has been carried on for the last three years
on Maternal Mortality in Ontario, by the Provincial Department of
Health, under the direction of Dr. J. W. S. McCullough, Deputy
Minister, and Dr. W. J. Bell, Pediatrician to the department. The plan
adopted has been to issue the subjoined letter to the physician whose
name is signed to the death certificate of any woman between 15 and 50
years of age at the time of death.

The results of this investigation show an additional number of deaths
which were really deaths in childbirth, though not returned as such on
the certificate of death. The increase amounts to about 25 per
cent--in other words--there were, in 1921, 483 deaths in childbirth in
Ontario instead of 387, and 465 in 1922 instead of 370.

Dr. Bell received replies from about 95 per cent of the physicians
concerned.

     SPADINA HOUSE,
     Toronto, Ont.

     DEAR DOCTOR,--The Provincial Board of Health in
     conjunction with the Department of the
     Registrar-General is making a special study of the
     subject of maternal mortality.

     For this reason and in order to make the investigation
     as complete as possible, it has been decided to inquire
     into the death of every female between the ages of 16
     and 49 years inclusive. Your co-operation in this
     investigation is earnestly solicited and will be much
     appreciated.

     Your name appears as the physician who attended the
     deceased named below, will you therefore be good enough
     to furnish the information requested in the form and
     return at earliest convenience.

     Yours very truly,
     JOHN W. S. MCCULLOUGH,
     _Chief Health Officer and Deputy Registrar-General._


Name.....................................................................................

Age............  Date of Death...........................................................

Nationality....................  Married or Single.......................................

Was deceased pregnant at time of death? Yes or No........................................

If so, was pregnancy or parturition a factor in connection therewith, or had pregnancy or
parturition any relation, contributory or otherwise, to the woman's death?...............

Was the deceased a primipara or a multipara?.............................................

What was the length of the primary stage of labour?......................................

Were instruments used?...................................................................

Was pituitrin used?......................................................................

Was the baby born alive?.................................................................

Was the labour full term?................................................................

If not, what was the age of the foetus?..................................................

Did the labour occur in hospital or at home?.............................................

Signature......................................

Address........................................


MIDWIVES

By request, the following official information has been made
available:

No regulations or official recognition in the following
Provinces:--Alberta, British Columbia, Manitoba, New Brunswick,
Ontario, Prince Edward Island, Saskatchewan.

Quebec.--Midwives are licensed by the College of Physicians and
Surgeons of Quebec.

Nova Scotia.--"The only regulations respecting midwives, so far as
this province is concerned, are those contained in the Medical Act.
The Act states that nothing shall prevent any competent female from
practising midwifery in this province, except in the city of Halifax.
In the city of Halifax no female shall practice midwifery unless and
until she fulfils such conditions as the Medical Board by regulations
or by-law appoints, and satisfies the examiners appointed by the
board. A diploma or certificate from a recognized hospital may be
accepted in lieu of an examination."


ENGLAND AND WALES

The following reports on public health and medical subjects by Dame
Janet M. Campbell, M.D., M.S., Senior Medical Officer for Maternity
and Child Welfare, Ministry of Health, have been issued in 1923 and
1924.


No. 15--Teaching Obstetrics and Gynaecology in the Medical Schools.
No. 21--The training of midwives.
No. 25--Maternal Mortality.


On page 57 of report No. 15, Dr. Campbell states eight conclusions
which have received general support.

On page 44, report No. 21, she recommends an extension of time of
training for unqualified women from six months to twelve months and
for trained nurses from four months to six months.

On pages 90 and 91 of report No. 25, Dr. Campbell states that the
maternal mortality rate is unnecessarily high, that it is highest in
rural counties and that "We can, however, with some confidence, assign
responsibility primarily to the adequacy or otherwise of the
professional attention during pregnancy, and at the time of birth. A
careful midwife and a skilful doctor rarely lose a patient, given a
reasonable chance for the exercise of their competency."

A summary of Dr. Campbell's recommendations re securing a reduction in
puerperal mortality and morbidity is given on pages 92 and 93.

These three reports are of outstanding importance and influence. This
is illustrated by the following inquiry:--


_Puerperal Sepsis_

At the request of the Ministry of Health, the Royal Society of
Medicine have taken up this subject.[6] The combined Sections of
Obstetrics and Gynaecology and State Medicine, and the Society of
Medical Officers of Health met on November 6, 1924, to consider this
matter.

[Footnote 6: Page 1011, _The Lancet_, November 15, 1924. See also Dr.
Janet Campbell's Report No. 25, above.]

The following report was presented:--

Report of Committee representing the Sections of Obstetrics and
Gynaecology, and Epidemiology and State Medicine, and the Society of
Medical Officers of Health:--

     "Any case in which there is a rigor or a temperature of
     102 or higher for 24 hours, during the first ten days
     after a confinement or abortion, must be notified.

     "Get rid of the official term 'puerperal fever,' and
     use in its place the term 'puerperal sepsis'.

     "Puerperal sepsis is a febrile condition of the nature
     of wound infection, arising after labour or abortion,
     due to bacterial invasion from, or absorption of,
     products of bacterial action from some portion of the
     genital tract."

A recommendation brought forward by Dr. Bourne at this meeting was
that the services of specially-qualified obstetricians should be
available through the Department of the Medical Officer of Health or
otherwise, to help the general practitioner in difficult cases of
midwifery.

This proposal had already been made by Professor Louise McElroy, in a
letter to the British Medical Journal of October 4, 1924. Professor
McElroy pointed out the importance of having a medical inspector of
midwives who is especially qualified in obstetrics and who is also a
full-time officer, as consultant.

"The President, Dr. Russell Andrews, considered that the discussion
had been very useful. It now remained for the sub-committee to meet
and to consider the reply to be sent to the Ministry of Health. It
could be anticipated that there would be a demand for a comprehensive
inquiry."

It will be noted that the standard proposed by the committee is
somewhat different from previous standards.


STANDARDS OF MORBIDITY

1. The British Medical Association include within the term, "Puerperal
Morbidity," all conditions in which the temperature reaches a height
of 100 Fahr. on two occasions from the end of the first to the end of
the eighth day after delivery.--(B.M.J. 1906, 1 Suppl. p. 264, May
19).

2. _Congress of Puerperal Fever, Strassbourg, August,
1923--Resolutions:--_

(1) The congress considers that precise rules should be established
for determining the temperature in labour and the puerperium, and for
interpreting the results.

(2) The temperature should be taken morning and evening during the
hours preceding the meal and also on each occasion when any symptom
indicates that there may be a rise of temperature.

(3) The record should show whether the temperature has been taken in
the armpit or internally, and in the latter case the locality chosen.
The congress urges the advantages of the rectal temperature.

(4) Excluding the temperature within the twenty-four hours following
delivery, every temperature exceeding 38 (100.4 F.) on one occasion
and persisting more than twelve hours should be considered
pathological during the puerperium.


SCOTLAND

_Notes from "The Report of the Scottish Departmental Committee on
Puerperal Morbidity and Mortality."_

The highest rate recorded for a single year was 7.0 per 1,000 births
in 1918, the year of the great influenza epidemic. Of the four years,
between 1855 and 1913, in which a mortality of 6.0 was reached, two
(1874 and 1875) were associated with the severest epidemic of scarlet
fever recorded in Scotland.

The most important avenue to the prevention of maternal mortality and
morbidity is through ante-natal care.

Every pregnant woman should be encouraged at an early date to put
herself under the supervision of a medical attendant. If necessary
this supervision should be provided by the public health authority.

We recommend that legislation be considered to make the conduct of
maternity homes illegal unless they are registered by the local
authority and conducted to their satisfaction.

We recommend that every death occurring within four weeks after the
termination of pregnancy should be fully investigated by a person
designated by the local authority, and the facts communicated to the
Scottish Board of Health.

Increased ante-natal care of the mother and due training and
co-operation of her professional attendants will together include most
of the remedial measures which are at present applicable to the
prevention of maternal mortality and morbidity.


RETURNS RE PUERPERAL SEPSIS

An effort is now being made in England and in the United States to
increase the accuracy of returns reporting puerperal septicemia. Dr.
Reginald Dudfield, Medical Officer of Health for Paddington, and
others have pointed out that this disease is not being satisfactorily
reported.

In the state of New York during 1920-23 there were 1,148 deaths from
puerperal sepsis recorded, but only 877 cases of the disease reported.

Dr. Harmon of the School of Medicine of Western Reserve University
deals with the variations in the United States death rates of
puerperal septicemia and makes the following statements:--

     "According to the published figures of the Census
     Bureau for 1920 for the United States registration area
     for deaths, it was the largest single cause of maternal
     mortality and was responsible for about 34 per cent of
     all such deaths.

     "All rates therefore in this paper are expressed as the
     number of deaths from puerperal septicemia occurring in
     an indicated area during a year per 100,000 married
     females, age fifteen to forty-four, credited to that
     registration unit."


The following are among Dr. Harmon's conclusions:--

     "For the whole period, when all the states are
     considered as a unit there is no evidence of a
     significant downward tendency in the rates from
     puerperal septicemia."

     "The high rates, the lack of a consistent downward
     trend, and the variability of the rates for the states
     studied demand that greater attention be given to the
     prevention of puerperal infections and that efforts to
     accomplish this end be organized as soon as possible."


AMERICAN ASSOCIATION OF OBSTETRICIANS, GYNAECOLOGISTS AND ABDOMINAL SURGEONS

Another important American report is the Report of the Committee on
Maternal Welfare to the American Association of Obstetricians,
Gynaecologists and Abdominal Surgeons, 1923.

The following is the conclusion of the report of this committee:--

     "Women will never escape what must be designated as the
     accidents of pregnancy and labour, but they may be
     spared much of the danger, which is now accepted as
     being of preventable origin. It is this phase of
     preventive obstetrics in which organizations,
     self-constituted and enthusiastic to do welfare work,
     can find a proper field for their activities. This
     cannot be successfully accomplished, however, in any
     community without a lay interest being manifested by
     persons who will, by a generous philanthropy, provide
     the means of financial support; and, also, by an
     interest on the part of semi-professional
     organizations, such as associations of trained nurses,
     as well as women's clubs; and finally by an interested
     medical profession, willing and ready to lend its aid.
     All such elements of the lay, the semi-professional and
     the professional people, if they co-operate, can bring
     about an organization powerful for good; and also
     elastic enough to recognize the responsibility of each
     class and to accept by agreement that each shall
     function as an entity, neither invading the prerogative
     of the other, and thus to impress upon the community
     its value as a factor in upholding the public health."


     (Signed) Henry Schwarz, M.D.,
              George W. Kosmak, M.D.,
              George Clark Mosher, M.D.,
                          _Chairman_.


STANDARDS OF MATERNITY CARE

It may be noted that the standards for maternity care have been
raised.

The following are the standards of maternity care adopted by Regional
Consultants in Obstetrics for the New York State Department of Health,
Albany, N.Y.


_Prenatal_

Continuous medical supervision should begin as soon as the mother
suspects pregnancy.

Hospital care should be advised when indicated and available, for all
parturients (particularly primiparae) and should be insisted upon for
all abnormal cases.

First visit should include:--Histories of previous pregnancies and
labours. Determination of expected date of confinement. Instruction in
the hygiene of pregnancy, including diet, elimination, exercise, rest
clothing, care of the breasts preparatory to breast feeding, marital
relationship, and provision of literature on pre-natal and infant
care.

Physical examination should be made as early in pregnancy as
practicable. Special attention should be directed to determination of
blood pressure. Urinalysis. Heart, lungs and kidneys. Thighs, legs and
vulva for varicosities. General nutrition. Posture with examination
for spinal curvature, subluxation of sacro-iliac joints or other
abnormality. Blood Wassermann when indicated. Pelvic examination.
Palpation of bony pelvis. Pelvimetry, the following measurements being
suggested: interspinous, intercristal, external conjugate, external
obliques, internal conjugate (estimated), transverse of the outlet,
posterior sagittal.

Classification as to type of pelvis.

Vaginal examination preferably after the first six weeks if there are
no indications of abnormalities.

Instruction of the patient to report promptly the following symptoms:
headache, nausea, dizziness, visual disturbance, epigastric pains,
bleeding, constipation, edema.

Frequency of visits. The patient should visit her physician at least
once a month until the sixth month, then every two weeks or oftener as
indicated, preferably every week in the last four weeks. Local nurses
and social workers could be utilized to follow up patients if they do
not return at the appointed time.

Subsequent visits should include: Determination of blood pressure.
Urinalysis. Examination for fetal heart. Any other examination that
may be indicated. Determination of presentation and engagement and
probable position of the fetus after the seventh month. Vaginal
examinations should not be made after the seventh month unless
indicated. If made they should be conducted under the same aseptic
precautions as for delivery. Rectal examinations will usually furnish
necessary information.

Instruction of the patient in: preparation of person, room, outfit for
confinement and for the baby. This may often be given by the patient's
nurse or by the local visiting or community nurse at the physician's
request.


_Delivery_

Time should be given freely.

Consultant facilities should be available. As any abnormality requires
more than average experience it should not be handled without the
advice of a consultant obstetrician.

Nursing care should be adequate.

Equipment sufficient to meet emergencies should be accessible.

Surgical cleanliness. Rubber gloves, sterilized by boiling or steam
pressure should be used for examinations and delivery.

The vulva should be shaved and the entire field cleaned and made and
kept aseptic.

Vaginal examinations should be avoided if possible. Usually
confirmation of previous findings can be made and progress
satisfactorily followed by rectal and abdominal examinations.

Indications for interference, the cervix being fully dilated or
dilatable and no other abnormality being present.

Failure of labour to progress.

Fetal heart rate below 100 or above 170.

Should radical interference become necessary, the same careful
surgical technique should be used as when entering the peritoneal
cavity.

Examination after delivery should include: the perineum and vaginal
outlet for evidence of lacerations, which should be repaired
immediately.

The placenta and membranes to see if they are complete. The uterus by
external palpation to see if it is empty and firm. Time should be
taken to examine the baby thoroughly and to give full directions for
the care of both patients.

Hemorrhage: Normal contractions of uterus, determined by abdominal
palpation should be maintained for at least one hour after it is
emptied. In event of persisting hemorrhage immediately after delivery
which does not yield to ordinary measures the fundus should be
massaged through the abdominal wall. If bleeding continues the cervix
may be examined for lacerations and necessary repairs made.

Freshly sterilized gauze for packing should be available.


_Puerperium or postpartum period_

The patient should be seen by the obstetric attendant as often as may
be needed.

Postpartum visits should be made at least, on first day, to determine
uterine contraction, bladder tone, to establish breast feeding and
note general conditions of the patients.

Third and fifth days, to determine possible evidence of infection and
not involution.

Tenth day, to determine involution, general condition of patients and
to fix the time when mother may sit up.

A final bimanual examination should be made about six weeks after
delivery or before the patient resumes usual activities to determine
displacements, subinvolution, cervicitus, resolution of lacerations
with correction of defects.

The patient should remain in bed at least ten days after delivery.

She should not resume full activities for six weeks after delivery as
it takes six to eight weeks for complete involution to take place.

The services of a visiting or community nurse may be secured if
available for the aftercare of patients if such service is desired.




GENERAL CONGRESS OF OBSTETRICS AND GYNAECOLOGY, 1925


"At the General Congress of Obstetrics and Gynaecology to be held next
year, 1925, at the Royal Society of Medicine, Dr. Russell Andrews will
preside over a reunion of the various British and Irish societies
devoted to the subjects of gynaecology and obstetrics, when one of the
subjects set for discussion is the treatment of puerperal sepsis. To
this discussion two whole sessions will be devoted, and it will be
introduced by reports from two special committees in London and the
North of England, when the grave interest of the matter will secure
widespread attention for the conclusions of the Congress. From all
that has been written above it will be seen that now at least the
medical profession is alive to the supreme importance of a scientific
service of midwifery, and the status of work along all its lines is
thereby indefinitely raised."--(The Status of Midwifery, November 22,
1924, page 1075, _The Lancet_.)

