Doing Good : The Life of Toronto's General Hospital [1 ed.] 9781442621091, 9781442657755

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DOING GOOD The Life of Toronto's General Hospital

A history of Toronto's general hospital offers a window on a broader history of Upper Canada and Ontario over the last two centuries. In this lively and authoritative account, J.T.H. Connor traces the hospital's two-hundred-year evolution, as its mandate to 'do good' forced constant adjustment to changing social, medical, and government attitudes. Doing Good presents the hospital's history in three phases - roughly speaking, the first and second halves of the nineteenth century, and the twentieth century. From its conception in 1797 to the mid-1850s - it did not actually acquire a home until 1819 nor occupy it until 1829 — it functioned as a charitable institution, catering to the sick poor. It acted initially as a clearing station for sick immigrants; it later was deeply affected by political events and became embroiled in the medical turmoil of Toronto in the 1840s and early 1850s. In the second era, from the mid-1850s, it was a public charity, receiving stable government funding and constructing a new home in eastern Toronto. By the 1870s, it was winning praise as a model hospital. In the twentieth century, it early on established close links with the University of Toronto, building a vast and up-to-date new facility adjacent to the university, which opened in 1913. Its international reputation as an academic hospital grew over the decades to include a high profile in research, most notably in cancer and medical technology. By the 1960s the institution was being run as a public hospital, and the late 1990s saw its absorption into a hospital mega-corporation — the University Health Network - along with three other nearby hospitals. This work is the most comprehensive analysis of any Canadian hospital or health care institution yet to appear. Using trustees' minutes, medical journals, newspapers, and government reports, along with correspondence, photographs, and reminiscences of trustees, nurses, doctors, and patients, Connor offers acute observation and detailed analysis, as well as compelling character studies and revealing anecdotes. Broad in scope and meticulously executed, Doing Good brings vividly to life the day-to-day routines, the behind-the-scenes intrigue, and the people and politics of a great urban hospital. J.T.H. CONNOR is Assistant Director at the National Museum of Health and Medicine of the Armed Forces Institute of Pathology, Washington, D.C.

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DOING GOOD The Life of Toronto's General Hospital

J.T.H. Connor

UNIVERSITY OF TORONTO PRESS Toronto Buffalo London

> University of Toronto Press Incorporated 2000 Toronto Buffalo London Printed in Canada ISBN 0-8020-4774-2 (cloth)

Printed on acid-free paper

Canadian Cataloguing in Publication Data Connor, James Thomas Hamilton, 1952Doing good : the life of Toronto's General Hospital Includes bibliographical references and index. ISBN 0-8020-4774-2 1. Toronto General Hospital — History. I. Title RA983.T6T59 2000

362.i'i'097i354i

0)0-931841-0

University of Toronto Press acknowledges the financial assistance to its publishing program of the Canada Council for the Arts and the Ontario Arts Council. University of Toronto Press acknowledges the financial support for its publishing activities of the Government of Canada through the Book Publishing Industry Development Program (BPIDP).

Contents

FIGURES AND TABLES PREFACE

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ix

Introduction: A Social and Political Barometer 3 Part One: Providing for the Sick Poor, 1797-1856 / A Hospital for Muddy York -Eventually, 1797-1840

15

2 Medical Politics, Political Doctors, and a Beleaguered Hospital, 1841-1856 44 Part Two: A Public Charity, 1856-1903 3 New Quarters, New Status, 1856-1875 4 A Model Hospital, 1875-1903

81

120

Part Three: A Major Academic Hospital, 1904-2000 5 Millionaires, University Doctors, and Their Hospital, 1904-1930 6 An Evolving Urban Complex, 1930-2000

214

165

vi

Contents Conclusion: Holding It Together

NOTES

271

ILLUSTRATION CREDITS INDEX

255

329

331

Illustrations Follow Pages 116 and22O

Figures and Tables

Figures

2.1 Conditions treated, Toronto General Hospital, 1847-55 58 2.2 Types of fevers, Toronto General Hospital, 1847-55 59 2.3 Causes of death, Toronto General Hospital, 1847-55 60 3.1 Receipts and expenditures, Toronto General Hospital, 1841-56 83 3.2 Expenses, by category, Toronto General Hospital, 1841-56 84 3,3 Patients' nationality, Toronto General Hospital, 1870-5 108 4.1 Revenues, Toronto General Hospital, 1876-1903 145 Tables 2.1 Patients' place of birth, Toronto General Hospital, 1847-55 56 3.1 Salaries of employees, Toronto General Hospital, 1870-1 98 3.2 Patient profiles for hospitals in Ontario, 1870-1 101 3.3 Receipts for hospitals in Ontario, 1870-1 102 3.4 Patient profile, Toronto General Hospital, 1870-5 109 5.5 Consumption of medicinal beverages, Toronto General Hospital, 1869-70 no

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Preface

So many Torontonians have personal connections to their city's general hospital because they were born or were treated in it; others were trained or worked there. As a non-Torontonian and a relative newcomer to the city I had no personal memories or direct experience of the hospital; indeed, my only connection with it was chairing numerous meetings to facilitate the transfer to the hospital of the extensive artefact and historical library collections of an ailing Toronto Academy of Medicine. None the less, when I was approached in 1998 to write a history of Toronto's general hospital it was obvious to me that this was an opportunity to contribute further to the understanding of the development of health care in the city and in Canada. I set a goal of preparing an authoritative and scholarly account of the hospital's evolution, aiming to present it in as engaging a way as possible. I also wanted to convey to all who read the book, be they historians, health care workers, or general readers, just how interconnected the hospital's history is with that of the society that surrounds it. These aims were endorsed by Dr Alan R. Hudson, then the hospital's president and chief executive officer; I wish to acknowledge his vision in supporting this project. Scholarly authors often draw attention to the long gestation periods for their books - up to a decade is not unusual. I did not have the luxury of such an extended period to reflect on the scope and design of this study; I planned, researched, wrote (and rewrote), and produced this book in two years. That this project could be completed so quickly is the result of several factors. The provision of spacious and congenial quarters in the hospital was invaluable, allowing me to establish my own historical research laboratory. Although, owing to my varied professional

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Preface

experience, I am no stranger to the world of medicine, working in a hospital again put me in touch with its corporate culture: hallway exchanges between staff, cafeteria chatter, and institutional events and ceremonies. Often, too, my thoughts about past eras were jolted back to the present when I heard the announcement of a 'code blue' over the public address speaker, alerting us all that somewhere in the hospital a patient was in cardiac arrest, or when I shared an elevator with patients such as a man whose chest displayed a long, fresh surgical scar. These occasions were constant reminders of the human dramas that take place within the hospital. While never a direct participant in any of these events, I nevertheless became an informed observer of them, which I know assisted in the writing of this book. That my office was located in one of the older parts of the hospital also aided in the timely completion of this book. On one occasion two people wearing construction hard hats entered the room to take its measurements. They informed me that they were part of the team involved in the imminent demolition of the building to make way for a new hospital structure. This incident sharpened my contention that hospitals are never static institutions; they are constantly reinventing themselves and discarding parts as they become obsolete. The seeming likelihood of a wrecker's ball smashing through the walls around me also underscored the need to write speedily. Suddenly, my publication deadline became even more meaningful! This project also could not have been completed without the help of many friends, colleagues, and others. I wish to thank within the University Health Network, in addition to Alan Hudson, Gloria Bishop, vicepresident for public affairs and communications, and her predecessor, David Allen. Other past and present hospital staff members who assisted me include Ani Orchanian, Josey Panetta, Felicity Pope, Kathryn Rumboldt, Bogusia Trojan, and Kate Zeidman. Several people took time out of their own busy research and writing schedules to read early drafts of the manuscript and to offer useful suggestions; I am extremely grateful to Michael Bliss, Gina Feldberg, Bob Gidney, Jean Harris, Wyn Millar, and David Naylor. Most of these people also directed me to valuable source material, as did Martin Friedland, whose forthcoming history of the University of Toronto will complement my study of the university's main teaching hospital. I also wish to acknowledge those who assisted me at the Archives of Ontario; City of Toronto Archives; Special Collections, Toronto Reference Library; Thomas Fisher Rare Book Library,

Preface

xi

University of Toronto; and the National Archives of Canada. I especially wish to thank the efficient and helpful staff at Queen's University Archives. While writing this book I enjoyed the privileges of being a visiting research associate at the Institute for the History and Philosophy of Science and Technology, Victoria College, University of Toronto. I thank Trevor Levere and his successor, Janis Langins, who, as institute directors, made this affiliation possible. Thanks, too, to Muna Salloum and Bill (Zag) Zaget for the many courtesies they extended to me. Because of my connection to Victoria College I was successful in procuring an internal grant that allowed me to travel to Queen's University to examine the voluminous papers of former hospital board chair Sir Joseph Flavelle; this modest investment in the project reaped great historical dividends. (That the funds of a former Methodist college were put to use in this way probably would have greatly pleased Flavelle.) To Gerry Hallowell, Jill McConkey, John Parry, the anonymous manuscript reader, and everyone else associated with University of Toronto Press who assisted in the prompt production of this book, I offer my thanks. Many of the illustrations in this book are from the archival or public affairs photographic collections of University Health Network; I extend my appreciation to Allan Connor and the staff of the audio-visual department of Princess Margaret Hospital for their skilful technical assistance. Finally, I am eternally indebted to my partner and colleague, Jennifer. Although this book bears my name as author, from the project's inception it was a team effort. Without her prodigious research assistance and her unerring editorial knowledge, as well as her unflagging support in so many other ways, I would not have been able to achieve what has been accomplished in the last couple of years, (And all of this while she was completing another book of her own.) Only she truly knows the obstacles that we had to overcome during this period of our lives.

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DOING GOOD The Life of Toronto's General Hospital

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Introduction: A Social and Political Barometer

The Toronto General Hospital stands amid the bastions of power in one of the largest cities in North America. A stone's throw away lies Bay Street, Canada's equivalent to Wall Street and the hub of economic power in the country. Just north sits Queen's Park, site of Ontario's parliament buildings and provincial political power. The University of Toronto, the largest seat of higher learning in the country, hugs adjacent streets where banners proclaim * Great Minds for a Great Future' for in the world of academe, knowledge is power. Three architectural generations of buildings face the Toronto General, all headquarters at one time or another for the utility company now called Ontario Power Generation, which provides electrical power to the most populous and most industrialized province in Canada. The art deco image of Niagara Falls carved into the stone fagade of the middle building reminds the onlooker of the corporation's natural source of power. A host of organizations nearby signify medical power. Within steps are the College of Physicians and Surgeons of Ontario, the profession's regulatory body, and the headquarters of the Ontario Medical Association. Nearby are the main offices of the Ontario Nurses' Association. The regional laboratories for Canada's blood supply system occupy an adjacent building, the former Victoria Hospital for Sick Children. Active specialty hospitals cluster in the densest concentration of clinical facilities in Canada: the Princess Margaret Hospital (now joined with the Toronto General), the Hospital for Sick Children, Mount Sinai Hospital, Sunnybrook and Women's College Health Sciences Centre (Women's College campus), and the Rehabilitation Institute (formerly the Queen Elizabeth Hospital). In this setting, the Toronto General Hospital itself embodies physical

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Doing Good: The Life of Toronto's General Hospital

power through the size of its plant on a number of city blocks. Its board of trustees, comprising top university officials alongside some of the wealthiest, most influential members of the country's corporate elite, provides the hospital with a powerful decision-making body. The real source of the hospital's power none the less comes from something more, something intrinsic to its very purpose: its power to heal. Along with its counterparts in Western societies, Toronto's general hospital has been empowered as the cornerstone of modern health care. Everyone has experienced a hospital - its diversity of profession and occupation, of culture, gender, and class; its characteristic sights, sounds, and smells in a profusion of hallways, stairwells, pavilions, and wings where people can (and do) get lost. Yet except for its being a place of beginning, surviving, and ending life, the modern hospital defies neat institutional definition. Even an adequate portrayal would need to blend images of the private corporation, government agency, factory, school, church, grand hotel, shopping mall, and research laboratory.1 The modern hospital thus preoccupies the popular mind. In fictional accounts, the fusion of trauma with drama has supplied a staple for prime-time television over the last half-century. It is of little consequence to viewers that the heroes of Dr. Kildareor Sen Casey, the characters in ER or Chicago Hope, interact in a city other than their own, for the issues, incidents, and intrigue are of universal interest; at the same time, these shows influence viewers' perceptions of hospitals everywhere. The heroic and horrific elements of hospital life have formed the subject of feature-length films, too, while satirical accounts have portrayed the hospital as intimidating, dehumanizing, costly, and suited especially to the ambitious professional. Whether they focus on the power to heal, or on abuse or misuse of this power, their net effect is the same: reinforcement of the view that, in the public eye, the hospital symbolizes modern life.2 Because this is so, the real events that unfold in and around the hospital fascinate - and titillate - the general public. An endless stream of newsworthy material today feeds an insatiable print and broadcast journalism: clinical breakthroughs or tragedies; funding crises or philanthropic endowments; new buildings or sophisticated technology; restructuring or downsizing; the closure of hospitals or of emergency rooms; the reduction in number of beds; labour disputes or massive rehiring; the role of clinical scientists and academic appointments; the appeal for organ donors; the rare medical condition and the lifesaving treatment. But how did the modern hospital achieve such centrality in Western

Introduction: A Social and Political Barometer

5

society? This question has sparked considerable interest among scholars around the world, who see expressions of society's changing values in the activities of the hospital. Since the hospital does not operate in isolation, as Guenter Risse has shown in his magisterial book, its history brings in many external influences of religion, politics, philanthropy, education, ethnicity, technology, feminization, and the professionalization of medicine - in short, the broad trends of society at large.3 Similarly, to know Toronto's general hospital in all its current contexts, with all its current constituencies - with doctors, patients, nurses, paramedical staff, scientists, technologists, support staff, board members, and health sciences students inside; and with visitors, politicians, and media outside - is to appreciate first of all the tradition from which it, and all these contexts, grew. It was not until the eighteenth century that the hospital, as we know it, emerged. By then, its role as place of refuge had altered to one of treatment, and attendance by doctors became more frequently associated with it. In Britain, home to founders of the general hospital in Toronto, the ideal of the hospital was a beneficent enterprise. Although people went to die in hospital wards as before, many more left after their suffering was alleviated or their ailments were cured; typically under the control of the well-to-do who financially supported and ran them, hospitals therefore increased in importance by the end of the eighteenth century. The notion of charity that lay behind Christian hospices then fused with enlightened self-interest to shape a new concept of philanthropy: medicine, it was felt, would help to maintain the proper social order. People in hospital would learn deference to their social betters who dispensed medical charity. At the same time, those in power determined who deserved their charity: not the lazy or destitute; not those with chronic, infectious, or terminal disease; and, in the case of women, not the pregnant.4 Even though doctors never dominated the eighteenth-century hospital, it became an important place for them as treatment and evaluation of patients took place within its walls. It opened significant avenues for professional and social advancement by bringing middle-class doctors into routine contact with the sick poor on the one hand and wealthy hospital patrons on the other. Still, the hospital offered only a limited range of medical and surgical treatments that could just as easily be performed in the home. The nineteenth century brought real and lasting change. By its end, the hospital reinvented itself around features of its predecessors. From

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Doing Good: The Life of Toronto's General Hospital

roots in mediaeval Christian establishments, it continued its work of mercy, with late-eighteenth-century notions of charity and utility giving way to Victorian values of frugality and duty, and later, progressiveness. Medical and surgical innovations had considerable impact on the design, function, and organization of the hospital, while scientific advances encouraged its use for study of large groups of patients with similar conditions. Industrialization meant that greater numbers of lower-class people needed, or were persuaded to, obtain medical services in urban hospitals. This process of supply and demand partly explains the huge increase in number of hospitals in the nineteenth century. The nine hundred institutions for the physically ill (including workhouses) in England and Wales at mid-century expanded to over five thousand hospitals by 1920. Hospital numbers rose significantly in Canada: Ontario had just one in 1829 ~ the York General Hospital - and about seventy a century later. In the early nineteenth century there were only three hospitals in the United States; the number soared to six thousand by the early twentieth century.5 According to Charles Rosenberg, with the rise of the American hospital system in this period medicine became 'hospitalized' (centred on hospital practice) and hospitals became 'medicalized' (under greater influence of doctors) .6 Given several factors - the proliferation of hospitals, greater demand for their services by both physicians and patients, and their growing importance to medical education, to community pride, and to the economy - hospitals became much more complex to run and expensive to maintain. Western societies responded to this universal pattern in their own ways. In the United States, private or corporate interests have played a very major role; by the end of the twentieth century, American hospitals operated as businesses. In Britain and Canada, the state increasingly shouldered the financial burden. While the Canadian hospital's relationship with the state has for the most part been beneficial, shifts in political policy in the 19908 brought new demands for restructuring, downsizing, and re-engineering. The 'bad news,' declared the promotional information for one book on hospital administration, is that hospitals across North America 'are scrambling for cover from grim, cost-cutting governments and a hostile economy'; the 'good news' is that 'hospitals can reinvent themselves. Putting patient care at the centre and building from there, hospitals can achieve efficiencies that prepare them for a successful present and a promising future.'7 In this view, the twenty-first century will see the 'modern' hospital of the late

Introduction: A Social and Political Barometer

7

nineteenth century reinvented yet again to accommodate changing social, political, and economic imperatives. Canadian hospitals have been spared the excesses of American corporate hospital management. But they have not escaped entirely. Their development does suggest a rise and impact of professional hospital management and business ideology on Canadian hospitals. Yet without historical analysis of its hospitals, or even a sophisticated account of one large urban secular hospital, we do not know about these changes. As S.E.D. Shortt lamented years ago, the history of the hospital in Canada has been, to a great extent, grounded instead in internal discussion of buildings and doctors.8 Except for one or two institutional histories of hospitals in Halifax, Nova Scotia, and Owen Sound, Ontario, little has changed.9 The issue is also complex because of the country's bilingual, multicultural status. Many hospitals in French Canada, established and run by Roman Catholic orders, date from the seventeenth century. Their study needs to be placed within different cultural, intellectual, and religious contexts. Indeed, apart from notable recent exceptions,10 their institutional histories, along with those of their counterparts in English-speaking Canada, typically present studies of the Catholic orders and their religious duties.11 Toronto's general hospital, dating from the early nineteenth century, can provide the kind of insights helpful for understanding the emergence of the hospital system in this country. The Toronto General Hospital is one of only two internationally recognized non-denominational hospitals (the other is the Montreal General) that existed throughout the whole of Canada's development from a group of separate colonies to a Gy country. Its position is all the more remarkable because, unlike its European forebears, it did not evolve over many centuries in a populated area; rather, it appeared in the Canadian wilderness among forest, swamp, and mosquitoes. It also achieved its present stature within a very brief span of time. It took only one hundred years for it to form fully from 1797, when it was just an idea in the head of a colonial administrator, to 1897, when it welcomed international medical visitors to its wards. More impressively, its physical development took only seventyfive years - given that it was neither officially built until 1819 nor opened to patients until 1829 - and its managerial and medical maturation only thirty years, following decades of troubled existence. Once affirmed in its modern state in 1897, the Toronto General Hospital's growth paralleled other major North American hospitals in the twentieth century.

