Hospital Problems in Peace and War

THE PRESIDENT: Gentlemen, and Listeners on the Air: It is an honour and a pleasure to introduce the guest-speaker of today, an honour which is emphasized by the prominence of the degrees and positions held by him, in the medical profession.

Dr. Frederick G. Carter, Superintendent of St. Luke's Hospital in Cleveland, Ohio, one of the largest in that State, has had a noteworthy career in medicine, holding at times the Presidency of the Minnesota Hospital Association,--the Ohio Hospital Association, and the American College of Hospital Administrators, and he has now received the signal honour of appointment to the office of President-Elect of the American Hospital Association. He is a Fellow of the 'American College of Hospital Administrators, and holds his degree of M.D. from Johns Hopkins University Medical School, which institution is of much interest to Canadians in view of its past administration, and his A.B. from the University of Wisconsin. Dr. Carter is attending the 41st Annual Convention of the American Hospital Association and Allied Societies held in Toronto this week.

The subject matter of Dr. Carter's address is of prime importance to humanity, not only in times of peace, but in conservation during war. I take much pleasure in introducing Dr. Frederick G. Carter, who will speak on "Hospital Problems in Peace and War". (Applause)

F FREDERICK G. CARTER, M.D., A.B.: Mr. President, Members and Guests o£ the Empire Club of Canada: I want to assure you that it is a very great pleasure to have this opportunity of appearing before you today to talk to you about some of the things that are going on in the hospital section of the social structure. I come to you today as a representative of the American Hospital Association, although I must confess that after the strenuous week that we have had I am not clear in my own mind, or even my own thinking, as to whether I am a representative or an exhibit. At any rate, I bring you the greetings and good wishes of the hospitals of North America. Let us hope that your lives may be so ordered that you may never have use for our ministrations at a future date. As men interested in affairs of life in general, some of you may want to know a little about the things that are going on in our particular segment of the social structure.

As many of you know, Toronto, this week, was to have been the capital, so to speak, of the hospital world, but events have transpired which have made it impossible for many representatives of other continents to meet with us to discuss hospitals and hospital problems. The war clouds which have been gathering for several years now have reached the storm stage and the world is confronted with a great conflict which inevitably must bring the type of institution which I represent into a kind of prominence which none of us enjoy. The deliberations which we have looked forward to with so much pleasure are tinged with a note of sadness for our mission in life is to bring peace, comfort, freedom from pain, and joy in living to those who suffer and are in need. Our field of action, as a matter of fact, represents the very antithesis of war. Yet when war comes, as it has to you, I think you will find that the hospitals will not be found wanting. Our philosophy, I think, is pretty well expressed in a little poem. The author's name has slipped my mind, but it seems to me it is quite applicable to the situation we all find ourselves in:

'Tain't no use to grumble and complain, It's just as cheap and easy to rejoice, For when God sorts out the weather and sends rain, Then rain's my choice, We take as much pride as you do in the fact that one of your illlustrious citizens of Toronto, Dr. G. Harvey Agnew, is the esteemed President of the American Hospital Association. He has worked untiringly and unceasingly for the success of the series of meetings which we are holding here this week, and our experiences in these meetings are going to result in a very definite enrichment of our lives in hospital work.

I cannot allow the occasion to pass without voicing the gratitude that we all feel is due the citizenry of Toronto for the splendid reception which is being accorded us. We all know too well that the staging of a convention of the proportions of the one we are attending is a gigantic task, requiring many months of arduous preparation. We know, too, that in this case the work has been made doubly difficult by the intervention of war. Our hearts and our sympathies go out to you as they do to the peoples of all nations involved in this great crisis. That your citizens should have carried on with their plans for our entertainment under the circumstances is certainly a tribute to their solidity and their mental balance.

When I think of war I am reminded of a little Norwegian story that has an application in our lives that it seems to me is quite worth while. I don't know how many of you men have children but all of you have had experience with children, seven, eight, ten or twelve years of age. Maybe some of you have attempted to entertain a child on a rainy Sunday afternoon when you wanted to read the newspaper or a magazine, or have a sleep. Little Alfred was such a boy and he was being entertained by his father on a rainy Sunday afternoon, or he was supposed to be entertained by his father, who also wanted to read a magazine in which he was very much interested. The boy kept coming back for new things to do and finally the father cut a map of the world from his magazine in small pieces and said, "Here, Alfred, you take this and take it over to the library and put it all together. That will keep you busy for the rest of the afternoon." In about fifteen minutes they called, "Daddy, it is all together. Come over and ook at it." Daddy came over to the library and, sure enough, here was the world all put together, the mountains, the oceans and the seas and what-not all in place. He said, "Well, Alfred, you must be pretty smart in geography. You know a lot." Alfred said, "You know, Daddy, this was easy. I saw you taking the map out of the magazine, and I knew on the back of the map there was a man and I knew if I put the man together and fixed him up and made him right that the world would be all right. I turned it over and sure enough the world was all right." I think there is a philosophy in human relationships and human accomplishment in that story that is quite worth while.