The CHAIRMAN: Dr. MacMurchy has interested every member of the
conference in the excellent paper she has given us. The subject she
has discussed is obviously one that must be tackled by the profession
or the state, or by whatever authority can best deal with it.
Certainly we cannot afford to have mortality statistics in this class
of cases greater in this country than they are elsewhere. It does seem
to me that the subject, which is of such great importance, is one that
should be grappled with. The paper is now open for discussion.

Dr. JOST: If I am in order, I would move that there be submitted to
the Resolutions Committee for consideration the following question:
"Should a comprehensive investigation be made into maternal mortality
in Canada, and if so by whom?" I think that this conference might
suggest to the Canadian Medical Association the advisability of
calling the attention of the provincial societies to the importance of
this question with a view to the adoption by each society of such
action as it may deem advisable.

The CHAIRMAN: The question might be handed to the Resolutions
Committee for consideration.

Dr. J. C. CONNELL (Queen's University): Medical science is
cosmopolitan; it has no geographical boundaries, inasmuch as we are
concerned only in the extension of the frontiers of knowledge. At the
same time, I think it is acknowledged that matters relating to medical
education fall within the province of each country and appertain to
that country itself. In Canada such matters are provincial rather than
national. I propose to submit for your consideration, Mr. Chairman, as
well as for the consideration of members of the conference, a matter
which I consider of very great importance and which I think should be
carefully considered by this national meeting--a matter which may be
regarded not only from a sentimental aspect but, as well, from a
practical point of view.

About fourteen or fifteen years ago the American Medical Association
appointed a council on medical education, at a time when there were
some 200 medical schools in the United States. The primary duty of
that council appeared to be to inspect the medical schools of the
United States and to report on their condition. Following that
inspection, this council on medical education--on what authority I do
not know; I am quite sure it was not on the invitation of any
representative Canadian body--proceeded to inspect the medical schools
of Canada and to prepare a report upon them. To those of us who
concerned ourselves with these reports, it was from the beginning
quite evident that whatever criteria were adopted to determine the
standing of the various schools they were not applied in Canada in
just the same way as they were in the United States. This is not the
time to refer to the nature of some of the criteria, but one cannot
help observing that some of them were extremely artificial. As a
result of these inspections there has been published from time to time
in the annual reports of the council on medical education a
classification of the American medical schools together with one in
regard to the schools in Canada.

I shall not go into any detail except to say that as a result of the
last inspection of which I had any knowledge, which was made in 1921,
a report was submitted by the inspectors which, as it related to one
of our Canadian universities particularly, was so untrue in many
respects, and so absolutely unfair in many more, that the Senate of
the University and the Board of Trustees took the matter up and
entered a vigorous protest against the action of the inspectors of the
council. In consequence of that protest--at least following upon that
protest, whether in consequence of it or not--the classification of
Canadian schools was discontinued. For the years 1921, 1922, and 1923,
in the reports of the council on medical education no classification
of Canadian schools was included. In the report of the council
published in the American Medical Journal in August of this year there
appears again a classification of Canadian medical schools, and
apparently, at least so far as I know, that classification has been
made without any re-inspection. Certainly there was no general
re-inspection.

Now, let me point out just what this means. First of all, I want to
note that in the United States there are now about 80 medical schools,
of which only four are placed in Class B by this report. So far as
Canada is concerned five schools are placed in Class B, namely,
Dalhousie, Queen's, the Western University, Montreal, and Laval. On
the other hand, I would point out that the report includes in Class A
in the United States such institutions as the College of Medical
Evangelists, Loyola School, Chicago, Boston University, Boston, and
others of a similar standing. I know something of these institutions,
and it is quite evident that the criteria are not applied in the same
way to Canadian schools as to those in the United States.

There is another point to which I would call attention, and that is
that the judgment of this council on medical education is not
universally accepted in its own domain. The state of New York does not
accept its judgment in regard to Canadian schools nor even in regard
to the schools of the United States. One of the American schools
included in Class A in this report is not accepted in that category by
the Board of Regents of the state of New York, who have made their own
classification of Canadian schools. And the classification made by
that body in regard to Canadian schools is different from that which
appears in the report of the council. The state of Pennsylvania has
also made its own inspection with a different result. So that
obviously the judgment of the Council on Medical Education is not to
be accepted as finally authoritative.

Now, there are two aspects to this question: There is the sentimental
side of it, and there is also the practical point of view to be
considered. It is a humiliation that those connected with certain
Canadian schools should find themselves in the company indicated in
this report. Of course, after all, it does not concern us in Canada
very much as to what our neighbours think about us, and they have a
perfect right to adopt their own policy. That policy is one of
antagonism to the admission of Canadian students to their qualifying
examinations; one is constantly made aware of such an objection
throughout the United States. Objection is taken to Canadian
certificates and difficulties are put in the way of Canadian graduates
who are seeking state examination. We need not find fault with them in
this regard; as I say, it is a matter of policy. When, however, a
foreign corporation undertakes to classify Canadian schools without
invitation, although they may consider their results confidential,
without exception being taken to them, the matter assumes a different
aspect when those results are published throughout the world. I think
it is rather a serious matter, as it puts a grave disability on every
Canadian graduate from every one of these so-called Class B schools
who may happen to be in practice anywhere in the United States. Such a
man has not the same standing if he is called into court; it is
pointed out before his evidence is taken that he is a graduate of a
Class B school, and this prejudices him immediately in the eyes of the
court. That is the practical side of the matter: every Canadian
graduate who is in the United States, or who proposes to practice
there is under a serious disability as a result of this published
classification.

Now, it seems to me that it would be very proper for this conference
to take some action in the matter. All we want is to be left alone to
work out our own ideals in our own way, and in my judgment at any rate
there never was a medical school in Canada which was justly included
among the Class B schools of the United States. There never was a
school in Canada that gave a degree with less than four years work. I
am unwilling to take the point of view that medical education in
Canada has benefited in any way by the inspections of this particular
council. I move therefore that the matter of the classification of
Canadian medical schools by the Council on Medical Education of the
American Medical Association be referred to the Resolutions Committee
in order that a suitable resolution be drafted for the consideration
of the conference.

The CHAIRMAN: What is the opinion of members of the conference
regarding this question?

Dr. J. J. GUERIN (Montreal): I think we are all united on the question
of the advisability of having reports of our standing from our own
centres. These reports that have been submitted by the American
authorities have been gathered, I am afraid, in a haphazard manner,
and I am satisfied that whoever the gentlemen were who carried on the
investigation, they did not put themselves en rapport with the
authorities of the different schools; otherwise, I cannot see how they
could make any such classification as is indicated. Speaking for my
own school, I can state that there is nothing in the medical
curriculum to be found in any other school that is not covered in the
University of Montreal, where the course is of the same duration as it
is in other universities. We have two pre-medical years and five years
of medical study. I had heard before about this classification having
been made, but I am at a loss to know where the information was
acquired and through the medium of whom. I think it would be a very
excellent thing to pass such a resolution as has been proposed, and I
am sure that if we inspected our own schools we should find altogether
different results.

The CHAIRMAN: Did these inspectors investigate the Canadian schools on
their own initiative?

Dr. CONNELL: The inspectors were not invited to come, but they were
accorded every consideration. They come without notice and introduce
themselves, and whenever they have done so we have informed them of
the condition of affairs. Usually we have had pleasant assurances from
them that things were going along pretty well, but when the printed
reports came in we found that we were just where we were before. The
last visit was made in January, 1921. One of the statements made at
the time in regard to Queen's had reference to the location of the
institution; they thought that a medical school ought not to be in
that situation. It was quite evident that many artificial
considerations were taken into account in determining the standing of
the schools, but we did everything we could to accommodate them. I do
not suggest that we ever responded to the apparent proposal to make
our courses agree with theirs. At the time of the last inspection we
pointed out to the inspector that we had just made two appointments of
whole time men, and we were immediately informed that that was not one
of the standards required and that they could not put it to our
credit. I feel that we have been harshly dealt with, and it is
absolutely unfair that we should be prejudiced in the eyes of the
world by these reports, for which there is no justification. So far as
the situation of the school is concerned, we are not responsible for
its location, but there was every justification for its coming into
existence, and it need not apologize for its continuance. Let me
repeat that all Canadian graduates from these schools are constantly
prejudiced in the eyes of the public in the United States by means of
these reports, which cannot be justified on any ground.

Dr. THORNTON: I second the motion that the matter be referred to the
Resolutions Committee for consideration.

Dr. YOUNG (Saskatoon): Perhaps the Resolutions Committee would be glad
to have some expression of opinion from representatives of the other
universities as to what they think of the matter.

The CHAIRMAN: Further discussion, I am afraid, would be out of order,
seeing that Dr. Connell has closed the debate.

Dr. MACLEOD: I did not understand that Dr. Connell was summing up the
discussion when he last spoke a moment ago. Certainly it did not occur
to me that the matter had been closed, for I intended offering a word
or two on the question.

The CHAIRMAN: I do not think Professor MacLeod may proceed unless it
is the pleasure of the conference that he be allowed to do so. I am
afraid I must declare the discussion closed at this juncture, and
Professor MacLeod will have an opportunity to speak after the
Resolutions Committee has reported. I do not want to close the debate
precipitately, but it does seem to me that this has already been done,
and therefore any further discussion would necessarily be out of
order.

Dr. REHFUSS: In the circumstances, I move that the subject be reopened
for further discussion. In this motion I am seconded by Dr. Low.

The CHAIRMAN: Is it the pleasure of the conference to adopt that
motion?

Motion agreed to.

Dr. J. J. R. MACLEOD (University of Toronto):--I do not intend to
discuss this question at any length, but I want to point out that the
American Medical Association has done such excellent work in its
inspection of medical schools in the United States that the fact that
it should have applied this method in Canada should not be taken by us
too seriously. It is a fact that by means of this classification it
has been able very largely to discipline a number of schools in the
United States which were distinctly detrimental to the interests of
medical education. The usefulness of the classification is now
possibly coming to an end, and I think I am correct in saying that a
great many of those who have been interested in this work are now
prepared to drop the whole question of classification. It would
therefore, it seems to me, be a very unfortunate thing if we in
Canada, in taking the initial step in the co-ordination of our own
medical educational affairs should do anything that might cause
misunderstanding on the part of our colleagues in the United States.
We must work with them in harmony; we must remember that from many of
our medical schools as instanced by Dr. Connell of Kingston, graduates
are compelled to go to the United States. And they ought to go. Canada
has been a breeding place for medical practitioners, scientists and
teachers, and has supplied many of the leaders in the medical
profession in that country. So that in any resolution framed by this
body expressing any sense of criticism of the methods which the
American Association has applied, the language should be extremely
cautious and should be only suggestive of the possibility of Canadian
schools being omitted from any future published classification. What I
really want to point out is that we are prepared now as a country to
mind our own medical affairs without assistance directly from the
United States, and this sense might be conveyed by a tactfully worded
resolution. It does seem to me however, important to bear in mind that
we must work in close harmony with them and not do anything that will
prejudice the relationship.

Dr. A. F. BAZIN (Montreal): Perhaps it might be well if we could get
some information from other universities as to the accuracy of the
statement that in 1924 a classification of Canadian schools was made
without any inspection, the last inspection having been made in 1921.
If that is the case, the matter would seem to be very serious. Let me
offer one thought while I am on this subject. I sometimes think that
the word harmony is very much misused, and it is sometimes interpreted
by a strong and powerful party as signifying, on the part of a weaker
party, an absolute lying down to be stepped on. I am perfectly willing
and shall always be prepared to live in harmony with everyone as far
as I can possibly do so, but I certainly am not prepared to purchase
harmony at any such price as this. I am not ready for harmony under
any such unequal conditions.

Dr. W. H. HATTIE (Halifax): In substantiation of Dr. Connell's
remarks, I can say that while at Dalhousie we have been waiting for
more than two years for a re-inspection by the Council on Medical
Education, we have not had it, although such an inspection has been
promised us.

Dr. J. C. SIMPSON (Montreal): I ask for information only. I am not
aware that during the last two years the reports of the Council on
Medical Education of the American Medical Association contained any
classification of Canadian schools. The list of schools on the
continent during the last two years has given a classification of all
American schools, but so far as I am aware the nine Canadian schools
have been omitted.

Dr. J. C. CONNELL: The classification was discontinued in 1921, and
reappeared in 1924 exactly as in 1920.

Dr. OWER: The University of Alberta expected an inspection in 1919 and
was inspected in 1923.

Dr. D. S. MACKAY (Winnipeg): As a result of the first inspection
carried out at our school the institution was classified as an A
school but later on, upon a further inspection, we were demoted. We
were told that along certain lines we must improve. The inspectors
based their classification on what appeared to us to have no reference
to the quality of teaching but rather to the square feet of space
occupied in laboratory accommodation. We pointed out, however, that we
had sufficient laboratory accommodation and equipment for the
students, as well as an adequate teaching staff; but it seemed that
the kind of room we had did not appeal to the inspectors. Our
buildings were in course of construction and when we got into our new
quarters we expected that the unfavourable classification which had
been made would be rectified. It is true that we did not have a
full-time paid physiologist, but that was merely a temporary want. We
have had our university in Manitoba since 1906 and when our man left
us we were at a loss to find a substitute. At last we secured one and
we reported that fact to the inspectors, but I do not know whether any
inspection was made with that fact in view. This occurred in the fall
of 1923, and early in January of the present year we were notified
that we had again been placed in Class A. No doubt there is a bit of
sentiment in this matter so far as we are concerned, because I know
that we do claim to have good results.

I must concur in the remarks of Dr. Bazin so far as the word "harmony"
is concerned. I for one am absolutely sick of and fed up with this
advocacy of harmony, and we do not intend to lie down and take things
quietly when we have principles at stake. We are going to stand by
those principles. Our schools are founded on the best medical system
and are suited to the conditions in the West. We are prepared at all
times to put into effect all the good points that may strike us in any
system and we will give them a fair trial and endeavour to carry them
out to the best of our ability with a view to giving the students the
best possible instruction. But, I repeat, we refuse to lie down and
take things submissively; we will retain the right to decide for
ourselves such questions as intimately affect our own welfare.

The CHAIRMAN: As Dr. MacKay has remarked, our schools are modelled
after the best universities and we propose to stick to our own
methods. At the same time, however, I think we can do all that and
work in harmony with others. I am not at all taking issue with
Professor MacLeod, for there does not seem to me to be any reason why
we should not continue in harmonious relations with the United States
or any other country for that matter. A large percentage of our
graduates practice in the United States and we are closely related to
the people there in many ways. A very large percentage of Canadians,
too, belong to special societies in the United States and we cannot,
on inadequate grounds, do anything else than work in harmony with
them. I do not think there is any misapprehension in regard to that
term; I think we all understand pretty well what we mean by it. We
must however insist on fair play, and we do not mind telling the
United States that we will not take dictation from anybody but are
quite capable of pursuing our own course. That I think is the
sentiment of the Canadian generally, and this is a matter that
requires the best consideration possible. I hope the Resolutions
Committee will consider it carefully and take the matter up again
to-morrow.

Dr. V. E. HENDERSON (Toronto): I am glad that the Programme Committee
accepted my suggestion that I should be allowed to preach the gospel
to which I am called by the Canadian Medical Association on this
occasion. I may meet the chairman of the new Committee on Pharmacy,
which is a committee that has functioned in the Ontario society and
which, through the Canadian association approached the Government two
years ago in regard to the difficulty of getting pure drugs. The
particular type of pure drugs in connection with which we approached
the government comprised such medicinals arsphenamine, pituitary
extract, digitalis, adrenalin, thyroid, and acetyl salicylic acid. The
proposal we made to the government was that they should undertake to
standardize all these drug stuffs for the manufacturer and that no
drug stuff should be sold that did not comply with the regulations
which the Dominion government would lay down. That plan has been
adopted by the United States government so far as arsphenamine drugs
are concerned. The American Government standardizes them and if the
drug stuff submitted for analysis comes up to the requirements that
particular batch is given an official number and is sold to the public
under that number, so that any sample seized by a food and drug
inspector may be identified.