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Doing Good: The Life of Toronto's General Hospital

Over its two-hundred-year evolution, this hospital constantly adjusted its goal of doing good according to prevailing social, religious, fiscal, medical, technological, and government imperatives. In keeping wkh the trend identified by Shortt, two earlier histories neither emphasized the impact of these issues nor examined the role of patients and others in its development. Both written by doctors associated with the hospital, C.K. Clarke's A History of the Toronto General Hospital (1913) and W.G. Cosbie's The Toronto General Hospital, 1819-1965 (1975), not surprisingly, focused on the aspect of its history that most interested them: doctors and medicine; buildings and finances. Another book-length study, published in 1985, Martin O'Malley's Hospital: Life and Death in a Major Medical Centre, complements these approaches by throwing a journalistic spotlight on people and episodes in the hospital's daily life during a year or so: experiences of highly publicized patients receiving transplantation operations, staff at both ends of the hierarchy from the boardroom to the hospital kitchens. Colourful and detailed, like a snapshot, it captures only a fragment of the hospital's memory.12 Doing Good takes a wider view of the hospital as it acted in different capacities over a longer period - as a place of refuge and mercy, as a site for segregation and rehabilitation, as a facility to care for the afflicted and strive towards their cure, and as an educational institution of teaching, learning, and research. Through its two-hundred-year life, many 'stakeholders' - public, government, university, and business - have influenced the institution, and their joint involvement reflects Canada's distinctive system of health care. Yet its activities were determined by its trustees - elite members of society such as the powerful Anglican leader Bishop John Strachan, the wealthy industrialist Sir Joseph Flavelle, and generations of the family behind a national icon in Canada, the Eaton's department store chain. By addressing these issues of medical care and governance, along with those of class, religion, politics, gender, and ethnicity, this book considers Toronto's general hospital as a social and political barometer. A broad study requires a variety of sources to explain the hospital's corporate culture, its staff, its activities, and its impact.13 Unlike many other institutions, the Toronto General Hospital has not retained extensive records. This situation reflects in part its sporadic activities, a point made by contemporary physicians and politicians alike. It may also reflect the locale of Upper Canada, which, being predominantly an undeveloped area, took a longer time to form as established a European settlement as

Introduction: A Social and Political Barometer

9

those found in other, older Canadian sites such as Montreal. Whatever the reason, only the detailed minutes of hospital trustees provide an (almost) uninterrupted source of valuable information from the beginning to the present. A record of the hospital's clinical activities may be found published as reports on individual cases in medical journals or as numerical summaries in early reports of government inspections. The hospital's interactions with doctors, medical schools, government officials, and the press left many other published accounts affording different views of hospital operations in the nineteenth century. With the twentieth century, records of the Toronto General became standardized. Even so, many reports, pamphlets, and other official documents seem not to have survived; physician-historian W.G. Cosbie had an advantage in being able to refer to those apparently in his own possession for the period from 1945 to 1965. Since then, records have become more voluminous with the addition of those from other hospitals through amalgamation. Doing Good is in effect a biography of an institution. In charting the life of Toronto's general hospital to the present, this book also describes its physical changes and portrays those people most involved with it: patients and those who cared for them. Part I examines its origins as an idea in the 17908 and its activities as a government-endowed charitable institution providing for the sick poor until 1856. Chapter i reviews the nature of sickness and health care in the unsettled environment of Upper Canada. It considers the imposition of an eighteenth-century mindset on this fledgling British colony, one that greatly influenced the development of the York General Hospital once it was finally established in 1819. This chapter also discusses the hospital's role in the cholera epidemic of 1832 and introduces 'movers and shakers' in Upper Canadian medicine and hospital life, most notably Christopher Widmer. Shortly after this epidemic the hospital was renamed when York became Toronto in 1834. Chapter 2 analyses the hospital's chaos, administrative reforms, and clinical activities from 1841 to 1856. It also covers the hospital's role in the conflict-ridden world of medical education offered by several schools - a result of the rampant political and religious differences within Toronto and its medical factions. Part II covers the years from 1856 to 1903, when the hospital represented one form of provincial public charity among many (asylums, jails, houses of refuge and industry, and so on). Having endured the troubles of the previous era, the Toronto General Hospital gained

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Doing Good: The Life of Toronto's General Hospital

stately new quarters and additional provincial funding in 1856, as we see in chapter 3. It was forced to close temporarily in 1867 because of financial hardship - an unanticipated consequence of Confederation and of the creation of the province of Ontario. Once the provincial Charity Aid Act secured more stable funding for hospitals in 1874, the Toronto General developed a renewed sense of public duty - the main theme of chapter 4 - within the context of the formation of a welfare system composed of many other hospitals across Ontario. It underwent major reorganization and expansion, absorbing two other Toronto medical institutions in 1878, to emerge at the turn of the century as a more medically sophisticated and significant institution. It attracted praise nationally and internationally in this period as a model hospital in North America. With the introduction of formal nursing, including a school of nursing in the i88os, the internal structure of the hospital began to be more hierarchical. Part III encompasses the history of Toronto's major academic hospital in the twentieth century. The crucial link that was forged between the revitalized University of Toronto and its newly constituted Faculty of Medicine is the subject of chapter 5. This period, 1904-30, also saw the rebuilding and relocation of hospital facilities, including freestanding pavilions for private paying patients (an ever-increasing source of hospital income). At the same time, key personnel at the hospital helped to develop the field of hospital administration in North America, while other members of staff drove the eugenics movement. Although it survived economic depressions and the First World War, the collective impact of these events greatly taxed the Toronto General Hospital. Throughout the period from 1904 to 1930, Sir Joseph Flavelle - millionaire-businessman, philanthropist, and chair of the hospital's board for most of these years - exerted a lasting influence over the institution's affairs. From passage of the provincial Public Hospitals Act of 1931 to the close of the twentieth century, the hospital evolved into a corporate enterprise with an annual budget of half a billion dollars. As chapter 6 shows, research imperatives became more clearly delineated and emphasized as the Toronto General Hospital emerged as a leader in academic medicine in Canada. Medical and surgical 'stars' who pioneered or pursued the clinical application of heparin, the artificial kidney, the cardiac pacemaker, and many surgical techniques, for example, helped move the Toronto General onto the international stage after the Second World War. During this period, the hospital briefly amalgam-

Introduction: A Social and Political Barometer

11

ated with the privately owned Wellesley Hospital (1948-59). In the 19305 the provincial government created the Ontario Institute of Radiotherapy for the treatment of cancer, extending the hospital's clinical capability and its technological prestige. The eventual splitting off of this unit in 1958 to become the freestanding Ontario Cancer Institute/ Princess Margaret Hospital then inaugurated another phase of cancer care outside the Toronto General. This final chapter also considers the hospital's management as a corporation. Fiscal responsibility has always been important for hospital administrators, but the Depression of the 1930s brought particularly hard times for all, including hospitals. One outcome was the rise of third-party healthcare payment plans. Their implementation and government-sponsored health insurance schemes starting in the 19608 became a boon for hospitals across Canada. The Toronto General was one beneficiary of these seemingly limitless sources of revenue: the 'private paying patient' who had once been its major source of income disappeared as the hospital relied on the public purse once again. But the shift to dependence on public funds simultaneously tied hospitals to the vagaries of government policy on spending. By the 19805 and 19905, cutbacks in health, education, and welfare resulted in reorganization, including bed closures, hospital mergers, layoffs, and 'restructuring.' Once again, the Toronto General Hospital reflected these sweeping social changes as it expanded through amalgamation with the Toronto Western Hospital (1986) and Princess Margaret Hospital (1997), as well as through absorption of Doctors Hospital (1998). Its name changed to 'The Toronto Hospital' until its board adopted a new corporate name in 1999 as the umbrella structure for its three main hospitals: University Health Network. The conclusion addresses questions emerging from the study. How did successive generations perceive and interpret the goal of 'doing good'? How did hospital trustees, administrators, doctors, patients, students, staff, and the public juggle the imperatives of institutional survival, patient care, and professional development with the ever-changing social milieux of the city, province, and country to hold the hospital together? How has the public expected, and how does it expect, Toronto's general hospital - indeed, any hospital - to function in society? During its first two centuries of operation, many people have supported the Toronto General Hospital because they knew that it was doing good, although they may have occasionally reflected over the costs of'doing good.'

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PART ONE Providing for the Sick Poor, 1797-1856

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1

A Hospital for Muddy York Eventually, 1797-1840

In December 1797 Lieutenant-Governor John Graves Simcoe, then still in the original colonial capital of Niagara, received word that land had been reserved for a hospital in Upper Canada's new capital on the north shore of Lake Ontario. A letter sent by Peter Russell, senior colonial bureaucrat, did far more than this: it laid out a definite plan for the entire settlement at York. Russell's vision called for erection of public buildings - namely, a hospital, a church, a school, a courthouse, and a jail. Within two weeks, Russell informed the executive council of Upper Canada that it was 'absolutely requisite that some place of confinement be immediately provided in the Town of York,' revealing that his priorities above all were 'to preserve the peace ... and keep the people in order.' The jail, therefore, was built immediately, and most of the other buildings soon followed - all except the hospital.1 It would not be until 1819 that a hospital building would go up, and yet another decade would pass before it started functioning as a hospital. Russell's plan took so long to be realized because it was, in effect, premature. In his model community, the concept of a hospital had fitted an abstract ideal of English civilization - an ideal that was at odds with the raw reality of life in Upper Canada. A military surgeon, John Douglas, vividly depicted that reality for his English readers. In place of ruins from ancient settlements, here a land of virgin forest, vast lakes, and massive rock formations 'forcibly impressed' the traveller 'with the general stillness of nature, and the awful silence of surrounding solitude!' Its inhabitants were scattered across a country 'so wild and desolate... and secluded from civilized society' that their life was 'forlorn and deserted.' The sense of 'order and regularity' in its few villages, Douglas observed hopefully, pointed towards 'the future grandeur of this majestic country.'2

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Providing for the Sick Poor, 1^7-1856

Those charged with the responsibility for sculpting a British colony out of the Canadian forest shared common experiences and beliefs. They had seen British military service, they had fled the upheaval of the American Revolution, or they had recently arrived from the monarchical motherland. All were gentlemen in breeding, class, or aspiration. As local authorities and colonial subjects, they were expected to be loyal to the Crown, lawful, respectful of their betters, cognizant of their duties, and, if they wished to benefit from government patronage, Anglican in outlook if not in actual religious practice. For these gentlemen, the colonial capital of York should develop methodically through public institutions geared to imposing and preserving the peace, order, and regularity they so desired. To this end, they had transplanted English law to Upper Canada in 1792 - minus key provisions for care of the poor because of the impossibility of implementing them in a huge, unpopulated area. Furthermore, they believed that there was enough plenty in this colony for people to make their own way in life without charitable aid: for those in need, there was always family or church. Like so many other aspects of Upper Canadian life, self-reliance was the order of the day in matters of health and medicine. Medical care took place in the household, with family members determining and administering treatment; those who wished to pay for formal medical advice could also seek a physician's attendance to their home. In this worldview, Upper Canadians would exert energy to establish other needed institutions before they would build a hospital (1819) and begin to use it as such (1829). Doctoring and Health Care in Upper Canada In 1797 the lack of a hospital in a town of only a dozen log huts and 240 inhabitants probably seemed no pressing problem. A decade later, British gentlemen - patient and physician alike - still functioned in a domestic medical milieu. When York's planner became gravely ill, he was tended in his home by family and his personal physician, Dr William Warren Baldwin. His sister, Elizabeth Russell, recorded the progress of Peter's affliction and treatment over the next year.3 In the spring of 1807, Peter Russell apparently suffered a stroke. An 'oddness in his speach as if he could not well articulate his words, as if his tongue was swelled,' caused Elizabeth to send for Baldwin, who was busy in court in his other guise as lawyer. When he arrived later, 'he put on a solemn countenance' according to custom, then 'prescribed a Blis-

A Hospital for Muddy York - Eventually

17

ter to be aplied to the back of his neck and whey made of mustard/ After taking some tea, Baldwin called in a colleague, Dr Davidson. Elizabeth then related the interaction between the two doctors and their seventy-three-year-old patient: Davidson I believe thinks with Baldwin that it is a nervous affection but did not tell my brother so, but wished to ascribe it to some other cause. Told him that his pulse was good and chatted cheerfully to him. Prescribed instead of the Blister only Heartshorn on a flanel to the back of his neck, white wine whey, and have his feet well rubed with flanel when going to Bed and wash and gargle with hartshorn and water wh[ich] he did. The Doctor chatted him into tolerable spirits and seemed pretty well all but his speech. Some times he spoke much better than at others ... I rubd Peter's feet, put the Hartshorn at the back of his neck, & gave him hot wine whey to drink when he went to bed wh[ich] was between 11 & 12 with Hartshorn in it.

One year later, Baldwin was still attending Russell routinely to administer purges and enemas. Sometimes he mingled professional with social services: 'In the forenoon Baldwin came and gave Peter the injection,' Elizabeth commented, 'after which as soon as I was dressed he drove me in our sleigh to the Garrison.' On 26 March 1808, she worried: 'My brother got a very sore throat but the Doctor thinks it of no consequence, but I am uneasy about it. He gargles with sage, honey & port wine.' Elizabeth's unease was justified, for in a matter of months Peter Russell died. The diary of Elizabeth Russell provides an exquisitely rare window on doctor's care of patients in this early period in Upper Canada. As a gentleman of means, Russell expected attendance by his physician in his own home, with all the comforts and personal attention that it provided. Not only were most treatments uncomplicated, but their preparation and application frequently were best handled by caring relatives. More complex procedures, such as blistering, purging, and giving enemas, were all easily performed and monitored by Dr Baldwin in the confines of his patient's own bedroom. No hospital ever afforded such advantages for Russell's elevated social class. But this fact alone does not explain why a hospital had not yet appeared in York by Russell's death in 1808. Features of medical life in Upper Canada contributed to the delay in its establishment: the weak legal and economic clout of physicians; their small number in the col-

i8

Providing for the Sick Poor, 1707-1856

ony; the limited scope of medical therapy; and the reliance of ordinary colonists on self-help treatment for their health concerns. At the close of the eighteenth century doctors were not able to mobilize and champion the building of a hospital in York in part because they occupied a weak legal position. Ironically, the first select committee ever struck by the newly created legislature of Upper Canada in 1792 was to consider the 'most effectual means of preventing persons not duly qualified from practising physic.' Yet as there were only a handful of medical men active at the time, the committee prudently decided that in the 'infant state of the Province,' there was no need to place any restrictions on medical practice.4 From time to time, there were other efforts to legislate the practice of medicine. In 1795, possibly in 1805, and in 1815 various acts were passed or repealed, but even as law they were ineffectual. Those who practised medicine during the 17905 were primarily attached to the army or navy; their number grew as Britishtrained doctors and retired army surgeons set up private practices in the towns of Kingston, Niagara, and York. By 1815, however, there were still only about thirty-six practitioners, out of a total provincial population of eighty thousand - too few to worry about. So few, in fact, that it was all but impossible for doctors themselves to exert any pressure on authorities to do anything like building a hospital. This is not to say that Upper Canadian doctors could not have some influence or power. From the 17905 until about the mid-nineteenth century, they enjoyed some social advantages over their British and American counterparts. In Britain the regular (mainstream) medical profession was a tripartite group consisting of surgeons, apothecaries, and physicians, and while individual reputations and regional differences could affect the status of some practitioners, the professional and social prestige of each of these groups rose from surgeon through physician. The physician was a cultivated man of classical learning who typically served upper-class and aristocratic patients; the surgeon relied more on manual skills and had technical training; and the apothecary occupied a middle role corresponding somewhat to the modern concept of the general or family practitioner. A similar hierarchy existed in preRevolutionary America, but by the early decades of the nineteenth century this tiered system had collapsed. In its place, a form of medical anarchy reigned, as many practitioners vied to provide medical or health care to Americans in all walks of life. Under Jacksonian principles of democracy, it was believed that 'every man' could be his (or her) own doctor.

A Hospital for Muddy York - Eventually

19

Upper Canada contrasted with both these countries.5 From the 17908 medical practitioners were neither as stratified as in Britain nor as levelled as in the new American republic. Little distinction was made between physicians and surgeons, and all members of the mainstream medical profession were assimilated into colonial society as men of some social standing: 'young surgeons' were ranked by one observer along with Anglican clergymen, college graduates, and ex-military officers as members of the 'genteel' and 'good society.'6 Despite lack of legal recognition (a situation that would change only in the i86os), some doctors could gain status through their own social rank, with proper family and political connections. Their tenuous professional state at a regulatory level emerged too in doctors' problems in collecting fees from patients. Owing in part to a lack of circulating currency during the early years of the province, relationships often were formed on the basis of payment in kind with services or goods as several examples reveal. In the summer of 1790, Robert MacCauley sued James Connor, a surgeon, for payment of a business debt. The surgeon retaliated by suing MacCauley for 'medicines and attendances in Cureing a broken Leg, amounting to £50' - a fee that he claimed was 'not extravagant nor without a precedent and that the Cure he performed was of a dangerous Nature.' Other doctors supported his claim as reasonable.7 Only when the provincial secretary, William Jarvis, was about to move with other administrators from Niagara to York did his physician, Robert Kerr, present him with a bill for thirty-three medical services over the previous five years, from December 1792 to April 1797. The cost amounted to just over £25, for bouts of purging (i6/each) and bleeding (letting blood, a common treatment) (4/- each) .8 Between 1798 and 1801, the ledger of a physician in Ancaster, near York (probably Dr Oliver Tiffany), reveals that he received oats, flour, whisky, butter, potatoes, and a 'dryed carkus of venison' for his medical care. He did also receive cash: £10.6.0 from one patient; £4.3.0 from another for the removal of two teeth and for medicines (opium drops, a cathartic, de-worming powders, and calomel) .9 Doctors struggled, along with other colonists, to eke out a living. 'Nobody above the rank of a common cowherd would travel round a circle of forty or fifty miles in the wilderness for the pittance which could be collected,' wrote one settler in the early nineteenth century, 'and save in the larger Villages - Kingston, Niagara and York - nothing like a genteel subsistence could be obtained.'10 In 1822, a survey showed little change. There was no doctor in the village of Saltfleet 'and generally

20

Providing for the Sick Poor, 1797-1856

but little for them [sic] to do'; the nearest medical man, six miles from the town of Grimsby, had a practice 'not too lucrative from the country 12 miles round.'11 To overcome such problems, doctors (like Baldwin) might turn to additional means of support such as government administration, politics, trade, law, or a combination of these; others might advertise to attract business. Throughout the early years of the century newspapers carried announcements that gave the physician's name, address, hours of business, and perhaps a special area of expertise. Occasionally, these advertisements underscored the precarious livelihood of physicians:12 'Dr. Z. Smalley begs leave respectfully to inform the inhabitants of Kingston and its vicinity that he has established himself as a physician, surgeon and apothecary. From his having received a regular medical education, and from his experience in the different branches of his profession, he is induced to believe that he will be able to do justice to all whose misfortunes may render them under the necessity of soliciting medical aid. Also, drugs, paints, linseed, oils, dye-stuffs, glass, nails, paper-hangings, garden seeds, books and stationery.' A doctor's lot, then, was not necessarily a happy, prosperous, or prestigious one. He might have welcomed the prospect of a hospital, but he had more immediate problems in daily professional life to worry about. The delay in building a hospital in York would have been little cause for concern for others too. Those who lived some distance from York would have had little to gain by travelling to town for care; indeed, the journey itself over rough terrain and poor roads (if any) would probably have proved injurious in itself. Ordinary town dwellers would also have declined the opportunity, even if available, to enter a hospital, for they were accustomed to treating themselves. When Ely Playter, a York tavern owner, was called to a friend's house because his wife had dislocated and locked her jaw, for example, he first consulted the well-known eighteenth-century home care manual Domestic Physician, or the Family Physician, by William Buchan.13 Playter wrote casually in his diary that 'after examining Buchan's Family Phisitian we went with John and soon replaced Mrs P's Jaw by Buchan's directions, return'd home & went to bed.'14 If professional medical help was sought, prescribed treatments might be carried out by neighbours too. On one occasion, Elizabeth Russell aided a 'most dreadfully burnt' woman whose clothes had caught fire. Under Dr Baldwin and Dr Alexander Thorn, a regimental surgeon, as attending physicians, Elizabeth prepared some balm (ointment) and mint drink for their mortally wounded patient.15

A Hospital for Muddy York - Eventually

21

The self-help approach to handling injuries applied to the treatment of diseases as well. In the early nineteenth century settlers were 'generally healthy' or 'robust and athletic,' according to John Douglas, but he noted prevailing Upper Canadian diseases and ailments - frostbite in winter, heat exhaustion in summer, and always the endemic disease of ague or 'lake fever' in summer and autumn.16 Contemporary writers frequently commented on ague, a malaria-like fever that inhabitants associated with supposed poisonous vapours emanating from low, marshy ground; its symptoms and effects included nausea, lassitude, giddiness, confused vision, fatigue, fainting, and paralysis. Ague hit Native people and white settlers alike, but in the new Upper Canada it was a great social leveller. When well-to-do Elizabeth Russell was still living in Niagara in 1793-4, she contracted it, suffering so much that she all but decided to return to her native England. In September 1801, John Bennett, the king's printer in York, noted that he was just recovering after ten days in bed with a 'severe fit of fever and ague' - a disease, he lamented, that 'no body can escape ... who pretends to live here.' Bennett continued,17 Mr. McLean Clerk of the Assembly... has also been extremely ill with it and in some families one person is not able to assist another; there is a marsh about Vz a mile from where I live from which a thick fog arises every morning - people attribute it in great measure to that and to the low and uncultivated state of the Country I have been delirious almost every day, but by taking of bark every hour according to Dr McCaulay's prescription I have missed the ague these two days past - I am still under a course of bark - I hope in God I shall have no more of it it sets me quite crazy - the Chief Justice has lately recovered and the Speaker of the House is now ill with the fever.