Josh Billings expressed certain convictions about people in general when he said, "It ain't so much the ignorance of people that causes all the trouble in this world, it is their knowing so damned much that ain't so." I think you will realize from the things that have been going on in Europe that a great many people in Europe are believing things that aren't so, and have believed things that aren't so, and consequently our whole pattern of human relationships is affected by people who are believing things that aren't so.

But I am here to discuss current hospital problems. You know the term "hospital" in our day has come to have a far different meaning than it did prior to fifty years ago. We have learned so much about the care of the sick and injured, and about disease prevention, that institutions specializing in this field have become an absolute necessity.

I haven't liked the word "specializing", or the term "specialization, since I heard Dr. Morris Fishbein describe the specialist. Perhaps you have heard his description of the specialist as "an individual who knows more and more about less and less". If you follow that through to the logical conclusion eventually you get the person who knows everything about nothing. I wouldn't like to see that term applied to hospitals, having to do with the treatment and prevention of disease.

We have come to recognize more specialized institutions as hospitals. Up to fifty years ago or perhaps even less, hospitals attempted a blanket coverage of the entire field of charity. The Hotel Dieu, which is celebrating its Moth year in Quebec is one of the fine examples of the hospitals that attempted a blanket coverage of the field of charity, and that now restricts its efforts to the specialized type of thing I have been talking about.

In this transition from the hospital of the broad coverage of the field of charity to the more restricted institution we have provided a much more efficient method of caring for the sick, but with improvements have come complications. As medical care has become more and more complex it has become more and more costly and one of our great problems is to keep hospital costs down within reach of the largest possible number of people. This has become increasingly difficult because of dwindling philanthropy, decreased income from endowments, and increasing unemployment resulting in decreased ability to pay.

To fill the breach we have relied upon government subsidies of one kind or another in recent years, and in many instances community fund support has been very helpful. We have combed our business methods for economies. Hospital insurance, by whatever name we choose to call it, has mushroomed up, particularly in the last five years, to cover the hospital needs of about three and one-half million people on this continent. As most of you know, this is a scheme which, for small monthly payments, insures people against the hazards of hospitalization. Perhaps there is no real solution to our financial problems, but this insurance plan seems to be about the closest approach that we have thus far experienced. In Cleveland, my home city, about one-fifth to one-sixth of our income in hospitals comes from this source.

Then, too, people in general seem to be growing more and more conscious of the values inherent in hospital service in times of illness. Perhaps hospital insurance is stimulating this interest. At any rate, the utilization of hospital facilities appears to be on the increase. This trend brings us face to face with the problem of extending the scope of our efforts through new construction and modernization of old construction.

Medical practice is changing rapidly and the hospital becomes more and more essential to the type of practice which is developing. It is the one place where all of the intricate techniques of modern practice may be assembled and utilized to the greatest advantage. Efficiency in production in any field results from the strategic assemblage of materials, labour and tools. We haven't reached perfection in these details yet. We have made it possible to bring together the materials and tools but part of the labour is still not efficiently utilized. Doctors still maintain private offices in detached locations and treat their patients in many hospitals. In their physical plants hospitals must eventually arrange to serve the medical profession better by helping them to concentrate their work in and around hospitals without in any way usurping the rights and privileges of the medical profession.

I think it might be well to state my firm belief that hospitals have no desire whatsoever to impose their ideas on the medical profession in this regard. The only function of a hospital, so far as the profession is concerned, is to serve that profession. We are the work-shops of the medical profession and we want to do everything we can to help them in the problems with which they are confronted.