Now, Canada is a small country from the point of view of population
and is widely scattered. The medical profession is working in the
interests of the public and the idea is that we should aid the
manufacturers in Canada in overcoming certain handicaps by getting the
government to undertake this standardization. We found that the
government, through the foresight of the Deputy Minister of Health,
had already gone so far as to interest themselves in the appointment
of a pharmacologist. After about a year they found one and he
underwent a period of training. He should be able, I have no doubt, to
carry on the work efficiently; but if the mills of the gods are said
to grind slowly, it would seem that the mills of the government are
just as tardy. We are not sure that the time may not come when it will
be necessary, for the medical profession, if they are interested in
getting pure drugs for their use, to bring pressure to bear upon the
government to move a little more quickly. I do not think that the
department is entirely convinced yet that the step proposed is the
right one. In the United States a number of drugs are standardized by
the manufacturers, and a great many of these drug stuffs sold in
Canada by American firms are marked "physiologically standardized."
Most of the manufacturers, however, are careful to say that the drugs
are not standardized in compliance with the Pharmacopoeia of the
United States. There is some question as to whether a manufacturer
falling down on his standardization should be severely dealt with. I
understand that under the new regulations which will be in effect in a
year this matter will be made compulsory. The standardization laid
down by the United States Pharmacopoeia is in some cases not the best
that could be devised, and I know that the chairman of the Committee
on Standardization is now convinced that in one or two respects they
might be altered to great advantage. This has become apparent as a
result of the international congress which was held in Edinburgh last
summer under the League of Nations and which I had the honour to
attend as an observer. The Canadian Association urged the Government
to undertake a standardization not only from the standpoint of the
manufacturer but because our experience has convinced us that the
result which we have in view can be obtained in no other way. Under
the Food and Drugs Act the Department of Health is charged with the
duty from time to time of making inspections, taking samples from
druggists' stocks or from other sources and submitting them to
analysis, and instituting prosecutions wherever drug stuffs are found
to be deficient. We have no official knowledge of what the results of
these analyses have been; that information is not made public now as
it was in the past. It may be that the Department is exceedingly well
advised in this matter, and to a certain extent it may be said that
when the information was published it was not of very great value to
the physician. It was, however, of value to him in this respect, that
it showed what a large percentage of our medicaments can be
standardized and which were by no means up to the standard required.
The figures in days gone by were appalling; seventy-three per cent of
a certain drug analysed on one occasion was far from being what it
should have been. If that is the case with drug stuffs that are easily
handled it surely will be true also in regard to things which are
difficult to deal with and where it is necessary to have an expert
with trained judgment to carry out the tests. We therefore came to
the conclusion that in order to get some positive assurance in this
matter the method of government standardization was the only
satisfactory one to be followed. The chief duty of the Committee on
Pharmacy lies in this direction, and we want to have the medical
profession throughout the country apprised of the situation and
prepared to use their best endeavours to see that pure drug stuffs are
obtainable.

If I may, I should like to mention one or two instances that occurred
to me in recent experiences. As regards pituitary there is one extract
sold in this country which we have assayed on many occasions and we
have not found it better than one-twenty-fifth of the strength it
should be for medicinal purposes; and it has been as low as
one-thirtieth. I have had only one or two samples recently, of drug
stuffs susceptible of chemical analysis, examined in my laboratory.
And in passing, I might observe that we should have a laboratory to do
this sort of work properly. I have looked at several samples of
salicylic acid in double form and in no instance did it contain the
quantity of acetyl salicylic gases indicated. We were convinced that
it was exclusively sodium salicylic. These examples are enough to show
what we are driving at. We are in a difficult position. Suppose I
undertook at the present time a careful study of acetyl salicylic
acid: how am I to get the information contained in that examination to
the members of the medical profession? I can understand that the
department, perhaps rightly, is not in the position to publish the
names of the manufacturers and of the deficiencies found in their
products. Possibly the position of the department is quite sound in
that regard. In the United States the medical profession is largely in
the same predicament, but they subject drug stuffs from any source to
analysis themselves and in that case they are able to make use of
their findings for the information of the profession. The question is
a difficult one and I am continually asked why that information cannot
be got to the public. Of course, no one can make any public statement
in regard to the products examined from any particular source; one has
to be safeguarded before he can make any statement in public. But the
Committee on Pharmacy is bound to be interested in the question. The
profession, it seems to me, are rather at fault in the matter of the
growth of patent medicines. I am sure it is highly detrimental to our
own pockets as well as to those of our allies the druggists. In the
post-war rush I had occasion to make use of drug stores as a means of
giving to my students some knowledge of dispensing. I required them to
bring me forty prescriptions, filled in at any drug store or in any
hospital pharmacy, for inspection, to assure me that they had done the
work. I was astonished to find the number of proprietary substances of
various kinds, ranging from flavours to so-called remedies, which were
employed by the profession. And I was still more horrified to find
that my students could not make up these prescriptions without
including such things as Frost's 127. One student in great distress
reported from a small town that he had been unable to make up forty
prescriptions in the time he had spent there and could not see any
possibility of being able to do so, inasmuch as the whole business
consisted in dispensing Frost's 127 or some other medicament for the
patients. This sort of thing is absolutely unsound, and the doctors
lay themselves open to criticism in that type of dispensing. It seems
to me that we contribute in that way to the use of patent medicines,
so that the people of the country are led to believe that they can buy
ready made preparations that will serve their purpose just as well as
the prescriptions of the doctors. Thus we tend to destroy the
confidence of the people in the profession. One might speak with
fervour and enthusiasm on this particular point, but I do not think
that it is necessary to dwell upon it at any length. There is one
point on which I desire to appeal to members. The Committee on
Pharmacy constitutes a small nucleus of men doing pharmalogical work.
It would be well I think if we could get a physician or two in each
province to make a hobby of the thing and seriously to think about
this matter. Something of this kind might serve to advance the
interests of medicine in this particular respect. I can only promise
that anything I can do in supplying any such individual with
information, and furnishing him with the necessary ammunition, I shall
be glad to do.

Dr. AMYOT: The department has a limited control over such things as
food and drugs. For the last two years a serious effort has been made
to set up standards for these very drugs of which Dr. Henderson has
spoken. For various reasons we have been held up, but we are on the
verge of being able to launch out. We are making every effort possible
and in a short time shall be able to do something in that direction.
So far as publication is concerned, we have had many prescriptions
that were below standard, and these things were published in the
newspapers, or at least in some of them. Both in the United States and
in Canada, however, it is rather difficult to secure publicity on any
large scale, and this for various reasons. Many of those concerned are
large advertisers and to have the facts published in regard to these
people is a matter of extreme difficulty. This is one of the
difficulties that are encountered in Great Britain, in the United
States and in Canada as well. If the facts are published they are more
or less camouflaged, and in some cases they are not published at all,
so that we have to depend on the little local knowledge which people
have that druggist so-and-so has been caught and found guilty. And the
druggist endeavours to suppress the news as quickly as possible.

Dr. H. W. MCGILL (Calgary): One fact has often struck me and I think
it must have been apparent to most gentlemen of the medical
profession, and that is the terrific propaganda of a high pressure
nature which is made on medical men by the agents of proprietary
medicine manufacturers. Every morning my desk is piled up with
literature advertising these preparations. To those of us who have
been in practice for some years this is not a matter of any great
concern; we simply throw all this literature into the waste paper
basket. But in my opinion this practice on the part of proprietary
medicine agents constitutes a distinct danger to scientific medicine,
and in any case it is an intolerable nuisance. I know of young
physicians who have received many visits from these high pressure
salesmen who attempt to exploit their products. Every discovery that
is made is immediately exploited for all it is worth, and altogether
this practice is quite overdone. A tremendous campaign of advertising
is instituted to create a demand for some product that could not
normally exist. Vitamines is one thing in point; certain
pharmaceutical houses attempt by means of advertising to create a
demand for this article, of which there is no need whatever. A young
man starting out in practice may happen to be rather weak on
prescription writing, and this literature is apt to tempt him to find
an easy substitute for proper prescriptions. These suggestions coming
in day after day might indicate to him an easy road to the writing of
prescriptions, and this is a distinct menace. In the old days the
manufacturers of patent medicines used to get out almanacs which they
would leave at the country grocers'. These almanacs contained notices
of preparations which it was claimed would cure all the ills of
mankind; and in addition information of various kinds was given
together with recipes and so on. Now, instead of distributing these
almanacs, the proprietary medicine manufacturers send out literature
to the medical practitioners and every few weeks they dispatch a
detail man to explain the virtues of these products. This is something
which might be looked into.

Dr. BAZIN: Dr. Henderson, I gather, represents the Committee on
Pharmacy of the Canadian Medical Association, which made
representations to the Government urging the adoption of some system
of standardizing drugs. Does Dr. Henderson wish the conference to take
up this matter with the association with a view to securing some
action on the part of the department?

Dr. AMYOT: The matter is under consideration.

Dr. HENDERSON: I do not think it would do any harm if a resolution
were passed on the question. Quite apart from anything that we might
do, I think that such a resolution from the conference would have a
good effect on the profession throughout the country. I should be glad
to move that the Resolutions Committee be instructed to draw up such a
resolution. With reference to Dr. McGill's remarks, I can only say
again what I indicated in my address, that I think the medical
profession is itself largely responsible for the amount of high
pressure literature and the canvassing with which medical men are
assailed. It seems to me that if members of the profession would do
what a friend of mine did in one instance it would tend to diminish
this practice on the part of agents. He was visited on one occasion by
one of these men and he showed the agent that the essential drugs in a
certain preparation had never been adopted by the American
Pharmacopoeia, which is a liberal one. That sort of thing would
discourage this type of propaganda. The opinion is held by some that
the medical profession as a whole is easily gullible.

The CHAIRMAN: We shall now receive the report of the Resolutions
Committee.

Dr. J. C. CONNELL (Kingston): With your permission, I shall move the
resolutions clause by clause and they can be adopted or otherwise
disposed of as we proceed. The first resolution is as follows:--

     "That in the opinion of this meeting the conference has
     been productive of much benefit, and arrangements
     should be completed for its establishment upon a
     permanent annual basis."

Resolution agreed to.

Dr. _Connell_: The next resolution is this:--

     "That the conference of 1925 be held early in the month
     of December, in Ottawa, and under arrangement and
     auspices similar to those of the present conference."

Dr. MACDERMOT: Would that be early in December? From the point of view
of members from the East, December may be an ideal month, but for the
West it is not a very favourable time of the year. This year we could
have had a better representation from the province of British Columbia
had the conference been convened at an earlier date.

Dr. MCCULLOUGH: It is important that the meeting should be held next
fall, or either before or subsequent to the meeting of the Dominion
Council of Health. This year the Dominion Council of Health met
previous to this conference. It might be advisable to have a similar
arrangement next year.

The CHAIRMAN: Why not omit the words "early in December"?

Dr. YOUNG (Saskatoon): There is a meeting of another body in Ottawa
every year, the Medical Council of Canada. It is composed of two
representatives from each college or medical board in Canada and a
representative from each university. Those of us who come long
distances appreciate the fact that travelling costs money and takes a
lot of time. If the conference could be called immediately after the
meeting I have mentioned we should get a better representation than
would be possible otherwise. If the colleges agreed to be represented
by those who were on the Medical Council of Canada a great deal of
time and expense could be saved. That body meets in September next
year. I would ask that due consideration be given the fact that the
council meets next September.

Dr. _Connell_: I move that the resolution be adopted, amended as
follows:--

     "That the conference of 1925 be held in Ottawa, and
     under arrangement and auspices similar to those of the
     present conference."

Motion agreed to and resolution concurred in.

Dr. CONNELL: I move the following resolution:--

     "That the 1925 conference shall occupy four days, to
     permit of one or more sessions being devoted to
     sectional meetings of the various organizations
     represented, that is, Licensure, Education, Public
     Health."

Dr. MACKAY: I think we are making a mistake in this. We have 75
delegates on the present occasion; there are some of us from the medical schools
and we should like to carry away as many ideas as possible. Licensure,
education and public health are three important subjects and I am afraid that
we shall miss some important points in connection with these subjects. We are
carrying the practice of specializing too far. Specialization is all right as far
as it goes, but I think we would do better by having open meetings rather than
by dividing them into sections.

Dr. HILL: The great point of the conference is that medical men in
different branches have an opportunity to hear the point of view of others.

Dr. CONNELL: I withdraw the resolution.

Resolution withdrawn.

Dr. CONNELL: I beg to move the following:--

     "That the same organizations represented at this
     conference shall be called to the 1925 conference."

Resolution concurred in.

Dr. CONNELL: I move the following resolution:--

     "That this conference gladly accepts the offer of the
     Editor of the Canadian Medical Association Journal to
     publish in the February issue a full report of the
     transactions of this meeting."

Resolution concurred in.

Dr. CONNELL: I move the following resolution:--

     "This conference approves the principle of combating
     venereal disease by community efforts; appreciates the
     value of the work accomplished during the past five
     years; realizes the necessity of maintaining and
     augmenting the work of the clinics which should be
     closely supervised to avoid abuse; and strongly urges
     upon the federal and provincial governments the need of
     continuous and increasing financial support."

Resolution concurred in.

Dr. CONNELL: I move the following resolution:--

     "That we recommend a five-year period of medical study,
     each of thirty-two teaching weeks as a minimum
     requirement of which three years should be devoted
     largely to clinical subjects."

Dr. MACLEOD: How many schools in Canada at the present time have a
thirty-two week session? Does that include the examination period?
Most of the Canadian schools give no more than thirty weeks.

Dr. MACKAY: I understand, from information given us yesterday that
this thirty-two week period is exclusive of examinations.

Dr. HILL: It seems to me that a recommendation of this kind, made with
the weight of this Conference behind it, and providing no alternative,
will bind the hands of the medical section of the universities very
materially. I think it might be well to offer a tentative suggestion
rather than to recommend something definite such as is now proposed. I
have no doubt that the medical section of the universities wishes to
meet us on this point, but it is hardly advisable to pass such a
resolution as this in its present form.

The CHAIRMAN: If I might be allowed to do so, I would suggest omitting
the words "each of thirty-two teaching weeks." It would be a pity for
us to put ourselves on record in any such binding form, for I am sure
there would be a considerable difference of opinion on the question.
It seems to me rather unwise for us to commit ourselves on a question
in regard to which we know there will be a lot of discussion. I would
advise deleting the objectionable words.

Dr. CONNELL: I must explain that I am not responsible for this
particular resolution.

Dr. AMYOT: I move that this particular resolution be held over until
to-morrow.

Dr. MACKAY: I think we should accept the suggestion of the chairman. I
would therefore move that the resolution be adopted, amended in the
way proposed by the chair.

Dr. CRUIKSHANK: I second that motion. I do not think that the
committee had any idea, when it drafted this resolution, of laying
down any hard and fast rule. We simply wanted to equalize the various
teaching bodies in the different provinces.

The CHAIRMAN: Is it the pleasure of the meeting to adopt the
resolution as amended?

Dr. GRAHAM (Toronto): This resolution is based upon the paper which we
had from Dr. McCallum yesterday. The requirements in certain provinces
provide a period of five years and six months, but this varies. The
question the committee had under consideration last night was what
might be suggested as a minimum requirement which would be
satisfactory to all provinces, and it seemed that that minimum should
be at least five years. I think the condition of things would be worse
than it is at present if we left any room for misinterpretation of the
requirement; obviously it would not do to leave the thing in such a
way as to make it possible for someone to interpret the requirement as
meaning five years of two months each. I do not know that such an
interpretation is altogether an impossibility. We must have a
reasonable length of academic year, and simply to say five years would
seem to be inadequate. Most of the schools give thirty weeks of
teaching, with two weeks for examinations. To leave the matter in an
indefinite state is not advisable.

The CHAIRMAN: I would suggest, to make the resolution definite, that
we substitute the word "thirty" for the word "thirty-two" in
accordance with Dr. Graham's views.

Dr. CONNELL: I was not a member of the committee that drafted this
particular resolution, but I know that thirty teaching weeks is about
all that you can get in unless you begin early in September or carry
on your examinations into a period when the council examinations are
held. I move that the resolution be adopted, amended as follows:--

     "That we recommend a five-year period of medical study,
     each of thirty teaching weeks, as a minimum requirement
     of which three years should be devoted largely to
     clinical subjects."

Resolution as amended concurred in.