Adding to the misery of the disease was the relatively high price of 'bark' (Peruvian bark - cinchona, a source of quinine), the main drug used in its treatment; those who were able had relatives send it from the neighbouring United States. Another treatment was more extreme. In addition to Peruvian bark, Douglas advocated a regimen of depletion: frequent use of the lancet (a surgical knife) to open a vein and bleed the patient; application of blisters; and ingestion of emetics (to cause vomiting), purgatives such as calomel (mercury) and jalap (powdered root), and stimulants such as James's powder (antimony and hartshorn).18 Perhaps owing to the high cost of Peruvian bark or the fear of

22

Providing for the Sick Poor, 1^7-1856

such a debilitating regimen, though just as likely as a result of cultural belief, some sufferers adopted supernatural or magical means to alleviate ague symptoms; for instance, they might knot a thread to represent the number of fever fits they were prepared to endure and then tie it to a tree branch. The ancient and widespread belief that a disease could be transferred to an inanimate object lay behind such a practice.19 In addition to endemic ague, which would eventually disappear as marshy land was drained and the natural habitat for disease-bearing mosquitoes was removed, early settlers and their descendants faced the threat of smallpox. If it did not kill its victims, this disease could leave survivors permanently disfigured from the numerous pock marks left on the skin. At first, a measure to prevent acquiring smallpox involved inoculation, via a puncture in the skin with the exudate from pustules of those with relatively mild cases of the disease. In Niagara in the late 179OS, Dr Robert Kerr performed inoculation three times in the William Jarvis household - once each on Jarvis's two sons and once on his 'negro Boy.'20 Beginning in the late eighteenth century, many English doctors began to adopt a safer technique known as vaccination, which involved introducing cowpox matter instead (cows often suffered from a similar disease, one that was relatively harmless to humans). This procedure too would be easily handled domestically. In York, military surgeon George Davidson vaccinated a little girl, Betsy Denison, with the 'Cow Pock' in early May 1807; a week later, it was Elizabeth Russell who inspected the child's arm, concluded that the pock had 'taken and goes on very well,' and hoped that the young girl would revisit the doctor to have him confirm her opinion.21 Childbirth, a routine rite of passage, added to the significant health challenges in Upper Canadian households. As many markers or stones from this period still attest, childbirth could be dangerous. Infection, haemorrhage, asphyxiation, exposure, hunger - to name only a few problems - could quickly claim the life of mother or child. Medical attendance, even if available, could be ineffectual or might further complicate a difficult situation. For much of the century, the husband, sister, daughter, or neighbour provided the necessary support in childbirth. Another attendant might be the midwife, who would assist before, during, and after childbirth, typically comforting the woman in labour, helping with delivery of the child, severing the umbilical cord, disposing of the afterbirth, and perhaps performing sundry household duties. Isabella Bennett, wife of King's Printer (and ague sufferer) John Bennett,

A Hospital for Muddy York - Eventually

23

was probably York's first midwife; she assisted birthing women until at least the late i820s, and other midwives would join her in practice as the town grew. (Although midwifery as practised by women was not widespread in Upper Canada, from the 17908 to about the mid-nineteenth century midwives generally were free to practise.) In all these circumstances, whether tragic or joyful in outcome, the convenience and comfort of familiar surroundings would have made the prospect of a hospital unattractive for most York families.22 In any event, when York's hospital did become fully operational at the end of the 1820$, it officially prohibited the admission of pregnant women. In keeping with European views, it was believed that they would spread disease to other patients. Thus in the eighteenth and for much of the nineteenth centuries, not only did medical care centre on the home by custom and choice, but even full-time medical practice alone was not enough to sustain many physicians. As a gentleman in the same social circle, Peter Russell's physician was also his personal friend. More tellingly, as Elizabeth Russell recounted, the doctor was in court when he was first called to attend her brother. William Warren Baldwin was more active and financially successful as a lawyer, and later as administrator, politician, judge, and businessman, than as a doctor. He was not, however, an inferior practitioner. Despite the rugged conditions of York, through Baldwin the town had obtained the best medical training then available. A graduate of the medical school of the University of Edinburgh in 1797, Baldwin had been exposed to some of the greatest clinical and scientific teaching anywhere; his professors would have included Alexander Monro II, Joseph Black, James Gregory, and Andrew Duncan, Sr. Similarly, he could take advantage of the facilities of the Royal Infirmary of Edinburgh, one of Europe's premier teaching hospitals. Certainly, Baldwin's deportment and medical acumen show that he had learned his lessons well. As a physician and gentleman, he approached the ailing Russell (who was at one time also Baldwin's patron and entree to York society) with the necessary dignity and a 'solemn countenance'; his diagnosis of a 'nervous affection,' though vague, was not inaccurate; and his prescribing of hartshorn, wine, blisters, rubbing, and so on - basically, a stimulant regimen - was consistent with proper medical thinking of the time.23 In sum, Dr Baldwin's double profession attests to the reality of bureaucratic life in the colony, where lawyers had a considerably higher chance of financial success than physicians.

24

Providing for the Sick Poor, 1^7-1856

War, Charity, and the Prospect of a Hospital for York

William Baldwin can be viewed, too, as a paradigmatic Upper Canadian character. While his cultural and professional roots reached back across the Atlantic, Baldwin, like most other Upper Canadians, was aware of the necessity of having ties with the neighbouring United States. (For example, Baldwin had medical and pharmaceutical supplies shipped to him from a New York merchant.24) From this perspective, life in Upper Canada was a balancing act. With dual heritage, as Jane Errington explains, Upper Canadians 'could not help becoming conscious of the apparent contradiction of their position.'25 The war between the United States and Britain from 1812 to 1815 tested their dual heritage in the extreme. The conflict transformed the colony, its inhabitants, and the town of York itself, and it directly contributed to the inception of York's public hospital. The war greatly increased the level of medical and surgical activity and the public's awareness of it. In one account, a son told of the wounding of his father and the amputation of his leg; the patient's death shortly afterwards was a relatively common type of occurrence, accounting for half the wounded with this type of injury and operation. When York capitulated on 27 April 1813, the situation was deplorable. Virtually all public buildings had been destroyed by American troops, and medical aid was inadequate. John Strachan, York's Anglican priest, praised the townspeople for being 'exceedingly kind to the sick & wounded.'26 Strachan helped out, too, by permitting his church to become a temporary hospital; this measure, along with a small hospital within the British fort and the commandeering of private houses for the wounded, marked the first moves towards the creation of a local hospital. Yet it is clear from attending military surgeon John Douglas that all these steps, though expedient, were unsatisfactory:27 The general hospital at York, though a commodious building, was deficient in size for the accommodation of the sick and wounded. Its apartments being originally intended for family use, were too small for the wards of an hospital, and did not admit of a free ventilation. Neither were the adjoining houses of the hospital, which were fitted up for temporary accommodation, any way suitable for the reception of the wounded. When, in the course of the summer, the wounded became so numerous as not to be contained within the general hospital and its outhouses, the church, a large well-ventilated building, was dismantled of its seats, and, for the time being, converted into an hospital.

A Hospital for Muddy York - Eventually

25

The debilitated state of the wounded exacerbated the situation. Soldiers who had travelled considerable distances to York for treatment - especially amputation -were, Douglas observed, 'placed under most inauspicious circumstances.' They were extremely ill either from the fever of ague or from what would now be recognized as wound infections. With the truce of 1815 and the restoration of peace and order, Upper Canadians began to review and assess their recent experiences. In Errington's view, many colonists at this time shared a new perception of themselves as vanquishers of the 'forces of tyranny and oppression'; indeed, the events of 1812 and later 'came to be considered by many as the colony's rite of passage into young adulthood.'28 One manifestation of this maturation process was the beginning of organized medicine through, for example, the professional examining body of the Medical Board of Upper Canada, created in 1818. The town of York itself, and the life that it supported, also changed markedly. As the population rose from about 700 in 1815 to well over 9,000 by the late 18308, more houses were built, more merchants set up shop, more trades were established, and a 'middle class' emerged. Cultural institutions appeared - bookshops, a theatre, and literary and scientific societies. Even though this boom came from British immigrants, they introduced many new voices to compete in matters of class, religion, politics, and community affairs. As well, such a huge influx of people proved a mixed blessing for the whole colony and for York (their primary destination) , for along with needed skills and fresh ideas they brought problems in the form of those who were unable to become established immediately. York did not have official services to cope with poor, sick, widowed, orphaned, or unskilled immigrants. With the flood of destitute immigrants - especially from Ireland - the colony faced for the first time what Peter Oliver states 'might genuinely be described as a social crisis.'29 Eventually the York General Hospital would act as a lightning rod for a host of town concerns relating to these unfortunates. Around the years of its founding, however, many benevolent societies organized to help address some of the urgent social problems in the town. From 1817 until the late 18305, for instance, the Society of Friends to the Stranger in Distress operated as an early form of workfare program for the 'relief and employment [of] Emigrants, as may either now, or from time to time be in temporary want of assistance'; thereafter it became known as the Society for the Relief of the Sick and Destitute. John Strachan and William

26

Providing for the Sick Poor, 1797-1856

Allan, directors of this society who would also become trustees of the York General Hospital, reported that much of its funds went to the military hospital for medical treatment of 'extraordinary cases of disease, which required immediate and continued attention.' On one occasion, Strachan found Betsy Garland receiving treatment for frostbitten feet and 'worked on her to enter a better course of life'; he sent her out of York with a letter entrusting her to a family that would help place her into 'respectable service.'30 This spirit of charity stimulated York's leaders to revive the prospect of a hospital. Relief agencies for the less fortunate reflected a Christian duty to help and serve; at the same time, they showed clearly that charity was being dispensed by York's well-to-do only to those who deserved it. This value, Peter Oliver suggests, 'took the form of a Christian paternalism': notably, it was mainly Tory community leaders who formed such organizations, and prominent members of the ruling establishment in the colony - what became known as the Family Compact - served 'as long-time officers of the entire range of Upper Canadian charitable endeavours.' The work of John Strachan in a number of charitable agencies in particular was grounded in 'an unbending conviction that those who possessed wealth and education had a Christian obligation to assist the poor.' Oliver observes that Strachan, 'as a leader of the community ... regarded the performance of such obligations as essential to the maintenance of a peaceful and well-ordered society.'31 Such sentiments, crystallized in Strachan's observation in 1825 that Christians 'pant after the felicity of doing good,'32 formed an indispensable foundation for virtually every kind of activity in Upper Canada. Church and state were so closely entwined in this colony that they deeply influenced all of its institutions. Although representing a minority, Strachan's denomination, the Church of England, held official status. If Strachan's Christians panted after doing good, Anglicans in particular valued reason and order in all things. Nature, religion, government, social rank, family, and education - all were subject to hierarchical control in the Anglican worldview. Hence, as William Westfall has shown, Anglicans believed strongly that a 'loyal and ordered population was the basis for a Christian society, and thus the institutions of the state were, in effect, ancillary religious bodies.' More than this, in their view, the church would aid the state in achieving its objectives, for 'Christianity taught people to live virtuous lives, and virtue made people into useful and productive subjects ... A religious population would be a loyal

A Hospital for Muddy York - Eventually

27

population.' In short, notes Westfall, 'the alliance of church and state rested upon a reciprocity of interests.'33 'Doing good' in this period embraced all aspects of this reciprocity of interests. The concept then extended to the building of a public hospital in York. Given widespread recognition of the problems posed by massive immigration and the consequent need for social welfare services of all kinds, the time had arrived for serious thought about the value of a public hospital. Thus on 26 April 1819, the government of Upper Canada reallocated 400 acres of land originally intended for the lieutenantgovernor's residence, handing it over to a group of trustees as the basis for an endowment of the hospital. These trustees were the very essence of the elite of York society, which itself formed the nexus of church and state: Chief Justice William Dummer Powell, James Baby, and Reverend John Strachan. According to Powell, who would become the hospital's first chairman in 1822, the plan was to sell the former government land as smaller building lots. Funds from their sale were short of what was needed to build a hospital, however, and other legal matters apparently complicated this arrangement. Fortunately, funds from another quarter become available - a legacy of the War of 1812. At the beginning of this conflict some of the townspeople at York had founded the Loyal and Patriotic Society of Upper Canada, which aimed to collect funds to aid those who suffered in the war and to strike medals to recognize those who were meritorious; the society raised funds in both Upper Canada and England. Although this organization did assist some in need, the issuance of medals was a thorny matter, embroiling its members in thirty years of indecisiveness and forgetfulness: the society had medals struck, but since no one could agree on who should receive them, it placed them in a bank vault until 1840; then it had them defaced and sold them as precious metal. Around 1820, it received £4,000 from funds raised in England. This windfall also occasioned debate that led to the decision to invest one-third of the sum and use two-thirds to erect a hospital in York.34 In due course a two-storey brick building, which modestly reflected its Georgian architectural roots, became part of the townscape at King and John streets, near the garrison. We can infer the building's specifications from the eight tenders of contractors who bid on the project on I5january 1820. They emphasized the kitchen, which was probably

28

Providing for the Sick Poor, 1707-1856

located in a sunken storey. The main building contained two storeys above this, with provision for expansion into other wings later. It is possible that the second floor had a gallery along its outer walls, which might have proved useful when the building was commandeered for non-hospital purposes.35 Its numerous windows permitted good ventilation; as well, its physical orientation according to the cardinal points of the compass - with the front and rear facing north and south, respectively - was intended to help maintain a cooler building in summer. This way, it would never receive direct sunlight, while it would take full advantage of breezes from the lake - not from the pestilential marshes to east and west. A later description of this hospital building noted that it was pleasant, spacious, and airy. While her husband was becoming involved as one of the initial trustees for this hospital, Mrs Strachan, along with other women in elite York society- such as Mrs (William) Allan and Mrs (John Beverley) Robinson - turned attention to the needs of pregnant women, who would not be served by the hospital. In 1820, these elite women formed the Female Society for the Relief of Poor Women in Child-Birth to provide clothing, a midwife, and, if necessary, a physician for women in need. During its first year alone, sixteen women received assistance; Mrs Bennett, the midwife, attended the majority of births. In the four cases where a physician attended, he did so without charge, whereas the midwife charged 15/- per confinement. By the mid-i82Os, the society had assisted about fifty women, three-quarters of them newly arrived emigrant wives; the rest were inhabitants of Upper Canada who had been 'reduced to great need.'36 By 1822, the lieutenant-governor appointed the first formal board of trustees for the hospital, consisting of some of York's most influential men: William Allan, James Baby, John Henry Dunn, William Dummer Powell, John Beverley Robinson, Samuel Smith, and John Strachan. The board anticipated appointing a 'discreet Matron' to prepare the wards for the reception of patients; for these duties she would receive an annual salary of £2.10.0. Despite these brave beginnings, the hospital project stalled. The board did not meet again until i825.37 Meanwhile, the hospital building remained vacant. The historical record is fragmentary here, but according to an account by an elderly William Powell, which may not be reliable, it would appear that lack of funds had become a problem; it is possible that board members also may not have agreed on the exact purpose of the hospital. Apparently, Powell contemplated reverting to an

A Hospital for Muddy York - Eventually

29

earlier idea that the York hospital become a county hospital and serve the inhabitants of the province at large. By this means, he hoped, a much larger subscription base would be realized, which would enable the hospital to acquire necessary furniture and defray other costs. Other board members held that the primary purpose of this institution was to serve militia veterans of the 1812 war, much along the same lines as the Chelsea Hospital in London, England. After all, had not funds come from the Loyal and Patriotic Society of Upper Canada?38 The board's lack of activity more probably stemmed from its dysfunctional composition and divided loyalties. William Powell was past his prime, descending, as his biographer puts it, into 'pedantic crankiness.'39 As well, Powell and the powerful churchman John Strachan vied over 'ownership' of their protege John Beverley Robinson, himself a hospital trustee. The tension between them was heightened when Robinson sided with Strachan and Baby against the older Powell. Tragically complicating the situation, Powell held Robinson responsible for the drowning death at sea of his daughter, Anne, in 1822: she had run away to England to follow Robinson, who had little interest in her but with whom she was besotted. William Powell had been obliged to resign from the provincial executive council because of his erratic behaviour, and from 1825 to 1829, despite his perhaps-nominal continuation as chair of the hospital's board of trustees, he did not even reside in Upper Canada. In addition to a paralysed board and financial troubles, the hospital faced an insurmountable impediment to its development in 1825. A fire in late December 1824 destroyed the second parliament building in York, whereupon Grant Powell, a physician turned bureaucrat and son of William Powell, directed the removal of parliament to the 'Hospital as a temporary shelter.' The move seemed logical, given that the building lay unused. In 1825 a legislative select committee chaired by William Powell's arch-enemy, Attorney General John Beverley Robinson, recommended constructing a new legislative building; in the interim the committee hoped that the hospital would continue to be the government's home.40 But the word 'temporary' in the bureaucratic lexicon, then as now, is a flexible one: four years later the erstwhile hospital remained the official seat of parliament for Upper Canada. It is both an irony and a portent that the first public use of the hospital building was for politics: the hospital was, and remains, an institution subject to the winds of political change. The fact that its building could be so readily adapted to such a function also indicates that the hospital was not 'purpose built'; what would have been the large empty ward

30

Providing for the Sick Poor, 1797-1856

space would have easily accommodated an arena for parliamentary debate, especially if equipped with a gallery. Most important, the abrupt switch in the building's function dramatically underscores society's priorities at the time. Clearly, the need to govern the many and to maintain peace and order took precedence over the care and social welfare of a few. As during earlier decades, a hospital, regardless of its potential worth, was still not regarded as a necessity. The pressure of unprecedented emigration caused the issues of peace, order, good government, and health to coalesce. And the emigrants were coming and coming! Their primary point of departure was Britain, their primary destination Canada - in particular, Upper Canada, mainly through the port of York. During the late 18205 an average of about 13,000 people per year embarked for Canada; by 1830 this figure increased to about 30,000 people annually. Within a few years they turned the waterfront area into a shanty town.41 Under the auspices of the York Emigrant Society and other relief societies, newcomers received some aid. But these charities were not enough, and they were not designed to cope with the sick and dying who teemed at the harbour. Already by 1828, an urgent health problem confronted authorities. Accordingly, new Chief Justice William Campbell, who was also president of the executive council, speaker of the legislative assembly, and chair of the hospital trustees, wrote to the lieutenant-governor to seek action. Sick, poor, and distressed emigrants were arriving in York every summer, he informed his superior, which meant that their treatment by the town's doctors was of 'great inconvenience and expence.' The trustees were therefore 'induced to beg that Your Excellency will represent to the Legislature the necessity of making such provision for their future accommodation, as may enable the trustees speedily to apply the Hospital to its proper purpose, and that Your Excellency will express to them the hope of the trustees, that in consideration of the time for which the building has been hitherto occupied, a sum may be granted to the trustees, to be applied in furtherance of the objects of their charitable Institution.'42 This was not quite an ultimatum, but the message was clear: give back our hospital, along with some money, or the province and York are going to have a major problem on their hands. Although Campbell was successor to William Dummer Powell in several administrative capacities and was in poor health at the time, he had the distinct advantage of being on the right side of Strachan and Robinson. By summer of the following year, as more and more emigrants flowed in, Lieutenant-Governor Sir John Colborne announced that York would

A Hospital for Muddy York - Eventually

31

regain its hospital as soon as the legislature's session ended. Colborne wished the House of Assembly to understand fully the need for 'establishing immediately an Hospital and Dispensary, chiefly for the reception and relief of the sick and distressed immigrants.'43 Not all members of the House agreed with Colborne's decision. George Markland, an executive councillor and hospital trustee, fumed at his friend John Macaulay that during the next session of the legislature they would all be crammed into the courthouse - and for what? 'to get possession of one room with a small ward in the Hospital, which accommodation might have been procured in a £25-house in any part of the muddy town/44 A Charitable Institution for Sick Immigrants and the Indigent Poor Despite several false starts and the disdain of the likes of Markland, the York Hospital, with the help of £100 in government allowance, finally opened its doors to patients on 3 June 1829. As with all institutions, no matter how modest, this one soon introduced rules for its operation. Anyone wishing to become a governor could do so on payment of £1.5.0 to £25 annually, which allowed that person the privilege of recommending people for admission to the hospital and a sliding scale of voting power. The real power resided not among the governors but in the committee of management, which oversaw the hospital staff, the 'domestic economy of the House,' and the preparation of all necessary reports. The medical officer had to attend the hospital at least once a day; if unable to do so, he had to ensure that colleagues attended. The resident apothecary had charge of an 'ample supply of medicines' and could provide medical advice to patients who were indigent and not in need of immediate hospital assistance. The demarcation between the medical and non-medical spheres was not distinct, for, although doctors could decide who would be admitted to the hospital, governors, clergymen, and a few others had the privilege of recommending patients for admission. Many prohibitions were put in place. Except for the destitute, all admitted patients were expected to pay one shilling a day for subsistence. Only in the case of emergencies (such as violent wounds or severe accidents) were patients admitted without proper authorization; the insane, pregnant, or incurable were barred from admission altogether; and those who were admitted to the lock ward (a ward for those with venereal diseases) were charged one and a half shillings per day. Patients who misbehaved by drinking, swearing, acting disrespectfully,