Modern transportation has made it possible to construct hospitals of sizes that may be operated most efficiently. Motor ambulances move patients comfortably and safely to points where they may be cared for efficiently. In the State of Iowa the university hospitals of Iowa City maintain about twenty-five ambulances which are on the road every day bringing patients to Iowa City from all corners of the State. This arrangement is not without its drawbacks, however. In North Carolina we find the very opposite situation, the Duke Foundation having erected, or being interested in the erection, of many small rural hospitals over the state to care for patients in locations relatively near their homes. The authorities down there hope, too, that their programme will be the means of attracting competent doctors to rural practices by offering them first class hospital facilities in the rural sections. Both ideas have merit-the one typified by the University of Iowa, and the other by the rural hospital scheme in North Carolina. We also have a number of educational jobs to look after. Where will our supply of nurses come from if we do not offer our facilities for use in the education and training of this group? Doctors, too, look to us for a large part of their training after graduating from the medical schools. Dietitians, social workers, laboratory technicians, and many others continue to depend on us for their instruction and experience. Perfection in the treatment of sick people does not come from text books. It comes from contacts with sick people who are to be found in greatest concentration in hospitals, and these are the places where people must be trained to care for the sick.

A somewhat different facet of the educational problem has to do with the enlightenment of the public as to health matters. In this connection we hear much these days of publicity programmes. Hospitals must be alive to the importance of good publicity. We don't want to misunderstand our purposes in maintaining strong publicity programmes in hospitals. We do not have in mind the putting of two chickens in every pot, or two cars in every garage, or two appendixes in every belly. In our publicity programmes we merely wish to make the public acutely aware of the many good things we can do for sick people. We want to teach them to come to us without fear or prejudice, and leave us feeling that everything possible has been done to make them as good as new, and those are the only motives we have in our publicity programmes.

It is only in recent years that we have learned that we are using more intelligence in buying a can of beans than we were in buying labour. From twenty-five to fifty percent of our expenditures go into commodities, equipment, and things of that nature. We reason that this money .must be spent wisely so we hire purchasing agents to study our needs, draw up careful specifications covering these needs, follow up their purchases to be certain that we get what we bargained for, and that the items purchased best fit the conditions under which they are used. The remaining fifty to seventy-five percent of our expenditures go into salaries, yet, it is only recently that some of us have come to realize that we must use as much diligence and care in fitting people to jobs as we do in fitting foods to jaded appetites. We are fast setting up personal departments in our institutions to do the thing in the labour market that the purchasing agent does for us in the commodity markets.

I haven't made mention of some of the problems arising out of our relationships with the various units of government, for the reason that these relationships differ quite markedly in your country from those obtaining in my country. Across the boundary I am quite certain that all of us might welcome governmental assistance if ways and means can be worked out of freeing us of the threat of concurrent political sabotage of our institutions and our ideals. With reference to the part the government may play in hospitals, it seems to me that many of us are very, very prematurely taking the view that the government is going to take over the hospitals and before long there will be no voluntary hospitals. I think that that idea or that thought is very premature. It seems to me that the time when the government may interest itself in hospitals to that extent is very distant, indeed. We are all very appreciative of the efforts that are being made in voluntary hospitals and the efforts that have been made in the past to take care of the hospitalization problems of the people, both in Canada and in the United States.

No doubt all of you will agree that we have enough to worry about in the hospital field, without any additions to our burdens, but now we find that complications have set in. What is going to happen to our institutions?

It may interest you to know that no later than last Saturday, the Board of Trustees of the American Hospital Association spent the greater part of the day discussing the preparedness and the place of hospitals in the war picture, regardless of whether the hospital is located in warring or neutral nations. In that meeting we also called attention to the fact that the American Hospital Association and other Hospital Associations-the Catholic Hospital Association and the Protestant Hospital Association-all of these organizations recognize their obligations to their Canadian members as being fully as binding as their obligations to the members of the United States. We are an international association and we have many members in Canada, as well as the United States, and there are many things we can do for our members in both countries, and we fully intend to carry out our obligations in respect to our members in those countries.

Quite naturally the effect of the war upon member hospitals of our Association will depend to a great extent upon whether or not the country in which a given institution is located is a belligerent or a neutral country, but in either case there will be very definite and positive effects. I suppose, in present day parlance, those terms are all wrong. Perhaps they are somewhat medieval. We used to think nations at war would say they are at war, and those not at war would say they weren't. At any rate, at the present time we have a belligerent nation that tells the world it is at war and other people, too, regard it as being at war. We have perhaps neutrals who recognize the fact they are not at war, and do not hesitate to say they are not at war. We have the type of nation that is supposed to be neutral which has certain inclinations, one way or another, that are friendly toward certain situations. That gives another classification of those who are supposedly neutral. Then, we have what we call brigands or thugs who shoot without warning and construct their own code of conduct as they go on. Then, I think we have a finer classification in this picture-the vultures, who wait around until the kill and then step in to get all they can get out of it. I am going to be old-fashioned and talk about the neutrals and the belligerents.