Dr. CONNELL: I move the following resolution:--

     "That we recommend that students have instruction in
     pre-natal and post-natal care of patients, and
     attendance on at least ten maternity cases under
     instruction."

Resolution concurred in.

Dr. CONNELL: I move the following resolution:--

     "That the Provincial Council and the medical schools be
     asked to encourage students to register at the
     beginning of their medical course and that for such
     registration a nominal fee only be exacted."

Resolution concurred in.

The conference adjourned.




=SATURDAY MORNING SITTING=


The conference resumed, with Dr. Primrose in the chair.

The CHAIRMAN: As it is the desire of most of us to get away shortly
after noon, we shall have to adhere strictly to the time limit rules
this morning for speakers, and make a prompt start. I will now call on
Professor Macleod to present his paper on Medical Education.



MEDICAL EDUCATION

Dr. MACLEOD (Toronto): It is obviously impossible in twenty minutes to
consider in any adequate detail the principles involved in an
education for the medical practitioner.

The fundamental principles which must guide us in framing a course of
study for medicine are, first, to train the student to grasp the known
laws of science so that they may be applied in the detection,
prevention and treatment of disease, and secondly, to give him
sufficient practice so that he may apply such facts and procedures as
experience has shown are the most efficacious for these purposes.

It is essential that these principles be lived up to, and yet it is
impossible that the method of working them out can be the same in
different places. I cannot attempt to give review of the methods in
vogue in different medical schools in different communities, but must
confine my remarks pretty strictly to the type of medical education
which I believe most adequately prepares the youth in a Canadian
community for the practice of his or her profession.

There are several aspects of the problem which demand attention, and
the first is with regard to entrance requirements. There are two
purposes for these requirements: The first is that the student may
have a suitable general education so that the mind may be prepared and
trained to assimilate new knowledge; and, secondly, he must have had
some preparation for the study of medicine, some special training in
the fundamental sciences upon which the practice of medicine and
surgery depend.

Now with regard to general education, this must necessarily vary
greatly in different communities. The ideals of these communities
vary; the facilities for education vary; the traditions vary. It is, I
think, an accepted principle that you cannot have exactly the same
educational system in different countries, even although these may be
very closely related. In most countries of the English-speaking world
there are two examinations which are given to test the efficiency of
school education. These are generally the junior and the senior
leaving certificates. They go by various names in different countries.
Sometimes they are called leaving certificates, as in the Scottish
Education Department; sometimes they are called the certificates of
the schools examination board, as in Oxford and Cambridge; sometimes
they are matriculation certificates, as in London and the English
provincial universities; sometimes they are the High School graduation
certificates, as in the United States. In most places in Canada they
are known as matriculation certificates and are of the junior, and the
honour or senior standard. It is a very difficult thing to equate the
standards demanded by these various certificates; almost impossible to
do so exactly. I have compared as closely as I could the two with
which I am most familiar, the entrance requirements for the Scotch
universities and for the Canadian universities, and as a result of the
investigation, which I made with the aid of registrars and other
experts in education, I found that there is as close a similarity as
there could possibly be between the junior leaving certificate of
Scotland and the junior matriculation of Ontario. The senior
certificates--although I am not quite so sure of these--very nearly
correspond also. It comes to be important then, in equating the value
of preliminary education, to have some simple method by which this
can be done, and in my belief there is probably no one better than to
take the average age of the students.

Granted that the educational system of a country is sound, and is
based on established pedagogical principles, then I think we can take
the age on graduation from the high school or similar institution as a
fair standard of the attainment reached. I have taken the ages of
students on entry to the University of Toronto Medical Department, and
have tabulated them for each of the years, with very interesting
results. There are 780 students concerned, and the largest number
entered at the age of 19; the next largest number at 18, and the next
at 20. The peak is at 19; that is for all the students of the six
years' course. Three years ago the entrance requirements to the
Medical Faculty of the University of Toronto were raised in a manner
which I will explain in a moment, so that it is interesting to compare
these figures for the total six years with those for the first three
years during which the new entrance requirements have their effect.
The results work out pretty nearly the same: 31 per cent of the
students of the first three years entered at 19; 26.5 at 18, and 14
per cent at 20, which means that in the three years during which the
standard has been raised, the school authorities have so adjusted
their schedules so as to make it possible for the youth even in face
of these increased entrance requirements to get through his school
education in a somewhat shorter period of time than previously
obtained. Two-thirds of all the students in the first three years in
the University of Toronto entered at or below 19 years of age, which
means that on graduation after completion of a six years' course the
age of the students varies between 23 and 25, which, I think it will
be admitted by most medical educators, is about the age at which a
student should be graduated from his medical college.

Now with regard to the junior certificates. Junior certificates
include English, Latin, mathematics, history, experimental science,
and usually one other language. Some other subjects are usually added,
but the student has a certain option with regard to the choice. The
junior certificates are all pretty well standardized, as it were,
except perhaps with regard to the sciences. The sciences which can be
most advantageously taught in schools are mathematics, physics and
chemistry, and it is extremely important in the high school training
in these subjects that the heuristic method should be adopted and
encouraged as much as possible; that is the method by which the
student is taught to think out experiments for himself. He is given
the problem, and simple physical apparatus--it need be only very
simple, a piece of string and a weight will do a great deal,--and he
is made to work out the experiment for himself. And similarly in
chemistry; the apparatus and materials need not be elaborate. Teaching
by the heuristic method is of course applicable only in physics and
chemistry and not in biology.

With regard to the honour certificate, as a rule the requirements are,
I think, about equivalent to the high school certificate in the United
States, that is a graduating certificate from a high school. As a rule
this is considered a fair education. In the United States, and also in
Great Britain, it has been considered that for the medical profession
there ought to be further preparation; it has been considered there
should be further cultural training. In Scotland it has recently been
enacted that besides the junior certificate there shall also be
required a senior certificate in three subjects at least, and in the
University of Toronto the same principle has been adopted. We require
one further year at high school or collegiate institute, and we
require that the subjects taken in this extra year shall be English,
mathematics and one language. It is agreed by most educators, I think,
that this extra year at high school or collegiate institute is equal
to the first year in the Arts course in most colleges, and by
requiring an honour certificate we are really requiring one year of
college education besides the ordinary high school education.

We have chosen English as one of the obligatory subjects for obvious
reasons I need not take time to cite. We have chosen mathematics for
reasons which it may be well to explain. In preparing the student for
the profession of medicine, we have to remember that its principles
depend upon the application of the laws of physics and chemistry in
the study of animal function and in the investigation of disease.
Therefore a man must be trained to think in these fundamental
sciences. The schools, we believe, cannot carry the training further
than the junior certificate in physics and chemistry. Some schools
can, no doubt, but most schools cannot. All schools, however, are
capable of giving an adequate training in a science upon which both
these sciences depend, mathematics. There is no high school or
collegiate institute in which an adequate training in honours
mathematics cannot be given; and it is well to remember it is not that
the man may acquire the technique of mathematics that this training is
required, but rather that he may be taught to think scientifically,
and no training for this purpose is better than a course of
mathematics.

There are many other aspects of the entrance requirements that I
should like to dwell on as I consider them a very important part of
education, but time will not permit. I hasten on to the curriculum.

The first year of the curriculum in most places is known as a
pre-medical year. It is a training in physics, biology and chemistry.
It is obviously the foundation of medical knowledge, and unless this
foundation be well built the superstructure cannot be satisfactorily
added. The main thing in the course in these subjects is the training
in principles. Facts are not so important. Facts in physics are not
very important to medical men: the principles are. The mind must be
trained so that in after years, when it is necessary to do so, the
physician or surgeon may be able to grasp the significance of new
principles in the sciences and apply them in the treatment of
diseases. I need cite only as instances the application of X-rays, the
application of heat rays, and the application of the fundamental
principle of hydrodynamics in the measurement of blood pressure. Many
mistakes were made by the profession in the earlier years of blood
pressure measurement because so few comprehended the principle of
hydrodynamics. It is not facts, it is principles that should be
taught, and that is why a grounding in the pre-medical sciences, is
necessary.

The fundamental medical sciences I would subdivide into anatomy and
the institutes of medicine. Of anatomy I need say very little, only
perhaps it is well to emphasize that in its modern aspects this
subject should include the study of X-ray plates and their
interpretation, and some surface anatomy. Repetition is most important
in the teaching of anatomy. Anatomy is a science based on observation.
It is a science demanding a very retentive memory, and it is only
possible to learn this science on the principle of summation of
stimuli--repeat, repeat, repeat, until the subject sinks in and
becomes part of the automatic mental mechanism, as it were.

With regard to the institutes of medicine, this comprehends the
sciences of physiology, biochemistry, bacteriology, pharmacology and
pathology. It is really the part of the course in which the
pre-medical sciences are brought together, and their application in
the study of animal function, and in the interpretation of disease, is
worked out. It is the junction point in medical education. The whole
of medical education depends upon a thorough study in these sciences.

I will speak of physiology, and of that only for a moment. The
training in physiology, like the training in physics, should be based
on the principle that it is not facts so much as principles that you
endeavour to convey to the student's mind, and in this training
therefore the laboratory must play an essential role. In the
laboratory the student creates, by the experimental method, conditions
which are strictly analogous with those which are met with in the
clinic, where, however, they are created by disease. If, therefore,
you train the student properly in the physiological laboratory to
interpret the changes in function, and to investigate the changes of
function which result from these experimental lesions, you are
necessarily training him also in the symptoms of disease, and I think
there is no part of the course in physiology that is more important
for this purpose than the part that is often called the Frog and
Turtle course, where the student is required to go through experiments
of an apparently trivial nature on isolated muscles and isolated
heart. Now, gentlemen, I know that the value of this course is often
put at far too low a level, and that I think, is because, most people
do not understand its object. This is to train the student first of
all to formulate a problem, secondly, to simplify it to within his
limits of investigation, thirdly, to study it experimentally by the
physical and chemical means that are available, and fourthly, to draw
conclusions and test them by further experiments so that he may know
whether the hypothesis with which he started can be sustained or must
be dismissed. Diagnosis is the formulation of a hypothesis which is
then put to the test of observation or experiment. It is exactly the
same in the physiological problem, and to train a man properly in this
method, one must begin with the simplest conceivable experiment. These
are afforded in the so-called Frog and Turtle experimental course. I,
for one, as a teacher of physiology would never give up this course, I
consider it the most important part of the whole training. From the
simple the student proceeds to the more complex. He goes on to
experiment on mammals, and then finally ends up with experiments on
man, and in the course given in most physiological laboratories
now-a-days from one third to one half of all experiments are on man
himself. That has developed very much in recent years. I cannot say
more about the other courses as time will not permit.

I wish to say one word with regard to options. Besides the obligatory
courses in the medical curriculum a certain amount of time should be
set aside for options. These options may be either in cultural
subjects or in scientific subjects. In cultural subjects they should
be given with the point in view that the student may carry forward the
training he has had in high school into the medical curriculum. It
does seem a pity that a student who has had a course of four years in
High school in French should on going to the medical faculty drop the
whole thing so that he forgets it. It seems to me it is obligatory on
all medical educational organizations to afford the student a chance
during his medical course to apply his knowledge in French or other
school subject so that he may use it profitably in his profession. It
is easy to do it; it works out; it has worked out in the University of
Toronto. Finally let me read to you the number of students who have
elected to take the various options that we have offered. The details
as to the working out of these you will find in the University
Calendar; I need not take time to explain them here. In the first year
the students elected options as follows:--

    Scientific French      54

    Scientific German       3

    English                27

    Mathematics            21

    Exempt                  1

In the second year there are two groups of options, one group cultural
and the other scientific, and every student must take one subject from
each group. In the cultural options students took courses as
follows:--

    French                   18

    English                   5

    Psychology lectures      72

    Mathematics               2

    History                   2

    Exempt                    1

You will notice that 18 students took French again in their second
year. They are keeping up the study and can possibly now use French in
a practical way. We know how important a knowledge of French is in
Canada, and here a chance is given to the medical student of keeping
up what he has learned, and carrying forward his studies in the
language. An excellent course of psychology lectures is given in the
cultural options, preparing the medical man for the study of the
psychological aspects of disease, not that they may become
psychiatrists, but apply the principles of psychology in the practice
of their profession. I will now give the number of students taking
scientific options in the second and third years.

SECOND YEAR

    _Scientific Options_--

    Chemistry                48

    Biology                  45

    Physics                   3

THIRD YEAR

    _Scientific Options_--

    Cytology                 12

    Com. Neurology            6

    Parasitology              6

    Embryology                7

    Anatomy joints           40

    Anatomy cross sections   19

    Mathematics               3

    Physics                   3

You will notice that the student is given the chance in the second
year to repeat some of the things in chemistry he learned in the first
year. Why drop it? Let the subject spread over the years, and do that
partly by means of options. The psychology lectures, as well as the
cultural options in the second year, only take four hours a week, and
yet that is enough to give a man a certain experience in these
subjects. In the option of cytology the student is taught the
principles of microscopic technique more adequately than he could in a
big class. He is made to prepare slides for himself from the beginning
and study them.

In the moments that remain I will not give the numbers for the fourth
and fifth years, but will take the time to read, if I may, from an
article that appeared in the _University of Toronto Monthly_ some
years ago, and in which I think the principles upon which the medical
schedule should depend are summed up:

     "These principles have been stated in what I believe to
     be the order of their importance. For if the mind be
     properly trained, the acquisition of knowledge will
     unconsciously follow, and the graduate will enter upon
     his professional career prepared not merely to apply
     the already established practice of others, but as a
     critical thinker and investigator. Every graduate in
     medicine, whatever his particular sphere of activity,
     should be an original investigator. If he is engaged in
     general practice he must consider every one of his
     patients as furnishing a separate problem to be
     investigated by the application of scientific methods
     reinforced by a knowledge of the experiences recorded
     by others. If he is engaged in any of the other
     branches of medical science, originality in thought is
     equally essential to success."

And with regard to raising the entrance requirements to the extent to
which they have been raised, and that is not very far, let me add that
this standard which we require now is practically the same as that
required for most students of engineering. The student of engineering
has to deal

     "with measurable factors, with calculable forces, and
     with known magnitudes of error. But the physician must
     deal with a much more complicated type of problem, one
     which embraces elements of vastly differing categories,
     chemical, physical, biological and psychological.
     Surely to do this properly the medical student, before
     he enters upon his more strictly professional studies,
     must be at least as highly trained in the sciences as
     the technical student. And he should besides have a
     broader education in the humanities, for his science
     must be tempered by a sympathetic understanding of
     human nature if he is to apply it successfully in the
     relief of suffering."

The CHAIRMAN: Perhaps we had better take all the papers first this
morning. I will now call on Dr. Martin.

Dr. C. F. MARTIN (McGill University): To the very lucid explanation of
the point of view of medical education that Professor Macleod has
given I think there is very little, perhaps, to add in a general way
because he has covered the essential points, most of which may be more
or less covered in the remarks I have to make.

There is one point I would like to make, however, with reference to
the very wise procedure that is taken in Toronto University with
reference to cultural requirements. As most of you know, the course in
Toronto University is a six-year course in one sense, and in McGill
University and some others it is a five-year course, but the
difference is really only on paper. The plan that we have adopted in
the last year of making the medical course a five-year instead of a
six-year course was merely for the purpose of making a very definite
division between what we call the purely medical subjects, in
contradistinction to the pre-medical or cultural subjects. As
Professor Macleod has explained, it is very wise, to give a very broad
cultural touch to the pre-medical sciences, so we have adopted the
principle of relegating rather to the Arts Faculty than to the Medical
Faculty the sciences of physics, chemistry and biology. Chemistry, for
instance, is taught to the pre-medical students by a teacher who is a
graduate in medicine. The physicist and the biologist realize that
there are a number of students in their group who are going to enter
medicine, and so a medical "twist," so to speak, is given to these
courses--but not very much, because the principle that is held is that
the broad cultural value of these subjects and their power to make one
think in terms of scientific principles is more important than the
medical twist which may be given to them.