32

Providing for the Sick Poor, 1^7-1856

neglecting doctors' orders, or leaving without permission were subject to immediate discharge. Pauper patients unfortunate enough to die in the hospital were not to be buried at the institution's expense.45 How exactly these rules were followed on a daily basis is unknown, but extant trustees' minutes show that an apothecary and steward were hired to handle many of the routine tasks.46 Accountability for the institution's activities devolved on Christopher Widmer, York's most prominent physician. Widmer's training afforded him excellent preparation for medical life in Upper Canada: first, apprenticeship, followed by formal studies at Guy's and St Thomas hospitals in London, and a dozen years' experience as a military surgeon in numerous campaigns in both Spain and Canada. With his 'no-nonsense' manner, Widmer developed a sound reputation for his bold surgical skills. He became wealthy through family connections in his first marriage. In Upper Canada he enjoyed the confidence of the ruling Tory establishment, becoming part of it through affiliation with the Bank of Upper Canada, Upper Canada College, and similar ventures; he was also personal physician to LieutenantGovernor Sir John Colborne. In later life, Widmer displayed reformist tendencies. Activities such as his presidency of the provincial medical examining board and his long association with the general hospital as physician, trustee, and board chair garnered him well-deserved recognition as the doyen of medicine in Upper Canada. According to John Strachan, Widmer was the very 'life and soul of the General Hospital from its beginning.'47 Certainly, by becoming chair of the board of trustees of the hospital a dozen years later, Widmer achieved a status that no other physician has matched in the hospital's history. Dr Widmer's first report, for the period from June to December 1829, conveyed three main messages. First, both the hospital and dispensary were treating many of the sick from York and from other parts of the province too. At the dispensary, an early type of outpatient clinic that had opened with the hospital, about ninety-five people had received professional advice and medicines for their conditions. The hospital had admitted fifty-two patients, of whom seven had died and seven more remained under care; thirty-five had been discharged as cured, one was discharged for breaking hospital rules, and two cases were deemed incurable. The chief conditions treated were fever, ophthalmia - a serious eye infection - and ulcerated limbs. Second, the hospital clearly was a charity, for Widmer identified most of those treated as the 'poor' or the 'indigent poor.' And, since the mission of caring for the poor also

A Hospital for Muddy York - Eventually

33

involved reducing the burden they placed on society, Widmer remarked on the social success attending some cures: those whose leg ulcers had 'totally incapacitated them from labour' had been 'restored to their occupations,' he observed with satisfaction. Finally, Widmer concluded that although the hospital was a 'commodious' structure with 'free ventilation [and] cooler atmosphere' that aided in the recovery of patients, its advantages were not being fully realized because of insufficient funds. With this lament, Widmer initiated a long, and continuing, tradition in hospital history.48 It is difficult to assess the hospital's actual performance, since no records appear to have survived, yet Widmer's report for 1829 does suggest that it played a useful role in York society - it was already doing good. The next year its activities would double. Almost 600 people received care in 1830, the majority (442) obtaining prescriptions at the dispensary; of the remainder, 124 were discharged as cured and 6 as incurable, and 10 died. Fevers again topped the list of acute conditions seen, with the rest 'chronic diseases in surgical patients.' The hospital had also treated 23 cases of smallpox, of whom only 2 died, after speedily transferring them from ships in the harbour. Christopher Widmer used this particular success story to draw the social benefit of the hospital to people's attention:49 'If no Asylum had been opened for their reception not only the mortality amongst these poor people would have been great, but from the carelessness of the Lower Class of the population, in neglecting the benefits of vaccination; which is here constantly offered to them gratuitously, the rapid extention of the disease would have been inevitable.' The medical and the moral mixed freely here as Widmer chided the 'Lower Class' for its failure to perform what was, for him, a public duty. The smallpox incident highlights another facet of doing good that found dramatic expression in this era. Although we do not know how long these two dozen smallpox victims remained under care, their stay meant that, in effect, the York General Hospital was also functioning as an isolation hospital. The act of quarantine - segregating diseased people from the rest of society - has a long and, at times, troubled history. It often pits the rights of individuals against those of the larger community, and Widmer made it clear that he too was trying to balance the needs of the smallpox patients and the town of York by removing them from contact as quickly as possible. Within two years, this added role for the hospital became crucial with the arrival of Asiatic cholera in the port of York. Cholera had moved swiftly through much of the world via ships, so it was already anticipated

34

Providing for the Sick Poor, 1797-1856

with great fear by the town. After appearing in India in 1817, this 'new' disease had spread north to Afghanistan, Russia, and by 1831 to the Baltic. From the busy Baltic ports cholera was only a ship's journey away to Britain and thence to the New World, where it appeared by October 1831 and throughout the summer of i832.5° It came to Canada with the extraordinary wave of British emigrants that year - over 66,000 people. Cases were identified at all the ports of call along the St Lawrence River - first Quebec City, then Montreal, Prescott, and Kingston. By mid-June 1832, cholera struck York.51 Although it is now known to be an acute bacterial infection of the intestine conveyed through sewage-contaminated water or uncooked foods, this scientific fact does not diminish its impact as a frightening and devastating disease. Cholera frequently is fatal, and its victims may be dead within hours of exhibiting the first signs of sickness. Its symptoms instill horror: acute cramps, vomiting, diarrhoea, cold extremities, and such dehydration that it shrivels the skin to a blue hue. The events of the summer of 1832 tested the fabric of Upper Canadian society, as well as that of York. James Lesslie, of a prominent York family, catalogued in his diary his reactions from June to September. In early June he was quite happy that a 'better class' of Scottish and English emigrant was arriving in York - 1,500 in a matter of weeks. By mid-June, the first few cases of disease had broken out, but it was not until the end of the month that Lesslie became alarmed; the number of deaths then rose daily, while communications in and out of York started to become curtailed. Townspeople reacted with prayer meetings on 2 July 1832 to 'implore the mercy of God in his awful visitation upon our Land.' A few days later, Lesslie declared cholera a 'solemn & affecting warning to man.' Attorney General Henry J. Boulton evidently saw in the warning that only the 'drunken & profligate' were attacked, while those of 'regular sober habits' appeared to be spared. Yet the deaths continued unabated: '[Sabbath, 22 July 1832] This morning the Cholera Car passed our door in the morning to convey some person to their long home - and again as we came out of meeting at noon was it receiving the body of a man who had died in the house opposite. - how many cases may have been today I know not.' By i August the mortality was 'truly alarming,' as Lesslie heard of many more who had died within two to three hours of their first symptoms. By 25 September his diary entries convey a great sense of relief; no new cases were reported, and confidence was returning as the 'period of this terrible visitation is perhaps now terminated.'52

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35

Summing up the situation for the Anglican archbishop of Dublin, Rev. John Strachan called the cholera a 'terrible dispensation [that] came among us like a thunderbolt.' By his calculation, out of a population of about 6,000, about 1,200 contracted the disease and survived. Worse, 400 had died, leaving behind about 90 widows, 68 orphans, and approximately 400 fatherless children.53 Doctors quickly became immersed in their own response to the disease. The connection between emigration and epidemic disease triggered actions that married both medicine to morals and the clinical to the political. At the centre of the controversy over all these matters stood Christopher Widmer, the Medical Board of Upper Canada, the newly formed York Board of Health, and the York General Hospital. On 18 June 1832, the day that York's hospital admitted the first cholera case, Dr Widmer convened members of the Medical Board to discuss the outbreak. As president of this board he was empowered to call meetings, although strictly speaking consideration of such an issue was beyond the board's mandate. The Medical Board was only an examining committee that recommended to the lieutenant-governor those who should be licensed to practise medicine in the province, yet Widmer, no doubt sensing, correctly, that York was heading into desperate times, seized the moment. Accordingly, he and several other York physicians, including William Warren Baldwin (the Medical Board's vice-president), unanimously decided to turn the York General Hospital into the central cholera hospital for the area. They believed, along with contemporaries, that the cholera was spread by miasma or vapours. For them, this route was therefore the only sensible one to follow, as the hospital building itself afforded the best environment for treatment of cholera victims: its rooms were cool and airy, and, because the structure was built of brick rather than wood, the cholera vapour could not pass either into or out of it. The hospital could also serve as a general assembly point for all suspected cases of cholera among travellers who might arrive in town, allowing for 'quick access' and 'rapid removal' of patients for segregation or treatment. As well, a central location was ideal, so that doctors could continue with their routine professional duties and not have to attend cholera victims at some 'remote spot.' There can be no question of the logic - if not the wisdom - of this plan. As the summer progressed, however, it ran into difficulties. Only a few days after the Medical Board's meeting, the York Board of Health met to discuss measures to deal with the likely epidemic. This

36

Providing for the Sick Poor, 1797-1856

was a committee hastily convened at the request of the lieutenant-governor, composed of physicians, local politicians, and businessmen whose duties and powers were unclear and who had minimal funds at their disposal. Indicative of the politico-legal nature of this group is the fact that the lawyer-physician-administrator William Baldwin was appointed its president. Concerned primarily with the public health of York at large, Baldwin and his board dealt with matters such as the cleaning and purifying of houses and districts. They ordered the burning of sulphur, pitch tar, rosin, or 'any other anti-contagious combustables at intervals during each day'; the inspection of arriving vessels for the presence of cholera; and the gathering and dissemination of information about the progress of the epidemic. The local Board of Health also influenced the affairs of the hospital: it arranged for a cart (the 'cholera car') to transport sufferers to the hospital and then remove the dead from the hospital to the potter's-field burying ground at the outskirts of the town, and it recommended that people attend the hospital for treatment, 'especially in those cases when the means of friends cannot provide them at home with lodging, airy and wholesome, or with medical attention.'54 Despite all these good intentions, the Board of Health was thwarted by bureaucratic problems. Acting on behalf of the board, member George Ridout declared that 'every effort which the board had made towards removing the cause, and mitigating the evils of the dreadful pestilence now raging in the town, had ... been rendered perfectly nugatory ... and that therefore it was expedient for the board forthwith to dissolve itself.'55 This board did dissolve; then another was formed without Baldwin as president. This action alone hints at a variety of larger political tensions that were starting to bubble to the surface in the whole colony. Meanwhile, actions of the Board of Health directly, and negatively, affected the affairs of the York General Hospital. As residents struggled in various ways to contain the cholera epidemic, they none the less agreed that the hospital was the focus for treatment - the first, and often the last, resort of emigrants. This situation proved problematic for the hospital's image, which became inextricably associated with disease, dying, and death. Public sentiment against the hospital intensified with the rumour that people who appeared to be dead had been removed and buried prematurely. A grand jury was sworn in to investigate the charges, and subpoenas were issued to physicians and hospital staff. By mid-July 1832 the matter was officially settled when the jury concluded that there was no foundation in fact for the allegations of premature burial.

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37

Public prejudice, however, would not disappear. A great injustice had been done to the hospital, its servants and doctors, regretted prominent physician John Rolph. To George Ridout he complained that the Very persons' most likely to benefit from this 'valuable institution' were the ones who had initiated 'prejudice as unfortunate as it is unfounded.'5f) Dr James Cathcart, who died in September 1832 - probably from cholera - similarly knew of York inhabitants who would 'prefer dying first' to being received into the hospital. Cathcart admonished his patients that if he himself were attacked with cholera he would have no choice but to remain in his own lodging or be removed to the hospital; thus, 'often have I told them I would prefer the Hospital knowing that I could receive more assistance there than from my own attendants yet all proved ineffectual.'57 To overcome this stigma, Rolph and others suggested developing an alternative location for cholera patients, perhaps a building that was more neutral. One of the last discussions of the Board of Health was to debate whether an alternative to the hospital should be entertained; clearly, this was an issue that split the board, with those in favour carrying the vote. A former school building was brought into service to receive those people who did not wish to attend the hospital; similarly, a dispensary was established where the sick poor could receive advice and medicine for the treatment of cholera. Cholera subsided by September, and so did pressure on the hospital. Generally speaking, the hospital had weathered this storm fairly well, although Christopher Widmer readily admitted that the 'great influx of Emigrants' had taxed its resources. Had it not been for the 'judicious appropriation,of Charity,' he noted, the situation would have been much worse. During 1831-2 over 3,200 adults and children received medicine and advice through the dispensary, while approximately another 900 were formally admitted to the hospital for treatment.58 Recent events relating to the Board of Health and the hospital led to questions, especially in light of the provincial government's ineffectual handling of the cholera outbreak. When George Gurnett, editor of the York Courier - a Tory newspaper - criticized the hospital for its lack of action in a case in the autumn of 1832, he probably was not acting solely as a concerned citizen. In this case, Joel Whitacre was refused admission to the York hospital because of the lateness of the hour (admissions to the hospital took place only at 11 a.m.); he was then taken to a tavern, where he died. A coroner's jury considered his death a 'visitation of God.' Gurnett was not satisfied. As a former Board of Health member who had been critical of the hospital's performance during the cholera

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Providing for the Sick Poor, 1797-1856

epidemic, he thought that he would revive some of the antipathy that had dogged the hospital during the previous summer. He received instead a stinging rebuke from Christopher Widmer, who could be as skilful with a pen as he was with a scalpel: The funds of this hospital are not ample enough to provide for the accommodation of every person desirous of entering it, or whose friends are anxious to get rid of the charge of nursing and sustaining him; therefore discrimination and enquiry are necessary preliminaries when an application is made. If it followed as a matter of course, that every person applying should be taken in, the drunken worthless vagabond picked up in the streets, whose fittest place would be the stocks, or the debauched candidate for the lock wards, would equally participate in the benefits of a charity intended for the deserving sick poor.59

Widmer was again emphasizing the by-now-familiar mission of the hospital - to aid the sick within distinct limits of social accountability and individual worth. Widmer's understanding of the aims and limits of doing good were generally in tune with the temper of the times. And for all the hospital's shortcomings, perceived or real, it strove to achieve its goals within this frame of reference: it offered surgical and medical treatment, the dispensary gave advice and remedies when needed, and the service rendered during the recent cholera outbreak all helped underscore this fact. These activities formed the foundation for subsequent incarnations of the hospital. Even in these early days, the York General Hospital engaged in another venture that helped set it on its historical path in academic medicine: within only a few years of its opening, it assumed an important role in medical education. Although no formal medical school would be established in York - or indeed the rest of the province - until the 18405, Dr John Rolph, then in St Thomas, together with Dr Charles Duncombe advertised in the iSsos that they would lecture on the theory and practice of medicine as well as giving demonstrations on anatomy and physiology. In the 18305 and 18405 other physicians advertised that they wished a 'respectable young man as a pupil to the medical profession' or that they would 'receive one or two respectable Young Lads as Apprentices to the Medical Profession,' or 'devote two evenings ... to give private instructions, and examinations, to Medical Students.'60 Medical apprenticeship was a well-established educational practice in

A Hospital for Muddy York - Eventually

39

Continental Europe, Britain, and the United States, and it was by this method that some of Upper Canada's early practitioners had received their training. Under this approach, if a physician had established a good practice he might consider having a student indentured to him for upwards of seven years to act as his assistant. In return for room, board, and the execution of tasks such as preparing medicinal compounds, bookkeeping, and assisting in minor surgery, the student would gain access to his preceptor's library, lecture notes, experience, and perhaps medical wisdom. In York, the existence of the hospital and the presence of a relatively large group of physicians (about fourteen in the early 18305) that included Christopher Widmer meant that apprenticing could be extended in scope and somewhat formalized. In the spring of 1832, just before the cholera crisis, on behalf of the Medical Board of Upper Canada, Dr Widmer prepared a document for distribution that outlined the hospital's role in medical education. Consistent with the examining board's conviction that the highest standards of learning and training were necessary to 'improve the education and qualifications of those who are hereafter to have the care of the health of the community committed into their hands,' it appealed to the public, parents, and practitioners to ensure that future doctors received a sound and liberal education. The hospital at York could help achieve this goal because it provided many opportunities for students to observe diseases and their treatment. This message hit home, for by the end of the year the York General Hospital became the base for the York Students' Medical Society, the first such group to be founded in the province and the progenitor of many such student groups to follow. Meeting in the hospital itself on 7 December 1832, these students resolved that their society should 'impart reciprocally' knowledge of the various branches of medicine. To defray the society's expenses and to help buy books for its fledgling library, they set annual membership dues at four dollars.61 The acquisition of medical knowledge and skills, then as now, more often than not took place at the bedside under the watchful eye and ear of an experienced practitioner, so the chance to 'walk the wards' and be exposed to the various eye disorders, fevers, and internal ailments admitted to the hospital would be of great worth to students. Just how much so becomes clear in an 1834 petition that members of the York students' group sent to the lieutenant-governor when they heard of the possible resignation of Christopher Widmer from the hospital. Their special (and successful) plea for his continued services underscored the importance of the hospital as a 'valuable and necessary' institution - the

40

Providing for the Sick Poor, 1797-1856

'only source' for them to obtain the knowledge that would render them useful to society. It was only at bedsides in the York General Hospital that they learned of diseases and their treatment 'under the direction and instructions of an experienced and skilful practitioner.'62 Another popular teacher was John Rolph. One of his first students, James Mitchell, 'an attentive pupil of Toronto Hospital,' apparently survived a 'severe examination with credit' and in 1836 was admitted to the ranks of Upper Canada's medical profession.63 The last couple of years of the first decade of the hospital's operation combined routine and rocky events. Annual admissions of patients averaged well over 500, and anywhere from 1,000 to 1,800 people received treatment in the outpatient dispensary every year. The press of population on activities did not go unnoticed: in 1837, Anna Jameson, on a visit from England to her husband, Attorney General Robert Jameson, remarked: 'The hospital, a large brick building, is yet too small for the increasing size of the city.'64 This was true, for York had grown from just under 3,000 people in 1830 to almost 10,000 five years later. The hospital treated many conditions: inflammations affecting the eyes, chest, and gastro-intestinal tract; cases of ulcers, burns, fractures, dislocations, venereal disease, delerium tremens, and frostbite; and a variety of fevers. It also increasingly performed amputations and, curiously, assisted in childbirth. Hospital reports and returns in this period do not allow sophisticated statistical analysis, but the annual mortality rate for patients averaged about 10 per cent; the remaining patients were discharged either for 'irregularity' or as 'cured' or 'relieved.' Mortality rates for fever alone, in contrast, could be as high as 50 per cent - a figure that hospital doctors considered 'fearful.' Costs were rising. While the government grant fluctuated from between £100 and £500 in some years to no support at all in 1834 and 1835, according to John Strachan expenses were about £1,300 annually. The hospital thus was facing significant financial difficulties. Other sources of income included dividends from investments, proceeds from land sales and rent, and nominal sums derived from those few patients who contributed during their stay in hospital. Between 1829 and 1839, the institution collected approximately £500 from paying patients (the annual amount ranged from a low of just under £6 in 1835 to a high of about £222 in 1839). Hospital trustees recognized that the charge of i/per diem was to no avail because the great majority of patients were 'strangers, poor and destitute and without friends or resources of any description.'