If we remain neutral we are likely to find our financial picture complicated by the higher prices which prevail in war time. This is particularly true of surgical instruments and scientific equipment, much of which is imported from abroad. Interruption of trade channels with both neutrals and belligerents curtails supply, increases demand, and prices rise. There is much greater demand for our domestic products because of the fact that large proportions of those -normally engaged in peace time pursuits in warring nations are occupied with military, naval or air activities. Thus we compete with foreign buying power even for domestic goods of all kinds.

Our peace time practices are changed by the constant threat of war and the possibility of becoming a belligerent nation. Preparedness means sweeping changes in our educational programmes for doctors, nurses, and others. We have been talking about that sort of thing this week, what we are going to do in the United States if we get in the war, and some of the things that Canada is already doing. When war threatens, young men and young women are inclined to desire preparation for medical and nursing service in much greater numbers than they do in normal times. This may result in an over-production of personnel for these professions which later reflects itself in the postwar civilian economy.

Clerical details increase because of numerous governmental inquiries. Test mobilization procedures interrupt normal schedules of activity.

These are just a few suggestions as to the effects of a major war upon civilian hospitals in a neutral country. All of these effects and many others, too, are operative in a country at war. Hospitals must learn to operate with restricted personnel in order to free as many skilled people as possible for service in military and naval hospitals. I sincerely hope that in this war we won't make the mistake that we made in the last war, in taking the personnel of hospitals for military service, without regard to what we are doing to the hospitals whose personnel we are taking for war purposes. I believe that all of us are conscious of that particular weakness in the last war and we are going to see that it doesn't occur in this war. The Canadian Hospital Council meeting last week had this problem very much before it.

Hospitals must accelerate their educational and training programmes in time of war, in order to furnish replacements in the military medical service. The type of training

must be adapted to military needs. Here is something that seems quite important. In war time we can give a whole lot more thought to the question of reviving dormant skill. Many nurses have given up the nursing profession, perhaps have married and have homes of their own, and we will have to give a great deal of attention to the revival of the dormant skills. Civilian hospitalization must be sidetracked as far as possible in order to free beds and other facilities for military and naval casualities. I say sidetracked, but of course there are many problems from the civilian standpoint that will have to be taken care of through and after the war. Hospitals will have to use substitutes for many of the supplies formerly used. Any of you who had surgical experience in the last war will recall the crepe paper bandages which just wouldn't stay put under any circumstances. That is an example of the type of substitution we encounter in war time and the things which we may again encounter during this period which we are going through at the present time.

Hospitals must continue with programmes of research. You will recall that quite a number of practices and procedures in the development of new drugs and biologicals came out of the last war. Food conservation becomes a necessity. Techniques must be speeded up, revised, and new ones developed. I think the orthopaedic branch of surgery got a great impetus in the last war with new methods of taking care of injuries of all kinds, and the orthopaedic surgeon, with his knowledge of bone pathology and bone structure came right to the fore.

They also developed acclimatic service. Dr. MacEachern, who sits at my right, is very much interested in acclimatic service in hospitals throughout the country, and it has reached a degree of perfection not known at the time preceding the Great War. The handling of fractures is a totally different matter than it was at that time.

We should not overlook the matter of post-war adjustment, because a war does bring tremendous changes which may affect the lives of many generations to come. There can be little doubt that following the last war the centres of medical learning shifted from Europe to the Western Hemisphere. We find now in our hospitals and medical schools many visitors from European and South American countries, coming to us in Canada and the United States to learn the methods being used in these countries. I think there can be little doubt, too, that the war may be credited with the birth of a very great chemical industry on this continent, formerly centred pretty much in Germany. This shifting about of peace time pursuits determines the destinies of many nations and perhaps is more important in shaping the course of history than the immediate effects of changes in territorial boundaries. I might call your attention to the fact that should the time come when we in our country come into the war, and whether we do or not we must prepare for any eventuality whether it occurs or not, we have a tremendous amount of factual material on hand that we may use to enable us to organize our resources in the hospital field very rapidly. The College of Surgeons alone, in its office in Chicago, has some 50,000 records of investigations and surveys of hospitals in the United States of twenty-five beds or over. We know what our personnel is. We know what our physical equipment is, and many of these peace time activities are going to be of great help to us in any preparedness programme we may undertake.