In medicine we have two pre-medical years, and a five-year course, and
in Toronto it is practically the same, with one pre-medical year and a
six-year course, both being thus seven years' courses. We have
recently had the pleasure of going over with our Toronto colleagues
the entrance requirements, and have discussed the benefit of various
changes, as to the cultural value of these subjects; the differences
are essentially very slight. I was extremely interested in hearing
Professor MacLeod's remarks upon the cultural value of the pre-medical
sciences, because I think that is a very striking feature of the
fundamentals that should underlie the early education of those who are
preparing themselves for medicine.

I will now proceed with the paper.


MEDICAL EDUCATION

Dr. MARTIN (McGill University): The extraordinary development of
scientific medicine within recent years, as shown by the epoch-making
discoveries in methods of diagnosis and treatment, the improvements in
technical equipment, and the advance in public health administration,
have been one of the cardinal features in the world's progress.
Simultaneously, however, it has all enormously increased the
complexity of medical education--so much so that any effort to gain a
comprehensive view of its details leaves us in a state of intellectual
ataxia.

The attempt to overcome the errors and prejudices attached to older
methods of education has not entirely succeeded, and tradition still
guides our activities, and, not infrequently, dominates them. The many
unsolved problems that face us indicate all too clearly the confusion
that still exists as to the real purpose of medical education in our
schools. Is it any wonder then, that a year ago the Association of
American Medical Colleges deliberated for two long days to bring some
kind of order out of chaos? By the time these deliberations ended,
little progress had been made, and finally a commission was appointed
to investigate the whole field anew and, when ready, to bring before
the Association a summary of the most enlightened views obtainable. So
great were the divergencies of opinions as to standards that no unity
of plan up to that time could be attained.

Far be it from me, then, to offer to-day any solution of the many
problems that confront us! Let it be my function merely to present to
you a few suggestions as a basis for discussion with the hope that
thereby a better mutual understanding may be obtained with reference
to the needs of medical education in this vast country.


UNIVERSITY AND TEACHER

I take it that the dual function of a medical school is to _teach_ and
_investigate_--two very different and yet two very closely-related
functions. Every teacher of scientific medicine must needs be an
investigator in its broadest sense--while in the atmosphere that he
creates about him, the investigator stimulates thought upon all those
under his influence.

I should like to emphasize at the outset that the university standard
of teaching differs essentially from that of the high school. It is
not merely the impartation of accepted knowledge, nor the rehearsal of
facts at the bedside, in the theatre or the laboratory. In other
words, a university is not there to make of the mind merely an
encyclopaedia, but rather to train a working instrument for use in the
profession of medicine,--not to stuff students with an accumulation of
facts, but to teach them how and what to assimilate. Routine
instruction there always must be--the presenting of facts, methods,
principles--calling for no great skill on the part of the teacher and
requiring little effort or intelligence on the part of the student to
absorb. Too often this performance _seems_ adequate, and the student
is dismissed without a single stimulus to engender a live interest or
enthusiastic thrill. But modern scientific teaching has long since
outgrown the idea of carrying students through without at the same
time developing them. The successful teacher, realizing that it is
waste of time to rehearse mere facts (there are textbooks for that
purpose), inspires his students with higher ideals of service and
research, propagates an interest in scientific progress, stimulates
new ideas and surrounds himself wherever he may be with an atmosphere
of intellectual achievement--this is an ambition worthy of a
university chair, and otherwise the teacher is not fulfilling the
qualification for which he is appointed.

The teacher of medicine, then, must be something more than a mere
pedagogue. He must be a man with power to infuse enthusiasm and love
in the work, a capacity to open up new vistas even in the daily
routine.

And, so, the _purpose_ of medical education would seem to be primarily
to reflect the state of medical knowledge in general; to indicate the
method of approach to medical problems; to have the windows wide open
to the unknown, and to create an atmosphere of investigation--not
research for research's sake but because every individual patient and
every individual malady is a problem in itself for special
investigation and individual treatment. It is not a question of how
much or how many scientific subjects are in the calendar but what is
the quality of the instruction.

The broader the conception of medical education, the better. The more
philosophical the training the more the critical faculties develop.
Observe the recent tendency to include in the general university
curriculum subjects which hitherto have been allotted only to the
medical school--hygiene, general pathology, general physiology and
even anatomy, and at McGill we have already opened the way.

While it may be granted that a medical school must maintain a high
university standard to differentiate it from the methods of the high
school, it may be contended that in this new country, the main
business of the medical school is chiefly to turn out general
practitioners who are able to meet every ordinary emergency with a
ready wit and a skilled hand. Surely this is so--and let no one
underestimate the importance of the general practitioner, but
obviously this very importance it is, that, to my mind, makes the duty
of the medical schools all the more serious. Students must be trained
to be not merely good ordinary general practitioners, but
_better_--men not only with good commonsense and familiar through
spoon-feeding with the essentials of theory and practice, but men who,
fired with the spirit of inquiry, gain through their training the
attitude of the investigator and original thinker. Therein should lie
the difference between the practitioner of two decades ago and the
excellently trained man of to-day. Will anyone question as to which of
these two will make the better and safer practitioner of medicine?

Some of you may be aware that a few years ago an effort was made to
create a substandard type of physician--one who in two or three years
could perchance learn to meet requirements for the rural districts.
Was it any wonder that the plan met with failure, lacking as it did,
the fundamentals of sound pedagogic principles!


TIME-TABLE

It is obvious that every curriculum must have its frame-work--an
outline as it were of the various paths along which the student must
go, to attain power to be of service. There can be no difference of
opinion as to the need of a definitely prescribed training, but never
should this be so all-absorbing as to destroy initiative or an
interested enthusiasm.

On the other hand, there are always more subjects in the curriculum
than students can ever hope to master, and the rise of specialism has
not lessened the burden. A student can hardly hope to reach more than
the threshold, rarely indeed to enter into the outer courtyard of
medical knowledge, and even at best, he does not attain a very
intimate knowledge of any one of the subjects. There is, in
consequence, the urgent need of stressing the major subjects in their
essentials only and their general principles, while minor subjects and
the specialties may only be so treated as they relate to the general
problems of medical practice.

The specialist, unless unusually broad in his conception of education,
may not grasp relative values nor distinguish the essentials from the
non-essentials in the general plan. Specialism has, verily, gone to
the extreme--in dentistry, perhaps, even more so than in medicine. The
existence in St. Louis of a specialist on extraction of the unerupted
third upper molar tooth may be an extreme example of this!

Standardization, then, is necessary--not a standardization of hours
spent in effort to accumulate facts, nor even in the total number of
subjects, but a standardization which will furnish evidence of
attainment, a proof of the student's ability to approach the many
problems of practice, of his initiative and of his ability to convert
facts into power.

The time-table must, above all things, not be overloaded. The amount
of information required should be reduced, and the student's capacity
to understand principles must be increased. We at McGill reserve two
afternoons weekly for the students' leisure; no lectures are given
after five o'clock in the afternoon. It is recognized that the
curriculum is far too rigid, that there must be more latitude, more
flexibility in the time-table, with opportunity to read, observe,
think and breathe freely. Edsall has emphasized the fact that
independent judgment and enthusiastic interest grow with exercise and
atrophy with disuse, and unless there be some intellectual freedom,
there can never be proper mental development.

For the most part, in all our curricula, the time and effort required
to accumulate facts is far greater than that afforded for their
intelligent contemplation--and for the comprehension of the principles
underlying them.

Elimination, then, of unnecessary knowledge is an essential, and it is
well to substitute in place thereof free scope for independent work,
or a choice of optional subjects along whatever lines the taste may
be.

The month of April in McGill, during which post-graduate courses are
now given, has been rearranged so far as student activities are
concerned. The worthier students are allowed free scope to study as
they will, and to attach themselves to whatever service or teachers
they so desire. Post-graduate courses are open to them, as are also
the laboratories and wards for independent observation, and for a
leisurely contemplation and summary of the year's work.


THE PRE-CLINICAL SUBJECTS

The marked changes which scientific teaching in anatomy and physiology
have undergone at McGill University during recent years form an apt
illustration of the need to correlate more closely together not only
the preliminary sciences with clinical subjects, but likewise the
purely medical subjects studied in the early years of the course.
Anatomy has long ceased to be a study of structure only: to the
isolated work of the dissecting-room and lecture theatre has been
added the practical study of the living subject. The study of function
of anatomical structure has taken the place of mere study of form; the
why and wherefore of structure is explained by exhibition in the
living body; the normal living individual is exhibited, and when
occasion arises, perversions of the normal are presented to the
student class in the theatre or in the wards. In other words, the
living anatomical subject is made to demonstrate what formerly was
only done on the inanimate body in the dissecting-room.

So, too, in our study of physiology. Ward classes form part of the
teaching in physiology. The Professor of Physiology is the Director of
Experimental Medicine; he make rounds with the students in the wards;
he associates himself and his work with the attending physicians. Nay,
more, a course is given to clinical teachers on physiology in its
application to clinical medicine in order that he may better inculcate
physiological principles in clinical teaching.

Thus is brought to pass another great change in medical education. The
early contact of the student with patients is more and more stressed,
even in the so-called pre-clinical years. In the first clinical year,
moreover, students who only recently have been given some instruction
in physical examination are now brought into the out-patient
departments and wards in groups to learn by direct observation and
intimate contact the problems of internal medicine and surgery. In the
ward rounds, members of the senior class are called upon to instruct
the junior students by discussion of cases under their charge.
Correlation of all the preliminary sciences and the pre-clinical
subjects is emphasized in the later years, for it is our firm
conviction that the methods of the laboratory must ever be closely
linked with the clinic.

No more successful course is given in our school than that of the
clinical pathological conferences, which stimulate the investigating
spirit and a keener search for truth.

Fundamentally, these are the principles upon which medical education
should be based, for thereby the student is enabled to gain by
experience greater powers of observation, of interpretation, of
forming sound conclusions, and of trying them out in the light of his
constantly-increasing experience.


THE STUDENT

We have dealt with the teacher and the time-table. One word about the
student himself.

Next to the inspiring teacher, the student is, after all, the most
important asset of the school. The better the type, the greater will
be the reputation of the school. A poor type of student tends to lower
the standard.

It is for that reason I would like to emphasize here the need of
better early school training--better educators--and the misgivings
that one feels at the unfulfilled requirements that lead to entrance
on a professional career. Fortunately, the popularity of the medical
profession permits of a limitation of the number and a selection of
the fittest. How often does a candidate mistake his calling! How often
does his application form show that he lacks the essential qualities
of heart and head and breeding which are so necessary to the making of
a physician! Not infrequently, too, the unprepared student may succeed
in passing his matriculation, only to find later on that some other
calling should have been his choice. Verily, many are called but few
chosen, and of the few that are chosen, still fewer attain the goal.

Following upon a good school education, the prospective physician
needs a sound general cultural knowledge, such as is afforded by a
year or two in the Faculty of Arts. With this knowledge should
naturally go an elementary acquaintance with the simple technique and
principles of the preliminary sciences. Any effort to compel the
student to delve too deeply into these sciences, however, during his
pre-medical years is often liable to divert his interest from the
broader conception of his profession. On the other hand, to those with
a taste for such special lines every facility should be afforded.

As in other countries, in other states and provinces, so here--there
is a need--a very great need of better and more harmonious
co-operation between the Universities and the State Boards. Were it
but possible to achieve more success along these lines, Canada would
have no need to fear competition from any other country in the world.

To summarize--I would urge for medical education in Canada the
following suggestions:--

1. Improvement in education in the primary schools, and better trained
teachers.

2. A broader cultural training in the pre-medical years, with
sufficient teaching of physics, chemistry and biology to illustrate
the broad principles of the subjects and the elementary technique.

3. A better standard of English expression and composition.

4. Early contact of the student and patient as illustrated in the
teaching of function in anatomy and the teaching of physiology in the
wards as well as in the laboratories.

5. Better efforts at correlation of preliminary sciences with the
living patient.

6. Still more intimate contact of student and patient in the early
clinical years, with special reference to the out-patient department
for the study of the beginnings of disease and minor ailments.

7. Emphasis of the three major clinical subjects, and a frank
recognition of the fact that the specialties should be taught chiefly
in relation to these three subjects.

8. A better programme in the teaching of the specialties as regards
quantity and quality.

9. Less overloading of the curriculum and elimination of the
non-essentials.

10. Greater intellectual freedom for the student throughout his course
and examinations.

11. Insistence on adequate material for clinical work and laboratory
facilities in hospitals.

12. More careful selection of medical teachers in respect of their
power to stimulate the investigative spirit, while at the same time
exciting sufficient interest by disclosing the utility of the
knowledge imparted.

13. Limitation of students, and greater care in their selection.

14. The retention of some didactic teaching, with insistence, however,
on the importance of group instruction.

All that has been said in rambling fashion here represents but a few
of my own personal beliefs--subject to revision, and, no doubt, very
open to criticism. The somewhat chaotic state of medical education
to-day lends itself readily to discussion. After all, how few there
are with sufficient knowledge and experience to dictate a policy? Let
us hope that in our conferences here, our main motive will be an
honest desire to aim at raising the Canadian medical profession to
higher and ever higher levels of concerted, harmonious effort.
Divergence of opinion there will be--how, indeed, could it be
otherwise, most of all with the problems of medical education.

    "Now, who shall arbitrate?
    Ten men love what I hate:
    Shun what I follow--slight what I receive.
    Ten men who in ears and eyes
    Match me: we all surmise
    They this thing, and I that--whom shall my soul believe?"

The CHAIRMAN: I am sure we all are very much interested in these two
most important contributions to our proceedings. We have had
contributions on preliminary education entrance requirements, degrees
and the curriculum of study, and I think we had better hear from Dr.
Young now on post-graduate medical education before the whole matter
is open for discussion.



POST-GRADUATE MEDICAL EDUCATION IN CANADA

Dr. GEO. S. YOUNG (Toronto): At the present time medical post-graduate
work in Canada is being carried on in two ways:--

(1) By what may be called Intramural courses, conducted within the
teaching centres.

(2) By Extramural, or so-called Extension lectures and clinics.


INTRAMURAL COURSES

Of the former some lead to a degree, and with one or two exceptions
are intended to develop specialists. At least five of the Canadian
universities give courses, lasting a little less than a year, in
public health for the degree of D.P.H. One grants the degree of Master
of Science after a year of "residence as a graduate student" and an
approved "thesis embodying the results of original investigation."
Another grants a D. Sc. two years after graduation for original after
examination and an approved thesis. One at least gives a Diploma in
Radiology after an eight months' course. Two schools give
post-graduate degrees in surgery and one in medicine, after courses
lasting from two to three years.

For those of us who believe that no one should become a specialist
until he has had experience in general practice the question naturally
arises: Is there any recognition of this principle in the planning of
the courses mentioned? The answer is to some extent, yes. All the
courses in public health are open to the general practitioner. One
university goes so far (in the right direction) as to require a year
in general practice before entrance. This is a wise provision. The man
who intends to devote his life to public health work should at the
very outset, by personal experience acquire the viewpoints of the
public and of the family physician. It is with them that his future
career lies.

Of the remaining courses leading directly to specialism, one in
surgery rather effectually shuts the door on the great majority of
general practitioners, since it demands a year of interneship on a
rotating service in hospital as an entrance requirement. The other
post-graduate course in surgery, and also the one in medicine, both
admit the general practitioner, but the selection of students for
these courses does not favour the man who has been in general
practice.

It will be noted that the schools in Canada have made a fair beginning
in the training of specialists. The task is not an easy one. To carry
on post-graduate work concurrently with under-graduate teaching is a
tax on the staff, the resources, and the clinical material of the
universities. Perhaps that is the reason why it is easier to accept or
select as post-graduate students those who have just finished their
under-graduate course. They fit in better with the established order
of things. One cannot escape the fear, however, that the trend of
higher medical education in Canada, as in the United States, is toward
the selection by the Faculties of certain promising students whose
future will be shaped in such a way that they will receive a long
intensive training and will in time become the teachers of our
colleges without any experience in general practice. If this policy
should be carried too far it would close the door to the general
practitioner for teaching positions. There would come a time when the
future general practitioners would be taught entirely by men who had
never had experience in general practice. This, surely, would not be
desirable. Not only should the door to post-graduate education be open
wide to the general practitioner, but there should be a "Welcome" sign
on the door. It is this "Welcome" sign that attracts nearly one
hundred of our graduates to the United States every year, and too
often the best of them do not come back.