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Added to running costs was the need for new equipment. Dr Widmer hoped that new surgical apparatus would be purchased; he wanted in particular to see the wooden vermin-infested beds replaced with castiron bedsteads that 'are now universally adopted in all Hospitals.' Things seemed to be so bad that Strachan even hinted at the possibility of closing the hospital's doors.65 He was perhaps a bit alarmist: by the end of the decade, the hospital managed to generate a surplus of £500. As troubling as this state of affairs could have been, a more pernicious situation was emerging. Gnawing at the hearts and minds of some around the province, and especially in Toronto (as York was renamed in 1834), was deep dissatisfaction with the Tory establishment and its ruling Family Compact. Flare-ups during the cholera epidemic and through the Board of Health intensified by the mid-i83Os. From its early origins, the hospital was a creature of the Tory establishment, in need of government funds for support. Both the rival Tory and Reform parties saw it as grist for their respective political mills. York's medical profession included ranking proponents of both political groups. Some were vocal Reformers, notably Dr John Rolph. Many, like Christopher Widmer, were Tory. In 1834, the acerbic radical Reformer, newspaper editor, and mayor of Toronto William Lyon Mackenzie, along with his Reform colleague James Lesslie, defeated Widmer in a York aldermanic election. Not surprisingly, when Mackenzie mounted his program against the status quo in 1835, the hospital received a direct hit. What irked Mackenzie was the lack of accountability of hospital managers and trustees; as they were never elected but simply appointed by the Tory elite, he wondered, how could the 'inhabitants of the city and county' exercise any influence over hospital affairs?66 Mackenzie had a valid point. The terms of the original 1819 agreement, which saw the official creation of a hospital board of trustees, had actually accorded the staunch Tories James Baby, William Dummer Powell, and John Strachan governance rights beyond even themselves - their positions passed to their heirs and successors forever. It would not be until 1847 tnat a new agreement revised these terms. Members of the town's medical profession sowed further seeds of discontent. Under the chairmanship of Dr William Gwynne, who had trained in both Dublin and Edinburgh and established a practice in York in 1832, a number of Toronto's physicians convened in January 1836 to discuss the connections between the hospital and the Medical

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Providing for the Sick Poor, 1797-1856

Board of Upper Canada. The surviving account of this meeting reads at first as a tribute to the hospital, then as an indictment of it: the real thrust of the gathering appeared to be an attack on the Medical Board and, by implication, on Christopher Widmer. Those present fully applauded and endorsed the mission of the hospital, which was 'calculated to lighten the afflictions of the poor portion of society labouring under disease, or suffering from accident/ yet they were troubled about the rising prejudice that existed in the 'minds of the poor classes' towards the hospital. Though ill-founded, such popular opinion arose, they thought, from the belief that doctors experimented on hospital patients in lieu of charging them. This fear was supported by the 'veil of obscurity' that surrounded the hospital inasmuch as no public information about hospital activities, medical appointments, or other reports ever became available - the 'passing bier alone' was the only 'melancholy proof that this institution was still active. All of this secrecy prompted questions about the original constitution of the hospital, the appointment of trustees and physicians, and the statements of admissions, discharges, and ailments. This same veil enshrouded the Medical Board and its examining activities as well, for were not the same physicians who ran the hospital also in charge of the board? Was it right that only a couple of doctors (an indirect reference to Widmer and his close colleagues) should be allowed to hold 'their inquisition in utter darkness'?67 In a 'memorial' sent to the trustees, Gwynne reiterated his allegations that the hospital and the Medical Board had centralized medical power in the town to the detriment of physicians who had been excluded from this group. He charged that only three or four doctors were responsible for most of the major decisions respecting medical affairs and that matters were resolved 'solely by their own inclinations.' On behalf of the hospital, and for the Medical Board too, Christopher Widmer replied that if a hospital were to be efficient and hold the public's confidence, then it was quite right that only a few physicians should have the responsibility for operational matters. The wards, he explained, were always 'cheerfully open' to well-conducted medical students wishing to observe and learn from hospital activities such as major surgical operations. Finally, as indicated by the 'numerous daily applications' for admission, the public's confidence in the hospital remained intact. Widmer's rebuttal rings a bit hollow on this last point, in the light of earlier public dissatisfaction with the hospital, even though it is clear that many people did actively seek the hospital's help.68

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This exchange between Gwynne and Widmer brought more public notoriety and government scrutiny for the hospital - something that it could well do without, given its precarious financial position. Its immediate upshot was an enlargement of the membership of the Medical Board to make it more representative of the doctors of Upper Canada. A second outcome was the appointment in 1839 of Dr Gwynne as the resident medical officer to the Toronto General Hospital, succeeding Dr Peter Diehl.69 Once again, medicine and politics were inextricably interwoven. As in the past, there was an implied guilt through association because of the hospital's bureaucratic connections to the Tory Family Compact. After the appointment of the intransigent Francis Bond Head as lieutenantgovernor in 1835, political issues became ever more polarized, and in the period leading up to the Rebellion of 1837 rifts appeared in a variety of social and professional contexts. Widmer, still a Tory, found out that he was not Tory enough when he clashed with Bond Head over the creation of a medical faculty in King's College.70 The medical profession was as much affected by the convulsions of 1837 as were Toronto and the province at large. John Rolph had to cross the border with a price on his head; other physicians were arrested for treason. Partly because of these radical reactions to Tory rule, Christopher Widmer later changed stripes to run for public office on the Reform ticket. Many of the political tensions of these years remained unresolved through the 18505, continuing to influence the hospital's position and function in society. The closing years of the 18305 were troubled ones for the province and for the hospital. In the 18305, its first decade of operation, the hospital had undergone several trials of endurance and survived. Constant financial challenges, bureaucratic bickering, and political upheaval, followed by the appointment in 1838 of yet another lieutenant-governor to restore and maintain order, all buffeted the hospital. The unexpected resignation of a trustee in the same year after a hushed-up government investigation into his sexual encounters with a drummer boy and other young men added little to the hospital's reputation.71 It would have been difficult to predict just what its future would hold.

2

Medical Politics, Political Doctors, and a Beleaguered Hospital, 1841-1856 Lying vacant for its first five years, housing the legislature for the next five, the York hospital building from 1819 to 1829 had embodied only the concept of a hospital. Colonial inertia and bureaucratic appropriation had conspired to keep the hospital from becoming a reality. Once it did open to patients in 1829 - only after confronting the government occupants - events of the 18305 could easily have ruined it. While the fledgling hospital had managed to care for thousands of the sick poor and to become a focus for medical training, crises of epidemic disease and social protest had embroiled it in political battles, professional jealousies, and inadequate public support. Worse was ahead. As the colony of Upper Canada revamped the old order over the next few years, the scaffolding for modern Canada was erected. The Act of Union of 1840 formed the united Province of Canada out of Upper and Lower Canada. Institutionalization became the order of the day in all spheres of endeavour - the hospital itself received incorporation in 1847. Education became formalized at all levels, although early medical schools - as we see in this chapter - often gave off more heat and smoke than light.1 Industrialization brought prosperity along with the roots of the labour movement.2 This was a tumultuous process. In the 18505, riots broke out in Toronto over issues of public ownership and the form that public services should take. At bottom, they represented class struggles over who should control public agencies and whom they should serve.3 Such upheavals outside Toronto's general hospital had their counterpart inside in bitter strife over its organization and care of its patients. As a reflection of the temper of the times, the hospital's troubles made exceptionally good copy for newspapers read avidly across the prov-

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ince.4 The Anglo-American Magazine - a monthly publication that appealed to the province's rising middle class5 - delighted in making fun of it. After the Colonist published a charge that the hospital was a 'fountain of moral pollution/6 a raucous inquiry offered fodder for other newspapers. Feuds among Toronto's doctors spilled over into their brand new medical journals as well.7 As streams of the sick poor, augmented by another influx of diseased immigrants, swelled its wards, the hospital became the battleground for advancement of the medical profession, and its nadir occurred in 1855. The Old Order Crumbles In the wake of the 1837 Rebellion, which provided the impetus for official scrutiny of provincial affairs,8 the hospital received its share of government attention. In 1839 the government appointed William H. Draper to undertake a 'minute investigation' of the hospital's affairs, which were Very far from being satisfactory,' and to make recommendations for its future operation.9 Draper's appointment signalled an attempt to handle administrative and political matters in a new way. As attorney general of Upper Canada, an Anglican well-connected to the likes of John Beverley Robinson and John Strachan (now bishop of Toronto), Draper was a Tory aligned with the weakened Family Compact. None the less, he was a moderate conservative, had sympathy for the political principles of moderate Reformers, and even had hopes of forming a political party that was centrist.10 The report that Draper submitted in 1840 along with fellow commissioners Christopher Widmer, Alexander Wood, and the physician John King was not radical, but it did mandate change while catching up on 'housekeeping' issues. It called for greater fiscal responsibility in the hospital's accounting and reporting and for the election of hospital governors. It also recommended a more aggressive program of collecting back rents from those who leased hospital property. The most significant recommendation gave those responsible for the hospital the corporate authority to buy, sell, and hold land. Up to this time, others had looked after the hospital's land endowment (consisting of parcels of land throughout the city). Implementation of this recommendation would permit trustees to exert greater control over the hospital's financial management and would move the institution towards political autonomy and self-reliance.11 With the appointment of the first governor general of the new united

46

Providing for the Sick Poor, 1797-1856

province in 1841, Sir Charles Bagot, hospital trustees unsuccessfully attempted to follow up on this last recommendation.12 Public reaction was forthright. Although it steadfastly endorsed the usefulness of the hospital for doing good, the British Colonist reported 'repeatedly heard accusations' about trustees' mismanagement of hospital affairs and lamented that the commissioners' report had not been made public. If trustees did not discharge their duty and ensure that the hospital fulfilled its obligation to society, a full public inquiry was warranted.13 If these external rumblings did not produce strong winds of change, they at least sent a few breezes through the Toronto General Hospital. The meeting of trustees in October 1841 was the last for the old guard of William Allan, John Dunn, and John Strachan - all of whom had been trustees since the board's formal creation in 1822. The next meeting in January of the following year convened a new board comprising Christopher Widmer (chair), Rev. Henry J. Grasett, George P. Ridout, William Ross, and James Smith. This group would soon add James Armstrong and John Ewart.14 Widmer's appointment was not surprising, given his numerous years of service to the hospital, but it was an unusual position for a doctor. Apart from Widmer, these choices signified a new direction in board management from Georgian gentlemen to Victorian merchants. Henry Grasett kept the Anglican connection and a direct line to John Strachan, for whom he worked, even while he developed a reputation for being his own person. James Armstrong, George Ridout, and William Ross brought business expertise to the board, as iron founder, hardware merchant, and wine and liquor merchant, respectively. Armstrong injected a different worldview that would become vital to the operation of the Toronto General Hospital: he was a firm Methodist whose son-inlaw was Egerton Ryerson, the great Methodist force in public education in the province.15 John Ewart, the man who actually built the hospital, had long demonstrated his civic-mindedness in Toronto; as the first president of the Mechanics Institute, an early form of public library, he promoted the cause of practical education for workers. Along with Grasett, Ewart served as liaison with other medical institutions founded in the 18408 in Victorian Toronto. Ridout's experience also included membership on the local Board of Health during the cholera days of 1832, and, unlike former members of the hospital board, he was a moderate conservative. In short, the new hospital board reflected the society and political climate of the new province from which it was formed, retaining connec-

Medical Politics, Political Doctors, and a Beleaguered Hospital

47

tions to the Toronto elite while representing broader constituencies. In 1845 the board acquired the services of Thomas D. Harris and Clarke Gamble, a merchant and a lawyer respectively. Harris was known for getting things done.16 With his appointment, Gamble began an association with the hospital that would last almost 50 years. He later declared that he and the other board appointments in the 18405 were made to 'carry out the necessary reforms in the management which, up to that time, had been entirely in the hands of Dr. Widmer, and had run to seed fearfully.'17 Not surprisingly, within a couple of years of this team's assemblage, it managed to achieve the primary recommendation of William Draper's hospital commission report of 1839-40: the incorporation and consolidation of hospital management. Legislation to incorporate the hospital trustees encountered no difficulty in its passage through Parliament: from first reading to royal assent on 28 July 1847 took only six weeks.18 This act granted the trustees a level of authority consistent with their responsibility, allowing them full power over the hospital's affairs. As trustees of a corporation, they were to exercise 'better management and disposition of the lands and properties' of the hospital; to sue, if necessary, to recover rents; and to oversee the hospital's internal activities. The act also delineated the hospital's role in medical education, decreeing that medical students who had paid the appropriate fees could attend patients; this provision did not change actual hospital practice, but it did protect students and their educational opportunities while addressing criticisms lodged a decade earlier. Under this act the composition of the board of trustees changed significantly. New rules called for three city residents to be appointed by the governor-in-council, along with the mayor of Toronto and the president of the Board of Trade - at least 'for the time being.' Having both these men as trustees, no matter how temporary a measure, tied the hospital closer to Toronto's city fathers and introduced an element of reciprocal accountability. As well, the rules specified that 'two Senior Professors of any School of Medicine to be hereafter established in the said City [of Toronto], and in default or until the establishment of such School, any such medical men resident in the said City'19 would be nominated and appointed to fill vacancies on the board. Such mandatory appointments, and the method of selection, similarly created the potential for strife. This stipulation might have appeared sensible at the time, but what criteria would be used to define 'seniority'? Toronto's doctors were already anxious for

48

Providing for the Sick Poor, 1797-1856

inclusion on the board, so the possibility of acrimony and discord over the term was ever-present. The issue of a medical school also might raise hackles. What if more than one medical school were to be established? Would both professors hail from the same school? Would one be chosen from each? What if more than two schools existed simultaneously? These questions are not merely hypothetical. As we see below, there were up to six medical schools founded in Toronto, any two to three of which may have operated at any one time; furthermore, professors might change allegiances and move from one rival medical school to another. Unwittingly, in trying to solve one problem, this aspect of the new legislation opened the door for many others. Under the auspices of the new act, the board of trustees of the Toronto General Hospital met on 3 September 1847. Only Henry Grasett and George Ridout continued from the previous board; indeed, being president of the Board of Trade, Ridout was obliged to do so. The two appointed physicians were Dr John King and Dr Lucius O'Brien, both well-established medical men and longstanding members of the provincial Medical (examining) Board.20 Assuming the chair of the trustees was William H. Boulton, a dubious choice. On one hand, Boulton was an affluent lawyer with strong connections to the Family Compact John Beverley Robinson was his uncle - who had become mayor of Toronto the previous year; on the other hand, he was a brash Orangeman who had once exhorted electors to be wary of 'Tobacco-smoking, Dram Drinking, Garlic Eating Frenchmen.'21 With this bombastic style, Boulton probably would not have served the hospital's best interests even in a good year. But 1847 turned out to be terrible for anyone who was either mayor of Toronto or chair of its hospital's trustees - let alone both. The exodus to Canada of tens of thousands of starving, destitute Irish peasants brought typhus or 'ship' fever to Toronto and threw the city into turmoil. Of the nineteen trustees' meetings scheduled for 1847, half were abandoned because of lack of a quorum. Then, because city council did not reappoint Boulton as mayor at the end of 1847, ne resigned from the hospital board in January 1848. At this juncture, Christopher Widmer was unanimously reappointed as chair - a post that he would hold until his death in i858.22 Life in the Toronto General Hospital at Mid-century

In many respects, the hospital at mid-century resembled a patriarchal household economy. Staffing matters occupied a good deal of the

Medical Politics, Political Doctors, and a Beleaguered Hospital

49

trustees' time. There were three resident members of staff: the steward, the matron (usually the steward's wife), and the apothecary. Others included a head nurse, day- and night-nurses, at least one orderly, and a washerwoman. Because visiting physicians provided their services without pay, they were not considered staff; however, as they were 'appointed' to the hospital, trustees could revoke their privileges. The steward and matron received £100 per annum between them; they also received a food allowance and free lodging within the hospital. Together they were to maintain the building, see that it was properly furnished and supplied, keep routine accounts, oversee the general needs of the patients, ensure that all hospital rules were observed, and dismiss staff on the instructions of the trustees. Their combined role resembled the key positions of head butler and housekeeper in a wellto-do Victorian household. The board felt no compunction over dismissing either a steward or a matron for cause. Under such circumstances both would have to vacate their lodgings, children and all in one instance, and move on. In the event of a vacancy, there was no shortage of applicants for these positions, suggesting that these jobs were considered worth obtaining.23 As in the domestic sphere, sometimes the steward's and the matron's individual duties intersected. When the board instructed the matron in 1845 to ensure that all medicines prescribed by the attending physicians were regularly administered by ward nurses, she had to report any irregularities to the steward - who was, of course, her husband. A few months later, the board chastised the matron for not following this instruction and required that she report to the trustees, along with the ward nurses, at 9 a.m. and 4 p.m. In the same minutes the trustees then approved the purchase of a clock for the hospital, tacit acknowledgment that without it, staff had been unable to fulfil the board's orders appropriately - perhaps for the whole of the seventeen years the hospital had been in operation.24 The position of resident apothecary ranked considerably higher, receiving £100 per annum and living quarters on the premises. Typically, a younger, recently qualified doctor who wished to gain a breadth of hospital experience would take this post. He would prepare all prescriptions, tend patients daily under the orders of attending physicians, and be on call for whatever medical matters might arise.25 He would act as secretary to the provincial Medical Board26 and no doubt handle a good deal of 'scut work' as well. Before 1842, there was turnover in this position. Trustees dismissed the apothecary, F. St George Wilkinson, in 1840 for writing, under the

50

Providing for the Sick Poor, 1^7-1856

name of the head nurse, a letter of complaint about a physician's improper conduct. These actions attracted Hugh Scobie, editor of the Toronto Colonist, who published a pamphlet on the affair after talking to both the hospital steward and Dr Hornby, one of the visiting physicians. Christopher Widmer then wrote to Hornby, and the two physicians had a falling out. Trustees admonished all parties, noting that they had no intention of settling 'a series of petty disputes,' and they reprimanded Hornby for his actions.27 (Several years later, Hornby became embroiled in another dispute with hospital trustees, whereupon his appointment was terminated.28) In 1842, trustees accepted the resignation of the apothecary, Mr Givens, for dereliction of duty in his neglect of patients.29 Dr Edwin Henwood then served as resident apothecary from 1842 until he resigned to go into private practice in 1847; he was succeeded by Dr Edward Clarke, who continued in the job until his suicide in the hospital nine years later. Apart from the three key resident positions, the hospital employed several kinds of nurses. The concept of the nurse in the 18405, however, was a far cry from that of the professionally trained counterpart to come in forty years' time. As indicated by their wages, nurses fell somewhere between the washerwoman and the orderly in the pecking order. Day and night nurses received £1.15.0 and £2 per month, respectively; the washerwoman was paid £1.10.0 per month, an orderly £2.10.0 per month. Night nurses were provided with accommodation in the basement of the hospital. If employment was steady, these workers could make between £20 and £30 annually, a sum that probably was not enough to live on if they were unmarried. A male artisan or tradesman would earn at least twice this amount annually.30 All nurses were required to ensure that patients received their medicines; they also performed myriad domestic duties, rendering their role akin to that of a household maid. The hiring and letting go of nurses fluctuated with the number of patients admitted to the hospital.31 The position of orderly entailed (as it still does) the maintenance of order. Analogous to the job of a porter, it involved physical labour to move objects, patients, or the dead. On one occasion, the board fired an orderly for being 'privy to a coffin being sent from the Hospital for interment without the body of the deceased patient.' This charge suggested that he was implicated in selling the body for medical dissection - a not-uncommon, but frowned-on practice of the time. That the board considered fifteen applications for his replacement indicates again that a job with the hospital was eagerly sought.32

Medical Politics, Political Doctors, and a Beleaguered Hospital

51

Beginning in the 18405, trustees visited the hospital routinely to inspect its state, meet with staff, and talk to patients. Early on, they paid little attention to the building, except to schedule painting. They also approved plans for piping in running water and considered connecting the hospital to an external drain. Improving access was a priority. In 1847 trustees petitioned city councillors to build planked sidewalks around the hospital because in 'soft weather' doctors had either to wade through deep mud or to climb along the fence bordering the property; they petitioned, too, for a light at the hospital entrance to make access by the sick poor convenient 'at all hours.'33 Inside, they oversaw the constant demand for sheets, bedding, and other cloth and accounted for every blanket, piece of cutlery, cooking utensil, tin cup, bed pan, and spittoon (there were seventy-nine, two, and eight of these last three items, respectively). Christopher Widmer clearly had been successful in obtaining iron bedsteads, for board minutes in the 18408 show the presence of eighty - a figure that suggests the number of patients accommodated.34 Food was also important in trustee visits. Widmer, who always seemed to be present for lunch, often praised the 'excellent soup' or 'excellent meat' served to patients.35 Trustees controlled the admission of patients. First and foremost, because patients were only to be the sick poor, they ordered the hospital steward in 1845 to post the following notice in a 'conspicuous place' as a reminder: 'The Trustees desire to call the attention of Medical Officers of the Hospital to the class of persons they may admit as intern patients. In a charitable Establishment it cannot be contemplated that any but the actual destitute labouring under disease should accrue its benefits, this rule is especially applicable to persons applying for admission for Venereal complaints.'36 They forbade the admission of pregnant women as well, even though the hospital provided limited obstetric care. This particular proscription was grounded in medical and moral thinking. Pregnant women were believed to be high-risk patients because they would likely develop puerperal sepsis - a deadly disease that could easily spread to other women. (That this bacterial infection was actually transmitted by physicians themselves was not accepted until much later in the century.) They also saw unmarried pregnant women as undeserving of charity in a public hospital. In 1842 they stipulated 'that all persons of this description [pregnant], who are admitted shall be married women who bear the recommendation of some respectable inhabitant of the City.'37 By the close of the decade, a private lying-in (or maternity) hospital