I could talk to you at great length about preparedness in civilian hospitals, of the things we might do. I have only intimated some of the things we have been talking about here in Toronto in a very brief way, but the time is short and rather than proceed further with any discussion, I would like to say in conclusion, and point out to you that hospitals demonstrate a way of life and a philosophy of human relationships that are worthy of emulation. No hospital is sufficient unto itself. I think it is fair to say that the hospitals of North America and the hospitals of Canada and the United States have not developed as groups, independent and apart from the rest of the hospitals of the world. All of us in the hospital field have borrowed and imitated, and we like to think that we have also contributed to the end that sick people everywhere may have the benefit of collective thinking in all languages about the problems of health and disease. Throughout the universe we have felt that we have established bonds of friendship and mutual helpfulness which transcend and overshadow the barbarism and petty bickerings of better known types of international relationships. It seems to me there is a cosmopolitanism about hospitals and hospital activities, wherever they are, that the world might note with profit.

I am very grateful to you for having listened to this discussion of hospitals and I hope in any consideration of the needs and interests of hospitals in Canada that you will put your best thought on both the civilian and military problems, and above all, that you will not lose faith in the voluntary hospitals of Canada, which have been the backbone, perhaps I might say, of the work in this country, just as they have in the work of our country. (Applause)

THE PRESIDENT: Gentlemen, the Honourable Dr. Herbert Bruce has kindly consented, on your behalf, to extend our thanks to Dr. Carter.

HON. DR. HERBERT A. BRUCE: Mr. President, Gentlemen: Those who are laymen here I am sure have listened with a great deal of interest to the excellent account of what hospitals are doing not only in America, but in Canada, and all over the world, in the alleviation of the sufferings of the sick. We are, therefore, very grateful to Dr. Carter for his very splendid address.

Dr. Carter has spoken about co-operation between medical men and surgeons in different countries of the world, and it just recalls to me a memory of what the United States medical men did in the last war. Long before America came into the war, they sent medical men to join the British Medical Service in France, and help them in their work there. I recall that when I went to France in 1917 as a consulting surgeon, one of the hospitals in my area was situated in Etats, and it was staffed entirely by the Presbyterian unit of New York. Dr. Darragh was the Chief-of-Staff. Dr. Brewer also was connected with that hospital, and a number of other very distinguished men, whose names would be well known to all of you. They took over a British hospital there and relieved them of their entire duty, both professional and nursing. It was a very large hospital of about 1500 beds. In addition to that many surgeons came over from America. Some of the leading surgeons, notably Dr. Harvey Cushing, were attached to the British hospital, and in an area where he was very much needed he performed his splendid work in connection with injuries of the head and brain. Dr. Crile also came over and was attached to the British hospital at Rouen. Dr. Brewer served in France for a long time before the United States came into the war.

Early in 1918, the medical men in France were very hard worked. The resources of the British Medical Service were strained to the utmost and it was necessary to get more surgeons. I was asked to come on a mission to America, accompanied by Sir William Arbuthnot Lane, and Sir James MacKenzie. We went first to Chicago and attended the meeting of the American Medical Association, and I attended the meeting of the American Surgical later on in Cincinnati. We spoke there and in many cities in the United States, with the object, first, of interesting the people in what was going on in France and, secondly, in the hope that we would stimulate more medical men to join the service and come over and help us. As a result of our visit, under the kindly, benevolent leadership of the late Dr. Franklin Martin, we visited many cities, and one hundred American surgeons joined up and went overseas. I have no doubt that the United States will co-operate with us and with England and France in a medical way to the fullest extent possible, even though that great Republic may for a period avoid being involved in this way.

We are very proud of the fact that we have had in the position of President of this organization one of our distinguished Canadians, Dr. Harvey Agnew, and that you are succeeding him, Dr. Carter.

I see at the head table today, an old friend, Dr. MacEachern, formerly of Vancouver, and one of our very distinguished medical men who has been doing splendid work in Chicago in connection with the American College of Surgeons, first as a co-Director with Dr. Franklin Martin, and now as a Director. I don't know who he is co with now, but I am sure he is pretty well running the show, himself. We are very proud of the work that he has done for hospitals and for medical men on this continent. I want to express your thanks, Gentlemen, for the splendid address which Dr. Carter has given us today and to wish him the best of luck in his work for this Association during the coming year. (Applause)

THE PRESIDENT: I just want to express on your behalf our appreciation of the number of distinguished medical guests we have at our head table today.

The meeting is adjourned.