In addition to the training of specialists, several Universities give
short or indeterminate courses for graduates. In one instance
post-graduate lectures are given throughout the university session. In
at least two schools advanced laboratory courses are given to recent
graduates who wish to engage in research. One gives special courses in
industrial hygiene and school hygiene. Two schools at least give the
general practitioner an opportunity to spend as much time as he
chooses in following up the under-graduate clinics during the college
sessions. Several of the schools have short post-graduate courses
annually open to all graduates in medicine. The announcement of one of
these is so attractively phrased that I take the liberty of quoting
it:--

     "The object is in nowise to train specialists in any
     branch of medicine or surgery, but to afford an annual
     opportunity to the general practitioner to witness with
     a minimum expenditure of time and energy the practical
     and clinical application of those methods of diagnosis
     and treatment which have come into use since his own
     graduation, or which on account of local conditions he
     may have hesitated to adopt in his own practice."

The difficulty of combining post-graduate and under-graduate work has
suggested the idea of organizing separate post-graduate schools having
their own teaching hospitals. Obviously, such a scheme could only be
carried on in the large centres and would require university or
private financial backing, or both. It could utilize the university
teachers who were nearing the age limit to the advantage perhaps of
both university and teacher. In this connection I may quote a very
valuable paragraph from a recent letter from Dr. Hattie of Halifax. He
writes:--

     "I am strongly of the opinion that the Canadian
     colleges should co-operate in the endeavour to
     concentrate post-graduate teaching, where the greatest
     amount of clinical material is available, _and that
     exchange of teachers should be effected_ when
     practicable, _in order to give a national colour to the
     courses_. It seems to me that with real effort we
     should be able to so organize post-graduate teaching
     that few of our men would feel it necessary to go
     across the line in order to get what they want in this
     particular."

I am sorry that Dr. Hattie is not present, but I may remark that he is
a firm and ardent believer in a closer union of the provinces than
Confederation has yet brought about, and I do not think that one can
over-emphasize the point he stresses. To proceed.


POST-GRADUATE EDUCATION IN CANADA: EXTRA-MURAL WORK

It is now some years since extension lectures in medicine were
undertaken by Canadian universities. In Ontario until June, 1921,
these lectures were given on request, and beyond simple announcement
no special effort was made to secure audiences. At this time the
Ontario Medical Association entered the field as impressario and
advertising agent. Briefly the plan adopted was as follows:--

Lists of subjects and lecturers were submitted by all the
universities, and in a few instances by medical societies. From these
a schedule of over three hundred subjects was compiled and sent out to
all the county medical societies in Ontario. The societies were asked
to choose subjects on which they desired lectures and to notify the
central office of the Ontario Medical Association. The names of the
men who were prepared to lecture on these subjects were then sent to
the societies and from them a choice was made, dates set and the
details finally carried out through the central office. At first each
society was given the privilege of having four lectures annually. This
number was increased to six and finally to eight.

These lectures have been delivered without expense to the county
societies. All travelling expenses and a small honorarium have been
paid through the Ontario Medical Association. Fortunately, at an early
stage of the movement, the leaders of the Ontario division of the Red
Cross took an interest. They saw in it better medical service to the
public and made a grant of $5,000 a year for three years. This has
taken care of about two-thirds of the expense, while the balance has
been paid by the Medical Association. As already stated the
universities have borne the chief part in the providing of lectures.
The lecturers themselves have been willing at all times and have gone
to almost every nook and corner of the province. It was the business
of the Ontario Medical Association to create the demand, and you will
realize how successful its efforts have been when I tell you that in
three and a half years 750 extension lectures have been given in the
province.

You will notice that extra-mural work as it is being carried out in
Ontario does not wait for the individual to apply but goes out to seek
physicians everywhere. It is an organized effort to influence
educationally the whole medical profession. It is being conducted on a
large scale and involves the expenditure of time and money. The
doctors in Ontario ask that it be continued. The Canadian Medical
Association would like to extend it from coast to coast. The American
Medical Association has been keenly interested and proposes now to
inaugurate a similar movement embracing every state of the union. One
may well ask whether all this is worth while. The answer must take
into account the effect of environment on those who practise medicine.

With a few notable exceptions the men who attain eminence in medicine
are dwellers in cities, and yet a close acquaintance with the medical
profession outside of the larger places will reveal here and there men
of outstanding ability. They may not be able to discuss the scientific
aspects of modern medicine; they may be ignorant of the more refined
methods of diagnosis; but they can use the tools of knowledge which
they have, with unerring precision. They have learned to use these
tools under the drive of a personal responsibility to patients whose
lives may depend on their judgment. But they have been hampered in
their development by their environment. They have lacked the stimulus
of daily contact with their fellow practitioners. They have had to
learn from books rather than from men. They have missed that greatest
of all incentives to reading, namely, association with students. Too
often they have had to work without the aid of the laboratory and too
often, but naturally, they have gradually become skeptical as to its
value as an aid in diagnosis.

Now the object of the extra-mural work already described is to
organize or to stimulate into activity county medical societies, to
bring together frequently groups of doctors living within reasonable
distance of one another, to provide speakers who would not only give
information in regard to the latest things in medicine, but who would
bring a new interest and enthusiasm to the work of the rural
practitioner. In other words, the aim has been to give to him so far
as possible the advantages which surround the doctors in the teaching
centres.

It has been interesting to watch the development and results of this
movement. Sometimes at first there was a good deal of local inertia
and the attendance at meetings was small. This was considered a strong
reason for urging more meetings, and sooner or later out of the
original failure there grew a strong and enthusiastic society. At
first speakers reported that there was little or no discussion of
their papers; local men were diffident about discussing questions
which they were accustomed to approach from the standpoint of
experience rather than of scientific knowledge. To-day discussion is
generally free and the meetings are more profitable, not only to the
local men but also to the visiting speakers.

It has been the aim of the Committee on Education of the Ontario
Medical Association to have the programme of the county society
meetings supplied in part at least by local members, and this has been
strongly urged from time to time. An effort has also been made to
substitute clinics for lectures and papers wherever possible. Both of
these objectives have been realized to some extent. Recently at a
district meeting the excellent programme was almost entirely provided
by men from the smaller places, and one came away with the conviction
that country and small town practice offers a rich field for clinical
research.

After all, the ultimate test of the value of this intensive
extra-mural work must be this: Is it for the public good? If through
this educational influence on the whole medical profession it should
lead here and there to earlier diagnosis and more effective treatment
the public will gain. It is scarcely necessary to add that the
doctor's income will not increase but rather diminish. If it makes the
country more attractive to the recent graduate it will help to solve
the serious problem of inadequate medical service in the outlying
districts. If it should stimulate some men here and there to cultivate
the hitherto scarcely touched fields for medical research in general
practice, it might benefit not only our own Canadian people but the
world at large. Extramural post-graduate education as carried on
during the last three and one half years costs money. If it is to be
extended throughout Canada, it will mean an expenditure of $30,000 a
year. It is a movement for the people. _From where will the money
come?_

Dr. L. J. AUSTIN (Kingston): I feel somewhat diffident about offering
any criticism or any observations on medical education in Canada,
having had only three and a half years in which to study the matter. I
should like, however, to point out certain things in connection with
medical education in England, because we sometimes get comparisons,
between conditions in England and those in Canada, which are unfair.
Ordinary medical education in London covers a five year period, and
the boys come to medical school later in London than they do in
Canada, many of them coming from Oxford and Cambridge, where they
start their true medical studies, as old as 22 or 23. In the ordinary
course of things medical education in England--I do not know about
Scotland--is based on three years of clinical study. This is not
purely clinical, because a certain amount of anatomy is still carried
on as well as some physiology. The point I want to make is that the
two systems are really incomparable, inasmuch as the clinical year in
London is one of fifty weeks and not thirty-two. Once the student has
begun his work in the wards he is lucky if he gets a fortnight's
holiday in the year, and therefore, during the time they put in, the
students must necessarily get a broader view than they do here. The
amount of didactic lecturing is quite negligible, and all clinical
teaching is done in the wards and by means of out patients. The
consequence of this is very grave: no man can go into medicine in
London unless he has a father to pay for him because there is no
opportunity, and absolutely no arrangement is made to render it
possible, for the student in any way to make his own living and thus
to help himself through college. This of course has resulted in
medicine becoming a much more closed thing in London than it is in
this country. I am speaking from the point of view of what I have seen
at Queen's University, where many men in the summer months have been
able to make enough money very nearly to put themselves through
university. As I say, therefore, the two systems are really
incomparable. I personally am a specialist; I want that understood.
And I might say that I am in an impossible position, for I am supposed
to be a specialist in all branches of surgery. We know that that is
impossible in a way, although it is perfectly good enough for teaching
surgery up to the time of graduation, because anyone can pretend to be
a specialist in any one branch of surgery without post-graduate work.
The amount of post-graduate work done by a student in the Old Country
is vastly greater than it is here; the student must put in three or
four years in a big hospital, and it is absolutely necessary for him
to pass a fellowship examination if he means to get an appointment.
That means that a man who does surgery in the Old Country must undergo
a long period of special training. The pros and cons of what one might
call the closed class of surgeons as produced by the Fellowship
examination in the Old Country I will not argue. There are many points
of view to be taken on both sides; the system has its advantages as
well as its disadvantages. I want to make an appeal on behalf of the
student, for whom a word has been said by Dr. Bazin and Dr. Martin.
Where shall we stop? We have seven years now and then a period of
eight years is being required, so that the strain is enormous not only
financially but mentally as well. Where are we going to stop? We
passed a resolution yesterday providing that pre-natal and post-natal
hygiene should be added to the curriculum. What next are we going to
have? I do not know, but I venture the opinion that something else
will be suggested next year. We have embraced in the curriculum now
the major subjects in surgery and we have got to the stage where we
are trying to turn out men who will not be actively dangerous to the
public. We are also insisting, and rightly, that they must put in
another year in hospital. I find with my students that in the
intensive thirty weeks given them they reach a stage in which every
new fact inculcated drives out some other. So that it all gives one
furiously to think as to how to control the curriculum. I agree with
everything that has been said about not attempting to make
specialists; but what are we to do? It is hard enough to make a
uniform man with broad principles who can apply them with his patients
afterwards; but this increase in the number of subjects I look upon as
a grave danger. I could make allowance for physiologists, but it is
not my intention to do so.

Dr. J. C. CONNELL (Kingston): It strikes me that what we need is
something to stabilize medical education rather than to standardize
it. The condition of flux in which we find ourselves is apparently
becoming aggravated, so that we hardly know where we are. During the
twenty years that I have been on the medical faculty this tendency
seems to have been increasing. When I took charge we had a four year
course; we have passed into a five year course, and about the time the
war came a movement was introduced to have a six-year course, and that
is in process of development. Now there is a movement in regard to an
interne year. What is to be the attitude of the medical school towards
this interne year, which in Ontario is now taken by 97 per cent of the
graduates? What is to be the attitude of the schools and licensing
bodies towards making this a permanent requirement? That is something
we must consider. My attitude at the present time--and it is
constantly changing in the light of experience--is definitely against
options in the medical course and against the introduction of cultural
subjects in a purely medical course, that is to say, of cultural
subjects in a five-year medical term. That is my attitude at the
present time.

I think that something may result from this conference, continued from
year to year. If the Programme Committee, or something like an
educational committee, studied this question carefully we might be
able to succeed in having a definite minimum standard preliminary
education which the conference could unanimously support as a
recommendation to the medical schools. What I have in mind is a
definite minimum, leaving the universities and medical schools to
develop for themselves beyond that point, and to work out the details
in their own way.

Dr. HOUSTON (Charlottetown): I should like to refer briefly to
Professor MacLeod's excellent paper, in which there is food for
thought for us in Prince Edward Island. Those of you who are connected
with the universities know that our Prince of Wales College enjoys a
certain reputation by reason of the graduates whom it turns out. But
we have at the head of the college now a man who seems to think that
mathematics and science generally should have very little place in the
curriculum. If a student knows his Latin, French, English and history,
especially the history of Rome and Greece, apparently that is about
all he requires, in the opinion of the principal of the college. I
feel that we are going behind in the scientific subjects and I do not
know how the conference can help us. I was wondering whether a
resolution or some recommendation could be made from the Medical
Council to the educational authorities of Prince Edward Island on this
subject. It seems to me that a very useful purpose would be served,
from our point of view, if the Prince Edward Island Government could
be made aware of the facts which have been so forcibly presented to us
this morning by Professor MacLeod, so far as they relate to the
requirements for entrance to medical school. I feel strongly on this
point because I have a boy going through Prince of Wales College and I
am positive that the course lacks in the respects I have mentioned. I
have talked to the board as well as to the principal of the college,
Dr. Robertson, about this matter, but Dr. Robertson seems to think
that medicine is only a sort of course leading up to insurance or
something of that kind.

Dr. G. R. CRUIKSHANK (Windsor): Quite naturally the discussion so far
has come from the teachers, as it should, and I want to congratulate
the conference on the very excellent papers which we have had and to
express as far as I can, as an ordinary every-day practitioner, the
appreciation which I am sure the medical profession as a whole has for
what we have heard. However, I want to give the conference a point of
view from the other end of the line, so to speak; I want to refer to
the practical aspect of the matter. In the border cities we have about
one hundred practitioners, 90 per cent of whom do anything that comes
along in the way of labarotomy. I am not saying that this is as it
should be, but it is the fact nevertheless, and this will continue.
The graduates will go into practice and keep on doing this. If we
could devise some means of increasing their education along these
lines, if we could increase their dexterity, we should be doing
something for the general public. It has been stated that the medical
profession is harassed by manufacturers' agents who try to sell their
products and who, in order to dispose of their goods, resort to all
sorts of pestilential methods. Well, it seems that a lot of
practitioners are handicapped in other ways; they object to the fact
that some irregulars carry on a thriving business to their detriment.
I have asked some young graduates how often they have seen tonsils
treated with electricity, and to what extent they have seen the ultra
violet used, and invariably they reply that they have seen very little
done in this direction. The practitioner must consider not only the
curative effect of remedies, but as well the comforting influences on
the patient. I believe that this is really the only active agency in
all these things, and I hope that this method will not only be taught
but will be applied as well. One of the most successful post-graduate
schools I know of is that of Vienna. The teachers have nothing to say
about the course they teach. The students get together and discuss
what they want, and I believe that is why Vienna is as popular as it
is. One of the duties of the council is to protect the public. Some
man calls himself a specialist and claims to have had a little more
experience and to possess somewhat more skill along certain lines than
the ordinary practitioner. That may or may not be true, and I think it
is the duty of the Medical Council to see to it that any man who calls
himself a specialist should have something entitling him to the
distinction. I have been urging upon my council for the last fifteen
years the advisability of holding an examination for specialists and I
hope the principle will be adopted. There is a tremendous amount of
operative surgery being practised and those who undertake this work
should undoubtedly be possessed of the necessary qualifications, the
dexterity and deftness which are essential. And I do not believe that
our medical schools are doing enough in the way of teaching physical
therapeutics.

Dr. T. S. MCKIBBEN (London, Ont.): I believe that some of our
universities could do more than they have done in the past or are
doing now in the granting of diplomas not only on the basis of
academic excellence but also from the point of view of personality.
Those who are connected with licensing bodies will catch the drift of
my remarks because not only the graduates of our schools but others
too run amuck. Whenever we are considering matters of curriculum we
should be careful not to overlook the importance of ethical standards.