52

Providing for the Sick Poor, 1797-1856

had been established in Toronto. Funded primarily through subscription by well-to-do Anglicans, it cared for hundreds of married and unmarried women, typically in their twenties. As one annual report indicated, the admission of unmarried women to the lying-in hospital was grounded in morality: the 'erring sister' was thereby brought into 'contact with virtue and respectability, and being in some measure forced into the presence of religion, learns to value both as superior to vice and infamy.'38 Trustees of the Toronto General Hospital also barred people with incurable diseases or psychiatric conditions from admission. Generally speaking, these particular prohibitions were grounded in financial considerations. As both these kinds of patients had no prospect of recovery by any medical or surgical means then known, they might remain in the hospital indefinitely - not only occupying beds for an extended period but also costing the hospital a considerable sum in their maintenance and care. Lunatics presented an additional problem, for they could become uncontrollable; one incident of such an admission had led to 'much inconvenience and injury.'39 Lunatics might well be incarcerated in jail cells; however, by the 18405 a temporary asylum of sorts existed in Toronto. In 1850, a massive purpose-built institution for the care of the insane was built in the city - at '999 Queen,' as it came to be known to successive generations of Torontonians.40 When walking the wards, trustees freely obtained details of medical treatment from patients themselves - information that might reflect poorly on doctors. On one occasion, a trustee therefore could charge that patients had received no treatment for accidental injuries. He found out only afterwards that the medical officer of the week had indeed visited the patients on the evening of the accident and then twice again the following day, as entered in the physician's casebook.41 In 1846 trustees lowered the boom on what appear to have been commonplace domestic practices introduced to the hospital wards. They informed the apothecary that nobody was to reside in the hospital except people connected with it. Did this mean excluding patients' family members, such as small children with their widowed mother? Quite probably it did. That dogs and smoking were simultaneously banned suggests that pets and pipes had both outstayed their welcome.42 In these ways, the notion of a household had affected patients' behaviour in hospital. Even unrelated patients might develop substitutes for family bonds, as shown by one man's leaving '2 Sovereigns and an American Bank note of $3' to a fellow patient upon his death in hospital.43

Medical Politics, Political Doctors, and a Beleaguered Hospital

53

Patients, their conditions, and their treatments lie at the core of all hospital experience. Their plight formed 'truly a lamentable picture,' Dr John King informed colleagues in the Upper Canada Journal of Medical, Surgical and Physical Science, 'yet such has been the history of many poor patients treated by me in the Toronto General Hospital.'44 This medical journal, the province's first, gave physicians such as King an invaluable local platform for presenting and discussing their hospital cases. It was only as a result of hospital incorporation in 1847 that the Toronto General kept detailed records of its activities to report to the government. These records have not survived, but, as we see below, the published government 'return' derived from them paints in broad brush strokes a portrait of all clinical activities in the hospital in the 18408 and 18505. Some reports in the new Toronto medical journal, in contrast, were not representative (having been selected by physicians often for their unusual features), but in general they convey detailed information about individual patients: their names, gender, ethnicity, occupations, life histories, and sufferings; their length of stay in hospital; and their actual treatments. They also reveal doctors' attitudes towards charitable work in the hospital: 'feeling, as I do, that there is no class amongst the miserable and destitute more entitled to our sympathies and commiseration,' King explained, 'I have never hesitated cheerfully to afford my humble assistance to endeavour to relieve their sufferings.' Two Irish immigrants, Hugh Kirkland (aged nineteen years) and John Campbell (fifty-two years), sought King's help for their severe psoriasis. Hugh Kirkland, a labourer, suffered so much, King explained, that 'quarts of scales can be daily collected from his bed and cloths [sic].' In the Toronto General, he received mercury and arsenic treatment until 'perfect restoration to health.' A farmer turned grocer, John Campbell had travelled from Ireland to North America three times in search of a better life. He entered the Toronto General in January 1851 for extensive treatment: opium and jalap (a powdered root), purgatives, warm baths three times daily, Fowler's solution of arsenic daily, Plummer's pills (a mixture of sulphur, mercury, and gentian), potassium iodide solution (to stimulate secretions), Dover's powder (a mixture of opium and ipecac to promote perspiration) , and 'every other remedy that could be thought of.' When this regimen did not work, a special opium and mercury pill was prescribed three times a day, augmented by more doses of arsenic. When he was discharged after several weeks, Campbell was apparently cured and able to return to work; indeed, he described himself as 'regenerated.'

54

Providing for the Sick Poor, 1^7-1856

Two other detailed cases were under Dr William T. Aikins and Dr James Bovell. Aikins treated forty-three-year-old Daniel McKay, an unmarried painter, for several months for injured genitalia. After McKay had fallen astride a scaffolding plank that then collapsed, his injury had developed an abscess. A slow process of inserting catheters of ever-increasing diameter, and an incision to remove an accumulation of pus, allowed him to regain his health and the ability to urinate normally.45 On 23 June 1847 William Chase, a fifty-three-year-old 'black native laborer,' came under the care of Dr Bovell. Suffering from an ulcer on his right leg and large swelling of the skin and underlying tissue, he was placed on a special diet. He had applications of nitric acid solution to his leg ulcer, lotions to his head, and a blister (an irritating plaster) to his neck. He was also prescribed mercuric compounds and Dover's powder. By 11 July a nurse informed Bovell that Chase's condition was deteriorating: he was vomiting yellow and slimy green bile, had extensive pain and headache, and was unable to sleep. Two days later he was delirious, with a pulse of 120, incontinent, and cold to the touch. * Sinking fast' at 8 o'clock in the evening of 14 July, he died two hours later. The next morning, with his body 'quite fresh, and free from decomposition,' a port-mortem examination revealed no traces of disease other than swollen lymphatic glands in the groin that were 'enlarged to the size of a goose egg.' Recognizing that his patient had 'Barbados leg,' Bovell inferred it to be a disorder of the lymphatic system. (In all likelihood, Chase had filariasis, a worm infestation that eventually affects the lymph glands.)46 The most extensive series of physicians' narratives from the midnineteenth century for the Toronto hospital, numbering at least twenty, was published by Dr William Beaumont. An English-trained surgeon who arrived in Toronto in 1841, Beaumont soon became the hospital's and the province's - most prominent practitioner.47 In two examples of facial reconstructive surgery on young women, Beaumont demonstrated as much professional skill as his patients displayed remarkable fortitude, for these were the days before anaesthesia. Sixteen-year-old Mary Ann Marshall lacked a lower lip, resulting in her inability to speak clearly, difficulty in eating or drinking, and the constant escape of saliva from her mouth. During the first two months of 1846, Marshall endured three severe operations in which Beaumont incised and pinned parts of her face to construct a lip. On her discharge from hospital, the young woman had a new lip that covered her toothless gum, and she was able to articulate distinctly; her other problems were also rectified. In the

Medical Politics, Political Doctors, and a Beleaguered Hospital

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second case, Hannah Shea, aged twenty-five, underwent two operations during her stay in the Toronto General Hospital from 25 June 1846 to 11 July 1847. Because of severe facial burns, scar tissue had fused Shea's lips, leaving an oral cavity the diameter of only a small finger. Through a series of incisions coupled with appropriate suturing, Beaumont created an opening of normal proportions. This new, artificial mouth restored the patient's ability to eat relatively normally, but unfortunately, as she was deemed of 'unsound mind,' Hannah Shea subsequently was admitted to Toronto's lunatic asylum. She remained an inmate there for at least four years.48 Ophthalmic surgery was another of Beaumont's specialties. He reported his results on cataract and other eye operations in fifteen cases relating to men between eighteen and seventy-two years (the average age being thirty-eight). These patients stayed in hospital on average for about sixteen weeks, with a range from three to twenty-two weeks. Cataract surgery involved sectioning the cornea, opening the iris, and attempting to remove the cataract. Just under half of those who underwent this operation had their eyesight improved; others who suffered accidental eye injuries from gunshot or work-related hazard had a poorer surgical outcome. Out of all these ophthalmic cases, only one man died, the result of circumstances other than surgery. On 26 July 1844, Joshua Strother, a fortyfive-year-old 'African black,' was admitted to the Toronto General in feeble health and with a bluish-white opacity in his left eye; he was also considered mentally deranged. By 25 October, he had undergone an operation to remove the cataract. His treatment consisted of cold-water dressing and rest in a darkened room; forty-eight hours later he was bled (through venesection) until he felt faint, and then he was bled again and given calomel and opium until his gums were sore. This latter sign was interpreted positively as showing that the mercury had entered his system. Strother's cornea healed, and his eye was no longer inflamed. Seven days after this operation, however, he became totally deranged and fled from the hospital during the night. (The condition could have been the result of his original mental state or of aggravation by mercuric treatment.) Three days later Strother was found lying in some mud in an imbecilic state and was returned to hospital. On 3 February 1845, over six months after he was first admitted, Joshua Strother suffered a seizure and died in hospital.49 With incorporation in 1847, the Toronto General Hospital for the first

56

Providing far the Sick Poor, 1^7-1856 Table 2.1 Patients' place of birth, Toronto General Hospital, 1847-55 Place of birth

Number

2

Percentage

West Indies Wales Germany United States Canada Scotland England Ireland

519 4,428

0.04 0.13 0.40 1.70 3.90 4.20 9.41 80.25

Total

5,518

100.00

7

22 94 213 233

time began to keep close track of admission and discharge statistics as well as patients' birthplace and reason for admission. Its return prepared for the government shows that it admitted 5,581 patients for the period from 25 November 1847 to i May 1855; of this total, it discharged 5,518, with 63 patients remaining in hospital. Admissions ranged from 691 to 898 per year, with the annual average being 769, placing the Toronto General Hospital in the same size and class as a typical English provincial hospital at mid-century.50 Those who left cured or relieved made up 84 per cent (4,647) of patients. Ten per cent (559) died; 2 per cent (88) were considered incurable; and the remaining 4 per cent (224) either left at their own request or were dismissed from the hospital. The mortality rate of 10 per cent remained the same as that of over a decade earlier, even though the hospital was admitting, on average, about 50 per cent more patients per year. The place of birth of discharged patients was significant (see Table 2.i). The remarkable predominance of Irish-born patients - 80 per cent - accords with trends in immigration in the province. It also reflects a peak of Irish emigration during the potato famine of 1847. According to contemporary accounts of the utterly debilitated condition of most Irish refugees, they would be in greater need of medical attention when they arrived in Toronto. In addition, the typhus epidemic that they brought with them in 1847-8 wreaked havoc on most Canadian port cities, including Toronto, as the last stop from the St Lawrence River. Spread by infected lice, it migrated with their human hosts, and several physicians in Toronto succumbed after contracting the disease from their

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emigrant patients.51 Among them was Dr George Grasett, who died at the home of his brother, and hospital trustee Rev. Henry Grasett.52 The hospital's ability to cope during this crisis was helped by the addition of numerous fever sheds; operated by the city's Board of Health, the sheds repeated the plan, albeit more successfully, first implemented during the cholera epidemics of the 18308. Through an arrangement with the government, the Toronto General Hospital also received funds for the care of emigrants.53 With few - if any - family members or friends to whom they could turn for help in the city, these Irish would have found the hospital a place of refuge and care. It is difficult to interpret in modern terms the nature of mid-nineteenthcentury conditions treated in the hospital, for the naming and classifying of diseases - known as nosology- changes with evolving technology, medical theory, and treatment methods.54 Many of the specific terms in the government report are either archaic or have been redefined: 'phthisis,' for example, would now be called tuberculosis, a term that relates to one of the condition's main organic symptoms. Physicians identified over 100 diagnostic conditions for admission to the Toronto General, the classifications of which we can infer from entries made in close proximity. For instance, the report listed together conditions affecting the eye: amaurosis, conjunctivitis, cataract, glaucoma, ophthalmia, iritis, ulcer of cornea, ptosis, staphyloma, gonorrheal ophthalmia, and fistula lachryma. This type of arrangement makes some sense today because it groups conditions around a particular organ. The report similarly tended to list conditions around an anatomical system such as the respiratory system, as in bronchitis, pleuritis, pneumonia, pleurodynia, phthisis, and catarrh. The context of a system also led to the grouping of conditions today considered distinct, as in the case of diabetes, nephritis, irritable bladder, incontinence of urine, retention of urine, rupia, syphilis, gonorrhoea, and orchitis. As diabetes was once known as the 'pissing disease' owing to copious urination, its appearance with other genito-urinary conditions in this report becomes more understandable. To account for nosological differences over time, a different arrangement aggregates the undifferentiated categories of admission for the 5,5OO-plus cases of disease into broad categories. In this way, Figure 2.1 reveals immediately that fever was the primary reason for admission to hospital (27.7 per cent). The second largest category here, for gastrointestinal and internal diseases (13.8 per cent), similarly accounts for disparate complaints noted in the report - diarrhoea, dysentery, edema,

58

Providing for the Sick Poor, 1797-1856

Figure 2.1 Conditions treated, Toronto General Hospital, 1847-55

hepatitis, jaundice, and so on. Surgical/orthopaedic problems vie with accidental injuries for third-largest category, at 13.1 per cent and 12.9 per cent, respectively. Together, accidental injuries, fever, gastro-intestinal ailments, and surgical problems represent two-thirds of all hospital admissions in this period; seven other groups make up the remaining third. It is worth considering in finer detail the breakdown of the major category for hospital admission - namely, fever - since it clearly posed a significant and enduring threat. The debilitating ague that so annoyed the townspeople of early York continued to be a problem in mid-Victorian Toronto; as Figure 2.2 shows, about 22 per cent of all fevers treated were of this intermittent or malaria-like variety. Although specific diseases such as chicken pox (varicella), measles (rubeola), scarlet fever (scarlatina), and smallpox (variola) together account for a relatively small proportion of total fevers admitted - 12.4 per cent - they could vary in severity and might often be fatal. Cases of cholera and typhus fever both have incongruously small percentages, given the typhus epidemic of 1847-8 and another cholera outbreak in 1849. The great majority of these cases in Toronto, however, were treated in separate fever sheds or other facilities operated by the Board of Health. As well, doctors may not have accurately diagnosed these two diseases for any number of reasons, not least of which was difficulty in differentiating symptoms in

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Figure 2.2 Types of fevers, Toronto General Hospital, 1847-55

debilitated patients. It was probably much easier, and faster, to generalize the fever into an undifferentiated 'communis' (universal) or 'continued' class; hence, these large categories - at 30.6 per cent (communis) and 23.3 per cent (continued) each - no doubt included typhus, if not cholera too. That fevers constituted the single largest class of conditions admitted to the hospital in itself raises an important issue. In Europe and Britain, a trend well under way was not to admit fever patients to general hospitals but to build separate and distinct fever hospitals for their accommodation.55 To their credit, Toronto doctors were aware of this movement, and as early as 1840, Christopher Widmer, on behalf of the hospital, advocated creation of such a separate fever facility 'so generally adopted in the cities of Europe/56 None the less, the local response was to continue to put up only temporary fever sheds for the duration of any epidemic crisis. All these admission figures take on added meaning when compared with causes of death reported by the hospital. Figure 2.3 shows the breakdown of these causes within the overall mortality rate of 10 per cent. As with admissions, fevers and gastro-intestinal/internal diseases account for the bulk of the deaths, with rates of 23.7 per cent and 22 per cent, respectively. However, respiratory diseases represent the third-

6o

Providing for the Sick Poor, 1797-1856

Figure 2.3 Causes of death, Toronto General Hospital, 1847-55

largest cause of death (18.3 per cent), much higher than their fifth place among admissions. This situation is attributable, at least in part, to inclusion in this category of diseases that normally had a high death rate, such as bronchitis, pneumonia, and tuberculosis (phthisis). Another threat to life involved broken bones. Of the 170 people admitted with bone fractures, 28 had a compound fracture; 9 of these people died. When a bone punched through the flesh to the outside, it often led to a lethal infection that doctors were unable to control at the time. The chances of dying from a compound fracture were thus 1:3 - a ratio that corresponds with other, recognizably high-risk diseases such as cholera. Reports of the Toronto General Dispensary, and later the Dispensary and Lying-in Hospital, provide collateral evidence to sharpen the picture of patients and hospital life in this era. The dispensary originally had functioned as the outpatient department of the hospital before falling into decline and failing from lack of funds.57 In the mid-i84Os the dispensary concept was resurrected, and the Toronto General Dispensary became an independent but closely allied institution of the general hospital. As an Anglican-sponsored endeavour, the dispensary tapped into the roots of this extensive social and political network, evident in the overlap of medical officers and trustees between it and the hospital: the names of Bovell, Grasett, Ridout and many others appeared on the

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roster of supporters of both.58 The dispensary and the hospital had similar clinical activities in the types of ailments, conditions, and diseases of patients, as well as in the relative frequency of their treatment. As dispensary patients were also likely to be transferred to the hospital for additional treatment, often there was a direct correspondence between these two patient groups. Given the relationship between the Toronto General Dispensary and the Toronto General Hospital, it is reasonably safe to infer that the profile of dispensary patients was analogous to that for people admitted to the hospital. Consistent with the overwhelmingly Irish background of patients at both dispensary and hospital, the predominant religious denomination of the dispensary's patients was Roman Catholic. This situation provided yet more grist for the mill of medico-religious factions, for despite their sense of Christian charity and duty, the Anglican masters of these institutions bristled at the fact that the Church of Rome contributed nothing towards the maintenance of these patients.59 The occupations and backgrounds of the men and women treated at the dispensary probably also reflect those for Toronto General Hospital patients.60 Of the 907 people treated in the dispensary in 1846, for example, 324 (36 per cent) were infirm, aged pensioners, or young children; for them, no occupation was listed. The classification of those 'at school' (45) indicates that students attending various levels of educational institution might also be admitted. Of the 367 men treated, it is possible to identify the occupational backgrounds for over half. By far, labourers (109) accounted for most admissions. An assortment of tradesmen and artisans (80) comprised the remaining categories; in roughly descending order, they were carpenters, gardeners, sailors, shoemakers, fruiterers, tinsmiths, pedlars, hucksters, shoebinders, apprentices, tailors, weavers, bookbinders, carters, a currier, butcher, stone mason, printer, ostler, tinroofer, ropemaker, sailmaker, blacksmith, sawyer, miller, distiller, and limeburner. Many of these trades were respectable and in good times probably would have provided a living wage for these men and their families. Considered collectively, however, they represent a lower-workingclass group made up of those engaged in work for hire; there are no categories listed for clergymen, druggists, gentlemen, lawyers, merchants, proprietors, and so on. Men of this latter rank or higher still would never frequent the hospital or dispensary; rather, they continued to receive treatment in their homes in much the same fashion as had Georgian gentlemen such as Peter Russell.

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There were also 540 women (60 per cent of patients) treated at the dispensary. Their occupational and economic backgrounds reveal a social class similar to that of male dispensary, and thus presumably hospital, patients. One broad occupational group came from the needlework trade, where women were bonnet makers, knitters, quilters, and spinners (61). (This trade was a major source of employment for women during this era owing to market demands and traditional female training.61) Generally speaking, the concept of women-in-service describes the vast majority of female patients (52 per cent): domestic workers (159), servants and nurses (44), charwomen (41), and laundresses (36). Such workers would have embraced all ages, from unmarried young girls to matronly widows; similarly, they would represent a broad range of educational and social backgrounds, up to and including genteel governesses.62 It is possible that the percentage of women treated at the hospital was smaller than for the dispensary. Women may have been more inclined to seek medical care as outpatients at the dispensary, given either their own family obligations or their role of live-in helper in other families. None the less, it is reasonable to suppose that of those admitted to the Toronto General Hospital, a significant portion would be in these occupations. The British Colonist newspaper certainly advocated the advantages of the hospital for domestic servants, whose treatment there would reduce the danger of having illness spread within the home to family members.63 As trustees' minutes, physicians' case histories, and official statistical reports all reveal, hospital life at mid-centuryjnvolved people from both ends of the social spectrum - from well-to-do trustees to the rank and file of society, who were not only members of hospital staff but also patients. The trustees played an active role in day-to-day management of the hospital, its wards, and its patients. Their reports generally reflected well on the hospital, as did those of the medical attendants. These were all signs that the Toronto General Hospital did much good in the community. Yet all the while, undercurrents threatened to damage the hospital's still-fragile foundation. The greatest source of aggravation came from the medical profession itself. The Hospital as Professional Battleground Since the early 1830$ the hospital had assisted in the training of medical students, who walked the wards and learned from their medical masters

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as 'apprentices.' This tradition of bedside learning continued while medical leaders sought more structured methods of teaching. Indicative of their goals for academic medical education were the actions of the province's medical board. Examiners often rejected outright those candidates for medical licences who had never attended 'any Medical School,'64 and they repeatedly recommended that failed candidates either pursue 'further study and a course of lectures' or attend 'some medical university.' Those who passed the examination invariably had attended a medical college and been able to produce 'testimonials' or 'tickets of attendance' demonstrating that they had received formal medical instruction. This shift in educational philosophy created a serious impediment for those intent on a medical career, since there were no medical schools in Upper Canada. A student had to travel to Lower Canada to the Montreal Medical Institution (founded in 1824) - later to become the McGill College Medical Faculty - or to a medical school in Britain. Many Upper Canadians followed these routes, with study in Scotland the choice for most: half of the university-trained physicians in Upper Canada from 1783 to 1850 had attended Scottish medical schools.65 Because they were closer and cheaper than study at British schools, American medical colleges presented the second-most-likely choice for Upper Canadians. American medical education, however, was frowned on by both medical and political leaders in the province. In 1839 the College of Physicians and Surgeons of Upper Canada summed up the problem and the solution for the lieutenant-governor - founding a medical school would 'prevent hundreds of our youths resorting to the neighbouring United States for their education, from whence they too often return with little addition to their information, and most commonly with principles at variance with the allegiance due to their Sovereign.' To buttress this point, the college's executive recalled that former lieutenant-governor Sir John Colborne had been 'deeply impressed with the baneful effects of an education acquired in the United States upon the morals of our youths intended for the profession of medicine. '(>6 Politics thus afforded a stimulus in the 18408 for the establishment of formal institutions for medical education in the province. Over the next thirty years or so, such places would flourish or decline in a complex web of medical, religious, political, and financial interactions. The constant upheavals in local medical education produced shock waves that rocked the Toronto General Hospital. The University of King's College, an Anglican institution in Toronto,

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reorganized as a provincially funded university in 1843. It soon created its own medical department. Immediately it sought alliance with the Toronto General Hospital. Not surprisingly, the hospital responded favourably, for one of its own founding trustees, John Strachan, was president of King's College. Two other well-known hospital trustees also sat on the college's governing council: Rev. Henry Grasett and Dr Christopher Widmer.67 Initially, King's wished to place the hospital under its direct authority. To assist the new medical department while 'preserving a due regard to the independence and efficiency of the Public Institution placed under their management,' hospital trustees offered instead to allocate the upper floor of the hospital alone for clinical instruction. In return, King's was requested to pay f 100 towards the cost of equipment and bedding, to pay an additional daily charge for every patient assigned to the medical school, to provide a list of the medical faculty, and to ensure that all personnel observed the hospital's rules and regulations. The hospital's offer engaged it and the college in lengthy, though friendly, negotiations. During the ten months that it took to reach a formal agreement, talks were facilitated by King's College's bursar, Henry Boys, who had considerable financial experience and was himself a physician.68 Money was an issue, but of greater import were entwined matters of institutional autonomy and authority over patients. Medical educators also wished to ensure that a sufficient number of patients with a broad range of ailments would be available for study. Taking all these factors into account, the university requested accommodation for eighty patients, of whom thirty were to be divided equally among medical and surgical cases, with another six cases of midwifery or obstetrics. It wanted its medical professors appointed as attending hospital physicians, with access to all patients in the hospital but exclusive rights to treat those thirty-six people deemed university patients. Its medical students were to obtain the same rights and privileges. King's required that patients be segregated into wards for pregnant women, syphilitics, and those with infectious diseases. In return for all of this medical care, the university would pay £500 annually to the hospital; the costs of supplies and medicines were to be borne by hospital trustees.69 Faced with these requirements, the hospital board had to weigh the overall benefits and the costs of any arrangement with King's College. The Toronto General Hospital was well-disposed towards cooperation and the fact that it was the only institution of its type in town meant that

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it could have the upper hand in discussion - yet to surrender control of almost half the patient population to another institution was troubling. By the same token, compared with the hospital the university had a relative abundance of funds from government support - and that factor was not be to underestimated. Because the medical school had been scheduled to open its doors on 10 October 1844, time became another bargaining chip for the hospital. One week before the school opened, a tentative agreement was reached. King's College could nominate professors as medical officers, but the hospital maintained the right to appoint them. The hospital required that an assistant resident apothecary be hired at an annual salary of £50 and that the university increase its annual grant to £550 to offset this cost.70 Drs William Beaumont, George Herrick, John King, William Nichol, and Henry Sullivan became the first nominated and appointed King's College professors to attend the Toronto General Hospital.71 Becoming a university teaching hospital conferred new prestige on the Toronto institution. Though still very much a provincial hospital in size and outlook, its new status placed the Toronto General in the same class as much larger, better-established teaching hospitals in Continental Europe and Britain and those few in the United States. The regular income that the hospital stood to gain from its affiliation with the university could only aid its quest for financial stability. The augmentation of its medical staff boded well for the hospital; presumably, too, patients would be better off. Yet the hospital's connection to King's College and its faculty had drawbacks. Brought back into the orbit of Bishop Strachan and his Anglican college, the hospital once again was open to the charge of religious and political partisanship. Hitched to the government-supported university, it would also be affected by changing political and social winds. The overlapping roles of trustees might raise the issue of divided loyalties. Widmer and Grasett were already hospital trustees and members of King's College council, and the appointment of trustee Dr John King as professor of theory and practice of medicine in King's cemented the strong ties between the two institutions. As professor, trustee, and attending hospital physician, King was especially vulnerable to criticism, but his professional standing and ability to side with winning causes seem to have afforded him protection from overt attacks. King trained at both Dublin and Edinburgh and licensed to practice in Upper Canada in 1830. Though a Roman Catholic, he was well-accepted by Toronto's Orangemen. He supported William Lyon Mackenzie during

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his term as Toronto's first mayor - although it was rumoured that the two had once challenged each other to a duel - and later served on the opposite side as surgeon in the Queen's Toronto Guard during the 1837 Rebellion.72 The interwoven appointments probably heightened public suspicion about the motives of medical men. As students became more involved in anatomical dissection in their studies, leading to an increased demand for cadavers, some had occasionally resorted to unsavoury methods of obtaining bodies - including robbing graves. A particularly grizzly find in 1844 led to an inquest at the Toronto General Hospital and expert testimony from trustee and King's College professor Dr John King. King testified that a woman packed in a barrel and fished out of the harbour had not met with foul play; her dismembered body had rather been an anatomical 'subject.' At the same time, King maintained, neither the university nor the hospital was implicated in the case.73 The Anatomy Act had just been passed in 1843 to stop such furtive practices by making provision for a legal supply of bodies to the medical school.74 It gave the school legal right to unclaimed bodies of those who had died in publicly supported institutions such as the Toronto General Hospital. In the light of earlier rumours about irregularities in the hospital's disposal of bodies during the cholera epidemic, and the firing of an orderly for releasing an empty coffin, this incident would do little to calm residents' fears of potential abuses by hospital physicians eager to supply their medical school with bodies. Powerful competitors arose to King's College and its medical school. John Rolph had first offered medical courses in the 18205; exiled for his role in the 1837 uprising, he returned in 1843 under amnesty to Toronto, where he wasted no time in setting up the Toronto School of Medicine. Thus two medical schools operated in the city from 1844, with one key difference: King's required allegiance to Anglicanism, a sore point among doctors. With a shift in social climate and politics, the Reform government's new legislation in 1849 (the Baldwin Act) secularized King's College. In stepped Bishop John Strachan, the original force behind the college. Realizing that Anglican-oriented education at the university level was being curtailed in the province, he secured private funds and founded an institution to be known as the Church University or as Trinity University. In a show of support, and to further their own careers, six Toronto physicians discussed with Strachan the possibility of founding a medical

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department. In November 1850, the Trinity Medical Faculty came to be.75 Toronto now had three medical schools. In 1853 a new government was in power (partly the result of John Rolph's agitation to remove the premier). Its legislation (the Hincks Act) abolished the professional faculties of law and medicine in King's College. Within the year, Rolph's school repositioned itself by affiliation with Victoria College, a Methodist institution, to form that college's medical department. Although Victoria College was located in Cobourg (sixty-five miles east of Toronto), the medical school operated in Toronto. The college exercised little academic control over the school except to retain a portion of the students' fees and confer degrees on medical graduates. Within three years this marriage of convenience fed into strife among members of the medical faculty, and this school dissolved.76 Conflict appeared within the Trinity medical school too, once again over the religious question. Because Trinity was Anglican, it required all students to take a religious test. This stipulation directly affected the faculty members, for, as the medical department was proprietary in nature, professors' incomes came directly from the fees paid by students - the fewer the students, the lower the revenue. To guarantee their incomes, professors therefore ignored the regulation and enrolled students regardless of religious affiliation. Considerable friction between faculty and administration reached a climax in 1856, when all members of the medical faculty resigned; they were not reinstated until fifteen years later.77 The existence of these myriad schools, each with its own internal problems, led to fierce rivalries for students, fees - and cadavers. The issue of grave robbing again ignited public outbursts and professional jealousies. * Disgraceful,' * outrage,' 'horrible,' cried the papers over the next two decades as the public's revulsion deepened. Punishment was often immediate for those caught in the act: relatives and friends of the dead disturbed from sleep reacted by chasing, shooting, or beating medical students at the scene. Body snatchers who got away dissected their ill-gotten corpses immediately or left them to macerate to prepare skeletons for later demonstration and study.78 Physicians associated with the Toronto School of Medicine accused the hospital of preferentially supplying corpses to Anglican medical students and professors. William Aikins, a professor, complained to John Rolph, proprietor and dean, that George 'Herrick, who is an attending physician gives over ALL his patients to Hodder & Bovell the two Trinity men attending - and until we get our Anatomical Inspector [William]

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Beaumont & [Walter] Telfer will ask no questions as to what becomes of their dead friendless patients, but it is quietly arranged that [they?] may go to Trinity. Our [dissecting] room has been plentifully supplied, chiefly through the aid of students/79 Some of these physicians argued on this basis that robbing graves was justifiable and that legislation should prevent family and friends from claiming bodies from hospitals in the first place. It would not be until the closing decades of the nineteenth century, with the creation of a Faculty of Medicine in the University of Toronto and its eventual absorption of the independent schools, that stability in medical education was achieved in Toronto.80 Until then, when all was said and done, the Toronto General Hospital enjoyed university affiliation for only nine years, between 1844 and 1853, and in this short period King's College graduated only eight medical practitioners.8' From 1853 until their dissolution in 1856, the city's two remaining rival schools, Trinity and Rolph's Toronto School of Medicine, battled over professional matters other than the supply of bodies. Rolph himself was preoccupied by his government position until 1854. Simmering tensions erupted into open hostility, most of it engulfing the hospital. Allegations and investigations tarnished some professional careers and all but dashed others. People lost their jobs, the police laid charges, and, most catastrophic of all, lives were lost. Historical explanation of these events is hampered by the inexplicable disappearance of trustees' minutes for this crucial period in the hospital's development.82 The dominant voice remains the public one in both the medical and the popular press. Editorials about the Toronto General Hospital appeared frequently in the Upper Canada Journal of Medical, Surgical and Physical Science. This journal, begun in 1851, initially flew the colours of Trinity College, with Drs Bovell, Hodder, King, Melville, and O'Brien forming the editorial board; presumably these men wrote and/or authorized its editorials. They left no doubt about the importance of the hospital, while they used the shield of their publication to criticize hospital trustees and colleagues. The eyes of the 'whole Profession in Upper Canada,' they warned in December 1852, were on this 'School of Practical Education': 'if it is the desire of those priviledged to hold the honorable office of Physician or Surgeon to our Hospital, to advance Medical Science in Canada, they must endeavour to emulate their brethren in the Motherland, and laying aside self, join hand in hand for the furtherance of the common good.'83

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Invoking lofty causes, nationalism, patriotism, and virtuous behaviour - and all in one sentence - often betrays baser actions. Indeed, editors swiftly rammed wedges between medical factions and those responsible for the hospital. They decried the hospital's lack of operating facilities, its poor ventilation, and its unhealthy design and construction: the building had become the 'perfect picture of ruin and decay,' 'a snare and a delusion,' and 'a marvellous indication of the want of progress and improvement ... a disgrace to the city.' Trustees' complete power over the appointment of medical officers led to a 'baneful influence over the welfare of patients, for without some necessary check, incompetency and ignorance' would take the place of merit and talent. Writers also complained that records of diagnoses, treatment, and causes of death, if kept at all, were never available for public or professional scrutiny.84 This critique kindled more in the popular press. On 22 March 1853, the reform-oriented Semi-Weekly Leader published an indictment of hospital conditions. Lack of sanitary facilities created a noxious atmosphere that suffocated everyone associated with the hospital and led to outbreaks of disease. There was only one old tin bath for the whole hospital. The few blankets were so disgusting that they 'would be rejected by any spirited stable boy, if offered as horse rugs.' Dampness permeated the ceilings, and floors were worn and broken. Because there was no separate operating room, patients were privy to operations performed virtually in their midst, accompanied by cries from the those operated on. The following day, board chair Widmer confirmed this assessment when he wrote to John Rolph that the hospital was 'nearly a wreck.'85 Features in the Anglo-American Magazine drew heavily on the description in the Semi-Weekly Leader to satirize the hospital as a ramshackle, inhumane, badly equipped institution. A fictional physician visiting from Philadelphia, Dr David Cuticle, punctuated his attack on the Toronto General with poignant moralism: where a community leaves the pauper patient to be tended by a hired menial, where true charity gives not the 'cup of cold water in the name of a disciple,' when the offensive sore is suffered to exhale its noxious odours day and night into the nostrils of the poor, wasted, haggard being, who lies not even two feet from his equally unfortunate fellow-sufferer, the charity of the nineteenth century may not be vaunted. If you and others would but visit the dying couch of the victim of neglect, and stay beside their now deserted pallets, I trow scenes would be witnessed which would make you blush at the desecration heaped on the name when you hear men talk of

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their 'Christian institutions'; nay, how much has the lapse of Christian charity tended to turn what ought to have been an imitation of the abode of happiness into a fac-simile of the regions of torment.

That the editor-author, Robert Macgeorge, was a clergyman should be evident from the style of this essay. As an Anglican priest, he probably did not ingratiate himself with his superiors, especially when he called the hospital 'y°ur Toronto Tabernacle of erysypelas [sic] and death.' Within a few years Bishop Strachan revoked Macgeorge's parish appointment in Canada.86 Later in 1853 tne new editor of a reorganized and slightly renamed Upper Canada Journal, Samuel J. Stratford, entered the fray. No longer the official organ of Trinity Medical College, the publication did not carry the names of Drs Bovell, Hodder, King, Melville, and O'Brien on its board. Stratford had been a faculty member at both Trinity and Rolph's schools and took over the journal with a declaration that it would be 'independent... without reference to politics of any party or faction' so as to discourage the 'political and private heartburnings and bickerings ... so prevalent at the present day.'87 Stratford instead found himself engaged in battles on several fronts, all circling back to the hospital, its trustees, and its medical staff. He began by commenting that the new appointments of Drs Aikins and Wright as medical officers - both prominent faculty members of Rolph's Toronto School of Medicine - would prove especially beneficial.88 Then he made several dramatic recommendations. All medical schools in Toronto should unite, he pronounced, and, once united, should merge with the hospital. Should Trinity men not like this idea, they could build their own hospital: because they had already shown their 'illiberality and exclusiveness' in their domination of the Toronto General Dispensary, the medical profession would have 'everything to fear when they get full possession of the hospital,' he charged. Not stopping there, Stratford challenged the Anglican establishment by declaring that the truths of religion should only 'guide and direct1 medicine and its practitioners, not 'command' them, as he implied was the situation in Toronto. Both religion and medicine must support each other for the good of man, Stratford maintained, but they must also 'stand free and unshackled.'89 If Stratford began his editorship with a cause, he quickly turned it into a crusade. Trinity medical professors reacted by returning their copies of the journal.90 In almost every issue, Stratford managed to publish something that was guaranteed to foment agitation: an open letter

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to John Rolph asking that he bring about unification of the medical profession through government action; a response from Rolph that they should meet to discuss the matter; a protracted exchange between himself and senior hospital surgeon William Beaumont that impugned Beaumont's professional integrity and skill; and reprinted items from the popular press of Toronto and Montreal. Stratford railed at tyrannical actions of hospital trustees and claimed that he was being persecuted by them and the hospital's medical officers and staff. These last allegations were not without justification: the hospital board passed a by-law that was as hasty as it was illegal, barring Stratford from visiting the hospital.91 Stratford appealed in print to the governor general to intercede on his behalf against the hospital. Stratford accused the hospital and its medical officers of being behind the scientific times. It was a matter of 'wonder and amazement' to him that his erstwhile hospital colleagues could function without, for example, a microscope - an instrument that was quickly becoming an icon of medical knowledge and progress. Ignoring his own role in stirring up an already irritable hospital community, Stratford then offered medical science as a possible path to peace: 'The Toronto General Hospital should not be behind in this matter; we would say, let party and politics be forgotten, let all join in a fervent desire to advance medical science, then, and only then will the medical officers be fully respected, and the Toronto General Hospital gain the standing in popular estimation, and public usefulness, which its metropolitan position, and great advantages confer upon it.'92 Despite this plea, Stratford could not himself rise above the local politics of the moment. In a style much darker than that of Robert Macgeorge, he then wrote a tragedy in two acts. His characters, thinly disguised Toronto hospital doctors, botch a gynaecological operation: the patient dies after excruciating agony during their brutal attempt to remove a large tumour from her womb. Stratford claimed that everything was based on fact and promised more damning material in the next instalment of the journal.93 He would publish an expose of other operations that had 'lamentable results' to prove that certain doctors were 'unworthy [of] the position which they hold in that institution.'94 His article never appeared; neither did the Upper Canada Medical Journal The stinging exchanges between editor, trustees, and physicians and the threat of out-and-out whistle-blowing had precipitated the collapse of the province's only medical journal and the profession's only means of formal communication; it would be fifteen years before another similar

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venture was undertaken in the province. Stratford himself continued to practise in Toronto but soon left the city and eventually left the country altogether.95 The storm clouds hanging over the hospital stubbornly refused to blow away. 'POLICE INTELLIGENCE - Assault by an Hospital Officer/ reported Toronto's Daily Globe on 24 February 1855. This incident, and its publicity, was surely one that hospital trustees could have done without. To learn that a 'colored man, who had his head enveloped in several bandages,' was seized by the hospital's 'surgery-man' (orderly) and then violently 'jerked' out of the hospital was bad enough. To read further that this hospital worker had a reputation for taking 'hold of poor feeble old women' who were in attendance at the hospital and then pushing them 'rudely out of doors' must have struck all who read this report as reprehensible. Before fining him 20/-, the presiding magistrate admonished the orderly that he was unfit to work in the hospital. He had no right to 'fling the poor out like a dog,' he told him, and those 'helpless creatures' who sought hospital care and relief should receive treatment other than being 'seized by the throat and flung out of doors.'96 Only one month later, the hospital yet again became the centre of controversy. As with other fractious events, John Rolph was implicated in some way in the latest fiasco. One of his senior students, James Dickson, wrote a letter to the Colonist newspaper under the pseudonym 'Medical Student,' in which he alleged that the hospital was mismanaged. This action triggered a flurry of board activity, more letters, further polarization of Toronto's medical-hospital community, and ultimately a three-day-long inquiry that was painstakingly reported day by day in Toronto newspapers.97 The inquiry even spawned an instant book by Globe reporter George Ure, in which he chronicled this revealing and sorry saga in the hospital's history.98 The whole affair had an air of farce about it. Chaired for the most part by Christopher Widmer, then in his late seventies, the inquiry included testimony from trustees, doctors, students, current and former hospital workers, and patients. Held in the hospital's board room, which had to be cleared of women at one point because of the use of foul language, the proceedings were frequently interrupted by hisses, cheers, and repeated calls for order. Doctors hurled insults at colleagues like 'trashy toadstools.' When Dr Cornelius J. Philbrick collapsed and was escorted out of the room by his colleagues, several questioned his sobriety. Everybody was defensive; everyone was on the attack.