Dr. W. A. REHFUSS (Bridgewater, N.S.): As a country practitioner I
cannot fail to take this opportunity of expressing myself as being
absolutely in agreement with what Dr. Cruikshank has said. I think it
is the duty of every practitioner to cultivate a sympathetic
understanding of his patients. I do not think there is any profession
which comes more in contact with things that are heart-rending than do
medical men, and this is especially true of the country practitioner.
Personally, I believe that all universities should strive to fit every
student to handle emergency surgery. Often a doctor in the country is
confronted with a ruptured appendix or something of the kind and is
placed in a position in which any treatment other than radical surgery
must of necessity fail. If in the country districts immediate surgical
aid were available, even though from a hand not quite as deft as one
might expect, a great many more patients would be saved; certainly it
would be a great advantage over waiting for four or five hours before
assistance could be had from a so-called specialist. An attempt should
be made by the universities to see that every graduate has sufficient
skill to be able at least to take care of emergency surgery with some
degree of success. I agree with what has been said on the subject of
specialists. I think that there are a great many men who, if the test
of an examination were applied to them, would not describe themselves
as specialists. If they advertised themselves as general practitioners
it would be more nearly true. Certainly in very many cases so-called
specialists do not know much more about their particular subjects than
does the ordinary practitioner.

Dr. R. H. ARTHUR (Sudbury, Ont.): I was rather struck with Dr.
Cruikshank's statement concerning the equipment of graduates. It
reminded me of an incident that is related in one of the American
textbooks on obstetrics. The author tells of a very old practitioner
somewhere on the Pacific coast who was called upon before he died to
give his opinion of the new doctors who were coming into the place.
The old gentleman said that in his experience he had found that the
young doctor was all right but that he had one fault--he knew too
damned much that was not true. According to Dr. Cruikshank, however,
we are at present turning out young men who do not know enough. Dr.
Austin, perhaps unwittingly, in the course of his remarks said a word
for dad. I have educated one son in medicine and it seems to me that
from dad's point of view the extension of the course, and the
post-graduate years that are piled on, certainly make it difficult.

In the course of his remarks Professor Martin spoke of the limitation
of the number of students. For some years now we in Canada have been
manufacturing doctors for export, and no doubt there is a good deal to
be said on this point. But I wish Professor Martin would tell us what
means are being adopted to limit the number of students. This is a
very important question and the method of this limitation is one that
we hear discussed in the country a good deal. The opinion is held by
many that the determining factor in the long run, owing to length of
course and other considerations, will be one of finance.

Dr. S. L. WALKER (Halifax, N.S.): My lack of special knowledge has
kept me silent before the wisdom of so many who are specially
qualified to speak on the various subjects that have been presented to
the conference. However, there is one question which has been brought
up this morning that appeals to me strongly, and it is this: the
object of all our medical education, and all this talk that is carried
on in connection with it, no doubt is that we may better serve the
public in preparing medical men for their work. What is it that the
public needs? It is medical service. And where does that service come
from? From the general practitioner. And the general practitioner is
to be found in the rural and urban sections of the country. We are
turning out a large number of graduates who are looking to the United
Stales, and the crying need in Canada to-day is to turn out men who
will satisfy the needs of the scattered rural sections of this great
country. From what the western men say, one would imagine that only in
western Canada were scattered rural districts to be found, but the
little province of Nova Scotia presents a considerable problem in this
regard; for in that province there are stretches of country of 30, 40
and 50 miles that are served by one medical man without a trained
nurse to assist him in his work. I think our medical schools should
turn out general practitioners who can safely be permitted to go and
take up the burden that confronts them in the scattered rural sections
where at present there is very little possibility of affording the
people the care and attention they need. Perhaps the Conference might
be able to think of some method--perhaps by means of a bonus or an
honorarium, or possibly a scholarship--of encouraging students to take
their course and in return guarantee that for two or three years they
would serve those sections of the country which at present are not
being looked after. We need general practitioners above all, and after
they have been in practice they can then become specialists.

Dr. H. W. HILL (London, Ont.): I want to call the attention of the
conference to an academic point, and that is, the classification of
subjects into cultural and non-cultural. I do not think this is a wise
classification. It does not strike me that French, English, history
and philosophy are in themselves cultural subjects. I have seen them
so taught that they had an effect quite the opposite of cultivating
the student. In my opinion the classification of subjects into
cultural and non-cultural is a matter of method of teaching
altogether. As a matter of fact I have known physics to be taught in
such a way that it constituted a course of culture; the moment the
professor of physics decided to teach this subject with that idea in
mind he found the principle a sound one. Men can get just as much
culture from anatomy, taught as it should be taught, as from
philosophy or ancient Greek history, taught as these subjects
frequently are.

Dr. D. S. MACKAY (Winnipeg): I must express my appreciation of the
papers which have been contributed by Professor MacLeod and Professor
Martin. I think the time has come when this subject must be more
seriously considered, and this conference opens the way. We believe in
a sound preliminary education followed by a thorough medical course. I
heartily concur in the view that the period now allotted for a young
man going into university for graduation in medicine has about reached
the limit. I think the economic limit has been reached. I agree with
Dr. Martin that the young man in a university to-day is faced with a
problem which only the strong will survive. He works from eight or
half-past eight in the morning until five or six at night and in his
final years he must attend obstetrical clinics--and obstetrics come on
in hours over which he has no control. The student, then, is working
at high pressure and has no time for consideration of the subjects he
is taught in the day. As a matter of fact he has no time to think for
himself, and the consequence is that he must come out of the
university more or less as a sort of stuffed fowl rather than a human
being who can tackle a question and analyse it. We have found this not
only with our own students but with students from elsewhere. So far as
the question of curriculum is concerned, I think we in Manitoba are
now arriving at a fairly satisfactory solution. We have a two-year
pre-medical course and five years of an actual medical term, with a
final interne year. That is seven years altogether. We have no
intention of increasing the period; to do so would be economically
unsound. We have very little difficulty at present in increasing the
number of our students, although the question may arise as to the
placing of them. There is a large hospital in Winnipeg which can
accommodate a good many of them. The hospitals in which our students
are placed are carefully selected and the system is working out
satisfactorily. I think that the limitation of the number of students
is an important point, and the problem of finding hospital
appointments for them will no doubt to a certain extent control this
situation. We are up against a problem in that regard. It is claimed
that all British subjects resident in Manitoba are entitled to
education if they are capable of fulfilling the requirements. That may
be right, and we do not dispute it. At the same time the facilities
for giving a man a good sound education must be limited by economic
considerations, and we can I think satisfactorily take care of fifty
men in the graduating year. At the present time we have sixty-four
working over capacity, and if there were some means of having such a
conference as this pass some form of resolution it would strengthen
our hands materially. We are endeavouring to deal with the situation
ourselves, but it is always well to have outside help. I greatly
appreciate the stand taken by Professor MacLeod and Professor Martin
and I am sure that their addresses provide a great deal of food for
reflection.

Dr. F. W. ROUTLEY (Toronto): I rise as a general practitioner to make
one simple statement regarding the present day graduate of our
universities. It has been my privilege in practice during the past ten
years to have associated with me a considerable number of graduates
from our Canadian universities. They have usually been of high
standing in their year and I have greatly admired their academic
training. But I have sometimes wondered whether the present-day
university was not falling down in regard to some other things than
the simple study of scientific medicine. You know, the old Canadian
doctor of the last generation was in the habit of telling his
patients, or the family of his patients, when he arrived on a case,
that he was called just in time, and that half an hour in the
difference would have meant the death of the sick one. He would also
tell the patient how long he would be sick and when he might expect to
be out of bed. This was a point with him. In the present day, on the
other hand, I have found among recent students too great a tendency to
consider their patients as cases rather than as sick persons requiring
medical aid. I make this statement, because after all our duty is to
the public and in order to obtain the best results we should make the
best possible impression on the people with whom we have to deal. You
cannot possibly expect to get the best results in any department of
labour unless the people with whom you deal have absolute confidence
in your ability. While there never was a time in the history of
Canadian medicine when the graduate was as well qualified to practice
his profession as he is to-day, at the same time I think that some
attention should be paid by universities to the attitude of the young
doctor towards his patient and his patient's family. In this regard, I
think there has been something remiss in the universities in the last
few years.

Dr. W. H. HATTIE (Halifax): Dr. Routley's remarks have stimulated me.
One of the things that have impressed me at Dalhousie is the fact that
most of our students have been taught medicine as practised in the
hospitals and not in the homes, and our endeavour now is to make such
arrangements as will enable students in their five years to get some
opportunity of going into the homes of people and learning something
of social conditions which will have a bearing on their practice
afterwards. We are endeavouring also to let the students see as far as
possible the way in which various organizations that are interested in
public health are carrying on their activities. The work of the
Halifax Dispensary, the work of the Victorian Order of Nurses, and the
welfare work of the Massachusetts Health Commission are all being
carried on from offices in the public health buildings, and the
students, while not having their attention particularly directed to
these organizations, nevertheless have an opportunity of seeing the
way in which the work is done and the way it may be co-ordinated with
their future activities. One of the things I noticed immediately upon
taking over the duties which I have recently been endeavouring to
discharge, is the fact that students of the first year do not realize
that they are medical students at all. They are unable to see the
particular bearing of the subjects of that first year on the medical
course. We have been able to get over that difficulty to a large
extent by arranging for a weekly conference with members of faculty.
Practically speaking, only our full-time staff has been able to attend
these conferences, but we have learned as a result that there has been
a good deal of overlapping in teaching and there have been rather
serious omissions. However, we have been able to rectify these things.
We have succeeded in interesting members of the faculty of arts, who
are also members of the faculty of medicine, in the particular points
in connection with their teaching that apply to medical students. This
has worked out in an unexpected way. They have discovered that if they
pause long enough to call the attention of a medical student to some
point which they are demonstrating it intensifies the interest of the
art student, so that in consequence not only the medical student is
benefited, but the other students as well.

Dr. H. W. MCGILL (Calgary): I should like to pay a tribute of
appreciation to the three papers that have been delivered this
morning, and I am sure that had I been two days late my trip would
still have been worth while. I am not in a position to discuss the
subject matter of the papers, but Dr. McKibben has, I think, brought
out an important point. It is essential that a high standard of ethics
should be observed. The licensing body of Alberta has had some
experience in this regard. We have had men applying for registration
whose conduct in certain respects was not what one would expect. It is
quite evident that they have not the most rudimentary ideas of honour
and honesty and it gives us great misgiving as to what their character
will be later on when they become practitioners; there is reason to
fear that in very many instances they will not reflect credit upon the
profession. What the solution of this difficulty is I do not know, but
undoubtedly all licensing bodies will have to face the question. I do
not think that the misfortune is to be attributed to any defect in
university training, because I believe that when a man comes to the
university with such a mental twist no amount of training will
eradicate it. The careful selection of students might prove a way of
meeting the difficulty, but there is no doubt whatever that the
difficulty exists. Certain it is that the methods which some of these
students pursue are not very promising and would seem to afford some
reason for misgiving concerning their future honour.

Dr. OWER: I should like to emphasize this particular point which I
think is one that might come up for discussion at the next conference.

The CHAIRMAN: I fear further discussion will have to be deferred until
the conference meets again unless it is the desire of the meeting that
we should continue this afternoon.

Dr. GEO. S. YOUNG: If I am in order I would like to say this: I am
very glad that Dr. Martin, and I think Dr. Hattie, stressed the
importance of early correlation of the scientific subjects with the
clinical problems that come after. We have swung too far away from the
old apprentice system, and the result is that medical education is not
a superstructure based on a solid foundation, but a house in which the
scientific subjects are packed away in the cellar, and when the
application of these subjects is required in later years the student
has forgotten where to find them. It seems to me that early
correlation of the scientific subjects with the application of the
science in later problems is a very important matter. I am sorry that
the extreme importance of this subject of medical education has
somewhat overshadowed the question of post-graduate education. I was
just about to move:

     That this conference heartily approves of the
     Extramural post-graduate work as carried out in Ontario
     during the last three and a half years, and urges that
     every legitimate effort be made by the Canadian Medical
     Association to secure funds whereby this work may be
     extended to all the provinces in Canada.

Dr. A. T. BAZIN: I second that.

Motion agreed to.

Dr. C. F. MARTIN: I will try briefly to answer the various points that
have cropped up since the papers have been read.

First of all, in response to Dr. Arthur's inquiry with reference to
the selection of students, I may say we stop really at nothing in the
way of selection of students. We do not allow any written law to
dominate our selection. Of course, every candidate who comes to McGill
University for the medical course must fulfil certain preliminary
requirements. As to his knowledge of the preliminary sciences, in that
too we make fairly high demands. A man who was exceptionally good in
two of the three preliminary sciences might be admitted if deficient
in the third, provided his attainments in the other two were of a very
high order. I am merely giving that for example. That is one thing,
his knowledge.

Second, there are the cultural requirements. Every man must write a
letter of application in his own handwriting; we do not accept
typewritten letters of application. He must also send his photograph
or have a personal interview, and we prefer the personal interview. If
a man has the qualities of heart and head and breeding, as I said in
the paper I read those are the three requirements above all others
that concern us in the selection and admission of students. In order
to illustrate that point I have just got figures from Dr. Simpson. In
the course towards the study of medicine, 54 students were already in
course in the pre-medical years. That left 46 vacancies in the first
year of medicine--we accept 100 only. In order to fill those 46
vacancies we had to select from 285 applicants coming from all over
the United States and all over Canada. That selection might seem to be
a little difficult, but as a matter of fact so many factors can come
into it that we are able through consideration of the various things
to eliminate without very much difficulty. Dr. Simpson is a past
master of that, and he undertakes the responsibility of selection
almost entirely; only now and then in special problems is there a
consultation of the committee.

I would just like to combine one answer to Dr. Cruikshank and Dr. Fred
Routley. I had anticipated the remarks that have been made with
reference to the general practitioner and the service he renders to
the community. The teacher in a university should always in his class
work stress the importance of service. That is an obvious thing; it
may not be done enough. I think the success of the work of the
practitioner depends almost entirely upon his knowledge of the fact
that the first thing to do is to make his patient comfortable--not to
make a blood chemistry test, not to make a diagnosis of his immediate
need or a diagnosis of his ultimate scientific condition. Perhaps in
our universities we fail to inculcate that principle sufficiently; I
will admit it, but the effort is made, and more and more stress is
being laid in all our universities on the importance of it.

I would like to ask Dr. Aikens, privately, by what methods the
university can teach the student before he graduates to do a lobectomy
operation with skill. We are supposed to teach the men how to study
that after they become doctors.

I would like just to thank Dr. Hill for what he said about cultural
training, because practically every subject can be so treated as to
impart cultural training; I think his interpretation of that is
correct.

Dr. J. J. R. MACLEOD: Dr. Martin's reply to several questions is in
exactly the same terms as I believe the Medical Faculty in Toronto
would have used.

With regard to the use of the terms cultural and non-cultural, I am
sorry there has been perhaps a misunderstanding here. They are merely
convenient labels for the division of the subjects, and I would be the
very last to subscribe to the principle that there is not as much
cultural training in anatomy and physiology and the medical subjects
strictly as in Latin, or Greek, or Divinity or anything else. The
terms are used only for convenience.

With regard to the suggestion as to the advisability of teaching
elementary science and mathematics in the schools, I believe the
result of the extended debates that have taken place all over the
English-speaking world on this question has been to show that it is
advisable to give a certain amount of training in these subjects in
our high schools. Unless the young mind is trained to think in terms
of science early, it is very difficult afterwards to make successful
progress in these fields.

With regard to the importance of psychology--which I think has been
indirectly stressed in the discussion--I would point out that one
cannot teach the student to deal even with his normal fellow man, much
less to deal with his diseased fellow man, in a humanistic way by
systematic courses in psychology alone, but these do give him a basis;
they give him something to think about, and they stress for him the
importance of dealing with the human mind according to the same
principles as those with which he deals with any other academic
subject that can be systematized.

Lastly, Dr. Connell has asked the question, or rather he has done more
than that, he has given the negative to the question whether cultural
options should be a part of the medical curriculum. Let me explain:
These cultural options as given in the University of Toronto do not
take more at a maximum than five hours a week for the first three
years of the course, and they are designed merely for the purpose of
enabling the student to appreciate the value of what he has learned in
these subjects in the school. It does seem to me a shame that a
student should be brought to a large university merely to be taught
the technique of his profession. He should be given the opportunity at
least of seeing what a college course in the subjects of his high
school means, what the difference is between the university outlook
with regard to these subjects, and the school outlook. For these
reasons, therefore, I believe where it is possible to do so, a
limited, a very limited amount of so-called cultural study should be
offered to the medical student.

The CHAIRMAN: I think it is obvious to all members of this conference
that we have simply touched the very fringe of this question. I think
the discussion so far has been most useful, because it has been
presented by men who are engaged in education, and enlarged upon by
men who are in general practice, and I think that is a splendid thing,
both for the practitioner to know the viewpoint of the men engaged in
teaching, and on the other hand, for those engaged in teaching to know
the viewpoint of the general practitioner. That in itself, I think,
would justify this conference. Of course, the discussion has not been
as full or complete as we would like, but no doubt this subject will
take a very prominent place in the next annual conference.



REPORT OF THE RESOLUTIONS COMMITTEE

Dr. J. C. CONNELL (Kingston): I beg to present the following report on
behalf of the Resolutions Committee:--

_Resolution No. 1_

     Whereas the attention of the Conference of Canadian
     Medical Services has been directed to the
     classification of Canadian medical schools by the
     Council on Medical Education of the American Medical
     Association, as published in the Educational number of
     the Journal A.M.A., August 16, 1924;

     Resolved that in the opinion of the conference it is
     desirable that the publication of this classification
     be discontinued, and be it further resolved that the
     secretary of this conference be instructed to
     communicate with the Council on Medical Education of
     the A.M.A., stating the desire of this conference in
     reference to Canadian medical schools as expressed in
     this resolution.

The CHAIRMAN: Is it your pleasure that this report be received. I
understand you to move that, Dr. Connell?

Dr. J. C. CONNELL: I move that the report be received.

Dr. C. F. MARTIN: Before that question is put, I wanted to speak.

The CHAIRMAN: The report must be received before it can be discussed,
obviously.

Dr. C. F. MARTIN: It is the reception of the report I would like to
discuss, but that would involve a discussion of the case. I do not
quite know how to deal with it.

The CHAIRMAN: I am afraid I shall have to rule there is no harm in
simply receiving the report. Once received it is open for discussion.
Shall the report be received?

The motion was agreed to, and the report received.

The CHAIRMAN: Now the report is open for discussion.

Dr. C. F. MARTIN: I had the pleasure of coming down here with Dr.
Connell this morning, and asked him what conclusions had been arrived
at last night in connection with this resolution, and he kindly told
me what the resolution was, as just read. It seemed to me at the
moment quite a harmless thing, which I think I said, but on going into
breakfast I purchased the valuable morning paper published in Ottawa,
and that has given me reason to think more seriously about this
matter, and also to reconsider my view that the thing is as harmless
as at first seemed. May I just read the headlines, in case some of you
have not seen the report? In large type appears this: "_Strong protest
against report of U.S. Doctors--Dr. Connell hotly resents uninvited
act of foreign body's classification of Canadian Schools._" Of course,
Dr. Connell never hotly resented it. I am going to move an amendment,
if necessary, but I want to say this, for the sake of the Canadian
medical profession, and for the sake of the importance of this
conference being properly recognized. I hope nobody is so small-minded
or unkind as to think that I, happening to belong to a school which
was classed in Class A, would want to ignore that a sister school,
very worthy, has been treated perhaps unfairly, no doubt unfairly,
inasmuch as no proper supervision of the school was made prior to that
report; but I want to speak about it on the broader lines in
connection with this conference. This report printed in one of the
Ottawa papers, I take it is liable to be copied and circulated by the
Associated Press. It is more than likely it will be. It is a
contentious article, far more contentious, I think, than what actually
occurred. I do not think the original resolution ever meant that such
an idea should be conveyed. I think it is a great misfortune this
meeting has had this unhappy incident; it is the one blemish on the
meeting. I think it has put us in an unfortunate position, where our
dignity has suffered considerably, our dignity as serious minded
medical men, the leaders, may I say, of the medical profession
throughout Canada.

I think the resolution as it now stands, and as it may be carried on
to our friends on the other side of the line, coupled with this strong
protest as advertized in the Associated Press, would be construed in a
way as an unfriendly act. I think it is an unfriendly attitude for us
to take an eye for an eye, if such were the intention, with our
friends to the south. I have learned from our good friend Dr. Bazin a
new interpretation of the word harmony. Perhaps it is justifiable
under certain conditions. He says if we are going to promote harmony,
the first thing is we must not allow ourselves to be trampled upon. I
do not like to be trampled on any more than anybody else, but I think
there is a point of expediency here, and that a satisfactory solution
of this problem can be arrived at in another way. I had intended to
say nothing about this, for I am entirely in sympathy with any of the
schools that have been unhappily treated in this matter, and will do
all I can personally to avert the criticism.

But let me say just this, in explanation, as I see it. The American
committee have decided on this for their own purposes. We have nothing
to say about what the American committee on education want to do for
themselves. They are entitled, if they like, to make a survey for
their own purposes. We can refuse to give them any help when they come
to us, but they are entitled I think to say this: They do it because
our students apply to them for positions, students of every
university, and that is where I think Dr. Connell naturally feels
resentment, and so might other schools if they have been unjustifiably
treated. But the question is, is this the best way to handle it? What
will happen? We send on this resolution and ask that they do not
publish their reports on our schools. It seems an ordinary, simple
thing, but what would happen if it becomes a fait accompli, and no
further report is issued by the American committee--and the resolution
simply requests that nothing be published in future? It simply means
they will accept that _statu quo_ of 1924 for all time. What evidence
have they got? Unless we invite more friendly relations it means that
we are going to suffer; at least, McGill and Toronto won't suffer, but
Queen's will suffer, and the others that are put in that unfortunate
position; they will suffer because the _statu quo_ of 1924 will
remain.

I think it will reflect discredit on us all if it is done in that way.
There is an Association of American Medical Colleges in relation to
the American Committee on Medical Education, and I would suggest that
instead of this action being taken, that at all events an effort be
made by personal interview, if you like, by each university
undertaking to communicate privately with the colleges or with the
committee. Some of us will be mightily glad to take it up with them
for the protection of the schools concerned. We will do anything you
like in that way that we can. We are, of course, sympathetic with the
idea of the resolution, but I do not believe this is quite the way to
do it. I do not want to take up more time; I could say something
further about it, but I would ask, in conclusion, this conference not
to place itself on record in a way that is undignified or unfriendly,
but to try and correct this misunderstanding by individual means
rather than by a formal request to the American Medical Association
from this conference. I think we can arrive at our object by other
means, and I certainly hope we will agree to do so.

Dr. JAS. M. MACCALLUM: I have always gone on the principle that the
least said the soonest mended, and I hesitate to say anything about
this at all. I am in sympathy with what Dr. Martin has said, and I
sincerely sympathize with the feelings of Queen's and the other
institutions. There is a gentleman named Abram. Flexner who is now
compiling another report on medical education, and I am in a position
to know that there are criticisms of my university which I do not
think are justified. I think I also am in a position to say that the
University of Toronto will not ask anybody to take their part. This is
a private fight. I am Irish by descent and also Scotch and like a
fight, and what impresses me about this is that nothing has been heard
as yet from the other bodies which are affected. I advocated the
_entente cordiale_, and you see what the result of it was. That speech
that was delivered last night is another effect of my speech. Dr.
Normand will deny that, but then that is a part of the entente
cordiale. I am quite sure that if Dr. Connell and his witty friend,
Dr. Austin, will employ the means and methods of the _entente
cordiale_ as practised by myself they will have no trouble at all.

I do regard this with a great deal of apprehension, and I am sure that
if Dr. Connell will adopt what I believe to be the proper method, and
will act upon the principle of the entente cordiale, he will get
results which he will have no reason to regret.

Dr. P. S. MCKIBBEN (London): In London we have suffered from the
classification in which we have been placed by the Council on Medical
Education for a number of years, and I grant that the problem is a
considerable one. But as I see the situation at present, so far at
least as it affects ourselves, I am inclined to think that this
resolution will do our status more harm than good. I know some of the
men on this council, and I do not understand why Canadian schools
should have been classified in this way. I cannot understand why,
after a lapse of several years, the council has seen fit to reclassify
the Canadian schools. It seems to me that the suggestion is a good
one, that the matter might be taken up privately; it might be the best
thing in the circumstances to approach privately some or all of these
men. By this means we should no doubt obtain far better results than
would accrue from the adoption of this resolution. I doubt whether the
resolution, if adopted, would reflect the real spirit and dignity of
this body.

Dr. G. R. CRUIKSHANK (Windsor): About forty years ago the Russian
Government sent out a commission to examine the medical schools of the
world for its own information. This sort of thing is not new, and I
do not think that we Canadians object to anyone inspecting our
schools. Rather, we are glad to have anyone come, and I want to assure
Dr. Connell that nothing on earth can injure the reputation which his
own school enjoys.

The CHAIRMAN: There has necessarily been some warmth in the discussion
of this subject, which is one that we have not had really very much
time to consider. I do not know what this Conference may decide to do
in regard to the resolution that has been submitted, but there are two
courses open to us. In the first place, now that the matter has been
aired, the resolution might be withdrawn. On the other hand, however,
if we vote on the resolution we put ourselves on record as either
approving of or opposing its principle. If I may be allowed to offer a
personal opinion, I should think the better course would be to
withdraw the resolution, seeing that the matter has been at least
commented upon.

Dr. HILL: Subject to your ruling, Mr. Chairman, I would suggest that a
substitute resolution be entertained to the effect that it is the
sense of the conference that this matter be referred to the individual
faculties of medicine throughout Canada, to be dealt with as they see
fit.

The CHAIRMAN: That would be an amendment to the resolution before the
chair.

Dr. AMYOT: I would second that motion.

Dr. J. C. CONNELL: As a matter of procedure, no resolution of this
kind should call for a divided vote. I recognize the advisability of
withdrawing the resolution, and I am prepared to accept that
suggestion.

Dr. LOW: I would move that the resolution be laid over for further
discussion at the next conference. It might be desirable to take the
matter up on some future occasion.

The CHAIRMAN: That is really the effect of Dr. Connell's suggestion.
With the consent of the seconder, the motion is to the effect that the
resolution be withdrawn, and that further consideration of the whole
matter be deferred to the next annual conference.

Dr. THORNTON: Seeing that the mover and seconder of the resolution are
willing to withdraw it, I suggest that the whole discussion of this
question be deleted from the official record, so that the printed
proceedings will take no cognizance of what has been said on the
subject.

Dr. CRUIKSHANK: I am not sure that such a course could be followed
after the publicity which the matter has received.

Dr. REHFUSS: If it did not appear in the official record that action
had been taken in regard to the matter, the silence of the report on
this particular point would be an argument against the press statement
which has rather exaggerated the sentiment of the conference on the
whole question. I am inclined to agree with Dr. Thornton. If the
discussion on the subject were omitted from the official report, the
resolution would disappear and the press would be placed in the
position of having exaggerated the matter.

The CHAIRMAN: I do not think we should be in order in adopting such a
course. This matter was on the programme, it was announced from the
chair, a paper was read on the subject, and it was referred to the
Resolutions Committee. It seems hardly proper to delete the discussion
which has taken place on the question. That is merely my opinion. It
does seem to me, however, that the proper thing to do would be to
stand by what we have done. I think Dr. Connell's sugges
tion is the right one; it would be well to withdraw
the resolution.

Resolution withdrawn.

_Resolution No. 2._

     Whereas in each province the act requiring registration
     of all medical practitioners was passed to ensure
     safety to the public by protecting them against
     unqualified individuals, many of whom advertised
     themselves as doctors or practitioners, or otherwise
     unwarrantedly presume to indicate an ability to treat
     disease;

     Therefore be it resolved that the attorney-general in
     each province be urged to enforce the laws of the
     province with respect to irregular practitioners.

Resolution agreed to.

_Resolution No. 3._

     Resolved that the Conference on the Medical Services of
     Canada in session assembled at Ottawa on December 20,
     1924, records its warmest approval of the proposal that
     the federal Department of Health issue regulations in
     regard to the potency of such drug stuffs as require
     physiological standardization, namely, arsphenamine and
     its derivatives, digitalis, pituitary extract and
     adrenalin, and urge that all such drugs exposed for
     sale as standardized products should be approved by the
     Department of Health at Ottawa before being sold, and
     further, that the conference expresses its
     gratification that the Department of Health proposes to
     provide the requisites for the adoption of this policy.

Resolution agreed to.

_Resolution No. 4._

Moved by Dr. A. C. Jost, seconded by Dr. H. E. Young:

     Resolved that this conference suggests to the Canadian
     Medical Association the advisability of calling
     attention, through the provincial and branch societies,
     to the importance of bringing about the more accurate
     reporting of notifiable diseases, and, toward that end,
     the adoption of such courses of action as to each
     provincial medical society seems most advisable.

Resolution agreed to.

_Resolution No. 5._

     Resolved that the federal Department of Health be
     requested to undertake a comprehensive inquiry in
     regard to maternal mortality in Canada.

Resolution agreed to.

The CHAIRMAN: Is there any further business for the consideration of
the conference?

Dr. S. L. WALKER (Halifax): One thing has occurred to me during these
three days, and that has been the excellent manner in which the duties
of chairman have been carried out by Dr. Primrose. Without saying
anything further, I beg to move that this conference place upon its
records its cordial appreciation of, and its sincere thanks for the
services which Dr. Primrose has given in his capacity as chairman of
the proceedings of this conference.

Dr. THORNTON: I have pleasure in seconding the motion.

Motion agreed to.

The CHAIRMAN: I hope that both the mover and the seconder of the
motion, as well as members of conference, will accept my thanks.

Dr. CRUIKSHANK: Would it not be wise to express the formal
appreciation of the conference of the action of the Minister of
Railways and the Minister of Health in facilitating the proceedings of
the conference?

The CHAIRMAN: That is being done by the Executive of the Canadian
Medical Association on behalf of the conference.

This concluded the proceedings.


REPORT _of the_ CONFERENCE

_on the_

MEDICAL SERVICES IN CANADA

HELD AT

OTTAWA, DECEMBER 18, 19, 20,

1924

_Issued by_

Department of Health, Canada

Ottawa


Transcriber's Notes:

1. page 10--corrected 'Satistical' to 'Statistical'

2. page 11--corrected 'geater' to 'greater'

3. page 11--corrected 'Instiute' to 'Institute'

4. page 15--corrected 'collosal' to 'colossal'

5. page 16--removed first line from paragraph starting under heading
  'Canadian Activities' as being a repeat of a sentence from 3 paragraphs
   previous. Replaced with interpolated words [Several courses regarding
   matters of public...]

6. page 20--corrected 'wth' to 'with'

7. page 23--periods in number 45.000.000 changed to commas

8. page 24--corrected 'adminstration' to 'administration'

9. page 35--corrected 'viewpoiint' to 'viewpoint'

10. page 36--corrected 'discusson' to 'discussion'

11. page 38--corrected 'Aikins' to 'Aikens'

12. page 39--corrected 'permittted' to 'permitted'

13. page 48--corrected 'Unversity' to 'University'

14. page 58--corrected 'dstricts' to 'districts'

15. page 58--corrected 'pateient' to 'patient'

16. page 69--corrected 'quality' to 'qualify'

17. page 74--corrected 'cmmitte' to 'committee'

18. page 74--corrected 'volutary' to 'voluntary'

19. page 76--corrected 'out' to 'our'

20. page 76--corrected 'practioners' to 'practitioners'

21. page 79--corrected 'excedingly' to 'exceedingly'

22. page 81--corrected 'our's' to 'ours'

23. page 82--corrected 'thees' to 'these'

24. page 83--corrected 'In' to 'It'

25. page 83--corrected 'adquate' to 'adequate'

26. page 97--corrected 'especiallly' to 'especially'

27. page 99--corrected 'obstetries' to 'obstetrics'

28. page 101--corrected 'posteriror' to 'posterior'

29. page 104--corrected 'discontined' to 'discontinued'

30. page 107--corrected 'practioners' to 'practitioners'

31. page 112--corrected 'no' to 'do'

32. page 116--corrected 'subjets' to 'subjects'

33. page 127--corrected 'incentitives' to 'incentives'

34. page 130--corrected 'electrcity' to 'electricity'

35. page 137--corrected 'puchased' to 'purchased'




[End of _Report of the Conference on the Medical Services
   in Canada held at Ottawa, December 18, 19, 20, 1924_]