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All this sound and fury did signify something. Though exaggerated in the heat of the moment, the inquiry's deeply unflattering portrayal of hospital life and professional relationships made its mark. Patients were described as lice-infested from head to toe, prompting some students to avoid them instead of examining them; students who did examine them became lousy themselves. Bed sheets, originally white, had become so badly soiled through continuous use that trustee John Bowes had assumed that they were made of brown cotton in the first place (a point on which he had to be corrected). Staff members, according to Dickson and his student colleagues, were abusive. In particular, Mrs Donnelly, a nurse, was rough with patients, drank while on duty, and physically threatened students and patients alike. One patient testified she had jumped on him, exclaiming this 'd d nigger should have his head cut off.' More allegations of abuse related to the orderly charged earlier with assaulting a patient; even though he was an 'old soldier,' with a manner considered brusque, his conduct was still inappropriate. The inquiry also heard that the resident medical officer, Dr Edward Clarke, was sometimes unable to attend to his duties because he was drunk; colleagues dismissed this charge outright, although they and Clarke did admit that he resorted to opiates for the relief of pain. Mr Stewart, a missionary, did little to improve the hospital's reputation when he testified that the poor of Toronto generally resisted attending it. Physicians ratted on each other: over bungled surgical cases, theft of each other's patients, the bias of Trinity doctors against non-Trinity students, and over faulty, falsified, or misleading record keeping. The distrust between professors at Trinity and those at Rolph's Victoria school poisoned these proceedings as example after example was paraded to support the claim of professional discrimination. Students had considerable opportunity to voice their opinions - too much, for one doctor. Dr Edward M. Hodder, a Trinity man and one of the hospital's most senior doctors, shot back at students that he would not be interrupted by these 'boys.' But the boys would not be silenced. They complained about mismanagement of the hospital; about the failure of attending medical officers to appear at their allotted time to meet with Victoria students, who had purchased tickets of attendance for the hospital; and about clinical and physical facilities that were inferior to those of, for example, the Montreal General Hospital. In Montreal itself, the editors of the country's only medical journal at the time were aghast at the revelations about the Toronto General Hospital. Indeed, they thought that an 'evil spirit' working 'fiendish machi-

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nations' within Toronto's medical community 'delighted in mischief and preferred obliquity to rectitude of [moral] conduct.' The behaviour of hospital staff betrayed a 'trait of barbarianism'; the orderly's treatment of patients showed him to be a 'monster of cruelty.' Physicians' nefarious actions and acrimonious relationships demonstrated to the Montrealers 'how low an ebb of medical ethics' had been reached in Toronto: there was no excuse for the hospital to operate as it did in an 'enlightened community of British colonists, in the middle of the nineteenth century.'99 After it adjourned in April this inquiry did not release findings, leaving the task of assessment to the newspapers. The Globe determined that this 'general squabble' had brought the truth out 'fully and freely.' Not only had all complaints against the hospital been substantiated, but the conduct of all medical men had been so 'disgraceful' that it would be better if they would leave the hospital as soon as possible. The reformoriented Examiner expressed disgust over the whole affair, highlighting the hospital's disgraceful lack of facilities, its brutal staff, and its partisan administrators. It called for a 'thorough reformation' of the hospital as well as the removal of the trustees - by government action, if necessary. The widely read Methodist paper, the Christian Guardian, remarked on 'ample proof of the gross misconduct of some hospital workers, to say nothing of the 'evident partiality' of the hospital in favour of Trinity medical students and professors. The fact that hospital trustees insisted that there were no grounds for complaint, despite all this evidence, baffled the Guardian™ Incredibly, hospital trustees went further than denial and dismissed Drs Aikins and Wright from the roster of attending physicians. Previously praised by Upper Canada Journal editor Samuel Stratford as of special benefit to the hospital, they were the only non-Trinity men in attendance. The Guardian condemned this action as 'highly reprehensible,' deserving 'the unqualified reprobation of every person whose sense of propriety is not altogether under the control of prejudice and selfishness.' The board's real reason for these dismissals in the light of the inquiry and popular opinion remains a mystery, although it was apparently meting out punishment for the two men's role in the events. All these matters were immediately debated in the provincial parliament, then based in Quebec, where a select committee was demanded to investigate the hospital and its management. Opposed to this action was the Tory John G. Bowes, trustee of the Toronto General Hospital

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and a notable participant in the inquiry (who had denied the problem of filthy sheets). Bowes dismissed the affair as the misguided action of a disgruntled medical student and claimed that in 'no country was there an Hospital managed with greater efficiency/ In addition, he threatened, should the government undertake its own inquiry, hospital trustees would resign en masse. On the opposite, 'Clear Grit' side of the House, John Rolph quickly rose to emphasize that the dismissal of Aikins and Wright (his own professors) had resulted from a highly irregular procedure, as the board had lacked a quorum when it had decided the matter. He accused Bowes of fixing the vote by telegraphing his support to Toronto; amid shouts of 'Hear, hear,' Rolph concluded that the hospital's board had acted illegally.101 During the summer, some of the protagonists in the hospital inquiry became entangled in separate legal investigations. In July, James Dickson was held responsible for the death of one of Rolph's patients and faced a charge of manslaughter. The evidence for this charge came from the two physicians who conducted the autopsy: William Hallowell and Cornelius Philbrick - both Trinity men who had come out against Dickson and his fellow Victoria classmates during the hospital inquiry. Then, in an almost unbelievable reversal of roles in August, Philbrick became the focus of a coroner's inquest into the death of one of his own patients; of the three physicians who performed the autopsy, two were of Rolph's Victoria school.102 Although both Dickson and Philbrick managed to avoid prosecution and jail sentences, the loathing intensified among all those involved.103 A separate government inquiry never materialized, but Rolph had embarrassed the hospital at this, the highest administrative level. Although accounts of these medical feuds shared newspaper pages with descriptions of battles in the Crimea and lists of casualties, they dominated media and public attention. An influential editor and political enemy of Bowes's, George Brown of the Globe, asserted that there could not be a 'solitary individual' in the entire province who did not recognize the need for radical change in Toronto's medical world. An editorialist in Montreal summed up sentiment by paraphrasing Shakespeare to wish a plague on both medical 'houses'; in future, he hoped, doctors 'would wash their dirty linen at home.'104 Brown continued to hammer away at the 'High Church monopoly of the Hospital.' The hospital was the property of the country, he reminded readers; not only did members of medical staff not own it, but they entered it only to 'discharge the public duties assumed by them in

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their present honor.' That doctors appeared to breach this implicit social contract was bad enough, but when Brown learned of another piece of hasty and expedient board action in the form of a new by-law, he could not contain himself. This by-law enforced an official policy of professional discrimination whereby, in future, physicians could be allowed admittance to the- hospital only by invitation of the Anglican/ Trinity resident medical officer. These official panderers to the grabbing propensities of the High Church Tory exclusives [Brown fumed], have added wrong to wrong, and injury to injury in a ruthless style, by now providing that the Teachers of the Toronto and all other Schools of Medicine must be invited by the Teachers of the Trinity School, before they can enter the Hospital with citizens or pupils. And the same humiliating submission to their self-eulogized, selfvaunted European Doctors is extended to all the professional gentlemen in the country! European Doctors ... doubtless might receive an invitation; but the inferior (?) Canadian must keep his distance, unheeded and unasked.105

Brown's anger hinged on the popular distaste for the Anglican establishment; his allusions to the 'country' and the 'Canadian' doctor versus 'European Doctors' introduced the theme of nascent nationalism into this debate. The Christian Guardian, voice of the Methodist church that ran Victoria College (and its medical department), retained its dim view of proceedings at the hospital. After a thorough drubbing of trustees as blatantly partisan, it declared that they should all be removed, for they were not 'proper persons to hold any public trust of that kind.' The paper expressed serious concern over the hospital's role in human dissection by providing bodies to Trinity Medical School. Though ambivalent about the need for dissection as a source of professional knowledge, the Guardian strongly supported observance of 'proper and humane' laws and procedures; those who failed to follow them - including the resident medical officer of the Toronto General Hospital should be held responsible for any illegal actions and their consequences. The only positive aspect to all of this mess, the Guardian was gratified to report, was the governor general's rejection of the new bylaw concerning which physicians could be allowed admittance to the hospital.106 The events of 1855 surely marked the hospital's annus horribilis. In Jan-

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uary 1856, an exasperated editor at the Leader reviewed its affairs for the previous year. As the hospital turned into a professional battleground, the medical student's training had seemingly become more important tnan the care of patients; indeed, those admitted to hospital were more likely to be rendered 'subjects' for examination than seen as sick people who were to receive charity. * Medical service, which should be expended in relieving the distresses of the inmates, is directed to the furtherance of professional interests, and the advancement of particular medical schools. Are the public content that this state of things should longer continue?' asked the editor, Are they satisfied that, year after year, appropriations shall be made in behalf of a charity which is to be made thus subservient to ulterior ends? Are we to see the same clamor, the same antagonism, the same conflict of professional interests, the same disreputable fighting - in the presence of sickness aggravated by penury and distress, unmitigated by the kindly hand of friendship? Is the din of contending schemers to be the only soothing sound repeated in the ears of the sick and dying? And is the public beneficence which literally provides for the unfortunate and needy to be for ever outraged by the disgraces of the past year? It is time that the people should give the question their attention.107 This viewpoint captured a public mood that increasingly stressed neutrality, decency, and common sense. Battles within the hospital had mirrored those outside over who should comprise other civic services such as the police force and fire brigades. As the public became fed up with the convulsions and paralysis caused by extreme partisanship and party factionalism, it called for moderation to guide public-spiritedness and political action. No more could leaders appear as rabble-rousers, fomentors of agitation, or mouthpieces for particular groups: party interests had to be made subservient to the public good, not the reverse.108 Within this evolving consensus, the message being conveyed about the Toronto General Hospital was clear: doctors, trustees, everybody - if they were really sincere about doing good - must all discard their partisan politics and pull together for the patient and for the hospital in its role as public charity. The fever that gripped the hospital had to be broken. To effect this goal, the Leader echoed an earlier Globe editorial to advocate the complete cessation of medical training at the hospital. The many arguments that doctors predictably would mount against this measure would not dissuade the editor from his position - namely, that the

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hospital was a * public charity - not a medical experimenting room. And the public will sustain us in laboring to effect such a reform as will hereafter effectually put an end to these medical squabbles; or, at least, prevent their occurrence on ground consecrated to benevolent and charitable purposes.' Change occurred swiftly, within a few months. Owing to his autocratic manner, Rolph's faculty members abandoned him to establish their own medical school - which they called also, confusingly, the Toronto School of Medicine. In the same year, the entire medical faculty of Trinity resigned, leaving the college without a medical school. Undaunted, Rolph assembled another group of faculty and continued to run 'his' school. Revered within medicine as the father of medical education in the province, John Rolph was reviled outside the field. Contemporaries scornfully called him crafty, bloodthirsty, treacherous, cowardly, infamous, sleek, wily, traitorous, deep, dark, designing, cruel, malignant, and black-hearted. With his career characterized as a * study in ambiguity and double dealing' and his political role as that of someone who 'could be counted upon to undermine any movement with which he was associated,'109 he was also labelled 'devious, cunning, and self-seeking.' Hovering spectre-like over many of the incidents that turned the hospital inside out in mid-century, Rolph was conceivably the 'evil spirit' that Montreal doctors suspected 'delighted in mischief in the Toronto medical community. Clearly in his element in a 'din of contending schemers' in medicine, he personified the era of partisanship in the province at large. As profession and public sought moderation, he lowered his profile in both government - which he left in 1857 as a 'relic from a former age' - and medicine (only holding on to his own school until his death in 1870).110 In this calmer atmosphere, the hospital could look forward to a more constructive period.

PART TWO A Public Charity, 1856-1903

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New Quarters, New Status, 1856-1875

In the mid-i85Os, while political, social, and economic changes shook the united Province of Canada, the Toronto General Hospital too was being transformed. As if to put behind it its own annus horribilis, the hospital in 1856 moved into a new home in eastern Toronto, by the Don River, where it could implement the new rules and regulations that its trustees had prepared in 1855. The same year it received a sizeable grant from the government and, reflecting its new status, submitted its first formal report to the legislative assembly. The next two decades were to prove very challenging for the hospital in its new home. In the Province of Canada gains in the 18405 in autonomy vis-a-vis Britain and in self-reliance were followed by a broader political transformation, leading to the creation of the Dominion of Canada in 1867 through Confederation of three colonies - a grand process that produced a major crisis for the Toronto General. The western part of the Province of Canada, known earlier as Upper Canada, and then as Canada West, became the province of Ontario, with Toronto as its capital. Though still British in character, Ontario saw the domination of Anglicanism wane as Methodism grew into its largest religious denomination. The majority of the new province's 1.5 million inhabitants still depended on the land for their livelihood, but the expansion of towns and cities was rapidly altering the landscape as well as people's lives. Along with a new dominion came a first step towards a national professional identity for doctors, with the founding of the Canadian Medical Association in iSGy.1 Two years later, the College of Physicians and Surgeons of Ontario formed to license, regulate, and examine the province's practitioners, to seek out illegal doctors, and to control the curricula of medical schools. At the local level, doctors in the early i86os established

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a non-partisan medical society to unite the profession in Toronto.2 These organizations resulted partly from the increased numerical, professional, and economic strength of doctors. As their ranks swelled in the second half of the nineteenth century, from about 160 to about 2,400, the ratio of physicians to the total population grew from 1:3,000 to HQOO.3 The tenets of self-reliance and domestic care remained paramount for most people. None the less doctors were inserting themselves into the lives of more people and began to find it somewhat easier to earn a living.4 Among the expanded range of medical services that they offered,5 perhaps the most significant was general anaesthesia during surgery. As one Canadian doctor recalled, the new procedure allowed patients to be 'rendered unconscious of torture' for the first time - though in this early period it could also result in death for some patients.6 Toronto experienced tremendous growth. Like the province, it stayed predominantly British: at mid-century only a handful of Jewish and perhaps about 500 black people lived in the city. From 60,000 in the i86os, its population swelled to over 200,000 by the end of the century, and it became unrivalled as the bustling commercial and industrial centre of the province. Local businesses started or expanded whose names would become household words in Canada over the course of the next century: the biscuit bakers of Christie, Brown, and Company; the Consumers Gas Company; the distilling firm of Gooderham and Worts; the meat-packing firm that would become Canada Packers; the drygoods store of one Irishman, Robert Simpson, and that run by another Irishman named Timothy Eaton.7 As this generation of industrialists, businessmen, and merchants prospered and accumulated wealth, it formed the backbone of a new middle class. Its influence would be felt in many ways - especially through its sustained support of a long-ruling provincial Liberal party, whose policies aided such public charities as the Toronto General Hospital, including the Charity Aid Act in 1874, which provided secure funding. Not soon forgotten, earlier sentiments of Christian charity evolved as the state immersed them more and more within those of public duty. More important, many of these business leaders became instrumental in administration of their city's general hospital, and they often came forward with much-needed financial support for it. Reconstructing the Toronto General Hospital The hospital's trustees overcame the difficulties of the early 18505 by engaging in a massive rebuilding project: the erection of a completely

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Figure 3.1 Receipts and expenditures, Toronto General Hospital, 1841-56

new and enlarged hospital building far away from the original site. Such a new structure would help ensure that the past would be forgotten: it would literally and symbolically build a future for the Toronto General. A call for an enlarged facility came first in 1847, but no action was taken.8 Six years later, trustees resolved to quit the original edifice of 1819 and build anew.9 The plan included parcelling out the existing site into building lots for homes available on long-term leases, receiving tenders from a host of contractors, and selling £5,000 of debentures at a rate of 6 per cent to raise the required funds.10 Along with an increased government grant of £2,000 in 1856, this plan met the hospital's needs. As its first report to government in 1856 showed, the financial undertaking had been relatively immense, representing a four- to five-fold increase of revenue and expenses over what was customary for the hospital (Figure 3.1). In Figure 3.2 an itemized breakdown of hospital expenses for the same period demonstrates further just how significant was this project.11 Operating expenses - heating supplies, food, bedding, and so on - ate up the lion's share of costs (about 40 per cent), while the new hospital used up about 29 per cent. The hospital was neither a labour-intensive nor a 'medicalized' institution: salaries held a relatively low share (n.2 per cent), and surgical and medical supplies virtually nothing (i .6 per cent).

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Figure 3.2 Expenses, by category, Toronto General Hospital, 1841-56 If the decision to build a new hospital received little comment, the matter of its location did. Trustees decided to use the undeveloped and less valuable property that had been part of the hospital's original land endowment; at the eastern boundary of Toronto near the Don River, this property lay at a considerable distance from the centre of things. One medical commentator pointed to the long time that it would take to convey injured patients from the western section of town to the new site - a distance of five miles - and suggested that delay in treatment would jeopardize patients' lives. Medical students would also have to travel between their town-based medical schools and the proposed hospital. The site itself was also problematic: being so close to the Don River and to the low-lying marshes of that area - a region believed to be the primary source of malaria, ague, or intermittent fever in the city - it was bound to expose the hospital to a 'poisonous miasm.' No matter how many assurances trustees gave about the higher, and healthful, elevation of the selected site and about the thorough ventilation that was planned, this critic countered that 'whenever a moderate south wind should blow... it would convey... a very powerful dose of malaria to locations placed within its range.'12 Hospital trustees remained steadfast. They engaged William Hay, the Scottish-trained architect whose ecclesiastical and secular buildings later

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would become Toronto landmarks, to design the new hospital and oversee its construction. Hay's design drew on his idea of an architectural style appropriate for the Canadian climate and taste.13 In its old English domestic style, reminiscent of the fifteenth century, the structure resembled many large Victorian buildings.14 Situated within a four-acre enclosure, the central building, attached wings, and multiple roofed towers were patterned on the letter E, dominated by the central loo-foot tower. A flight of stone steps led to the first floor, where a spacious entrance hall welcomed the visitor. To one side was the board of trustees' meeting room, an impressive space - the size of a ward - that measured 33 feet by 21 feet; on the other side was a suite of waiting, examining, and consulting rooms for physicians and their patients, a dispensary, and quarters for the resident surgeon, the steward, and nurses. Two large wards, each 33 feet by 22 feet, were dedicated to surgical cases; both had toilet and washing facilities as well as other conveniences for patients. Several smaller wards for paying patients - more or less private rooms - were also on this floor. A 22-foot-wide staircase led to the second and third floors, which contained one large ward for up to twelve patients and smaller ones that could accommodate eight. The second floor also had sitting rooms for convalescent patients, more nurses' apartments, and ample bath rooms, wash rooms, and other sanitary conveniences. The top storey held large water reservoirs for the hospital and space to house anatomical and pathological collections in a i6o-foot-long gallery. The kitchen, servants' apartments, and storage areas were in the basement. In total, the new Toronto General Hospital contained twenty-two wards. Several were so arranged on each floor that they could be shut off, to restrict patients' interaction, thereby helping to control both their movements and the spread of any infectious disease to the rest of the hospital. Purpose-built rooms and facilities for patient care and confinement, personal hygiene, and accommodation for staff all set this new building apart from its predecessor; so, too, did a distinct wing that housed a large, well-lit operating amphitheatre (37 feet by 45 feet), below which was the mortuary. The distinctive heating and ventilation system was designed not only to heat the rooms centrally but also to create a circulating airflow to remove noxious vapours, odours, and effluvia from the internal environment. By the standards of the era, the hospital was 'state of the art' in design, and, most important, a real attempt had been made to relate form with function.

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The building conveyed a sense of grandeur and a presence not found in the earlier, smaller Georgian hospital. No doubt many of those admitted would be overwhelmed by its sheer size - by any measure, this was a place of grand institutional dimensions. A photograph shows it to be somber, even foreboding in appearance, but the architect's watercolour paintings of each floor present a warmer interpretation. Thus in 1856 the Toronto General Hospital began to assume an institutional shape and character that would increasingly separate it from other charitable agencies such as orphanages and houses of industry or refuge. Although the physical buildings and missions of these other charities did, and would continue to, share some features with the hospital, the more specialized function of the hospital - involving cure and treatment, in addition to custodial care - was starting to become more apparent. For example, Toronto's House of Providence, an orphanage and temporary refuge for sick and poor immigrants, was also designed and built by William Hay at the same time. Like the general hospital, the House of Providence had large rooms to accommodate its charges, a medical dispensary, and a refectory; however, whereas the distinct functional feature of the hospital was its large operating amphitheatre, in the House of Providence this analogous space was occupied by an elaborate chapel.15 Constructing a future for the hospital required more than bricks and mortar. In 1855, trustees introduced reformulated rules and regulations, indicating that earlier criticisms and revelations had had some impact after all.16 Outlining how members of the hospital community related to each other and presenting job descriptions for them, the rules had nine sections, on trustees, board secretary, hospital steward, medical officers, resident medical officer, medical students, hospital matron, nurses, and patients. In their prescriptive tone, these rules resembled earlier ones; in their detail and comprehensiveness, however, they moved away from a domestic model of management. While covering routine household-like activities such as the monitoring of supplies and expenses, they addressed the unique requirements of the hospital as a place for care and medical treatment. Staff accountability was prominent, especially in duties towards patients. The newly tided matron reported directly to the resident medical officer, not to the steward. Nurses, too, reported to the resident medical officer and were required to keep a close eye on patients' conditions and requirements at all times; they also were obliged to wash patients on their admission and

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to behave with 'tenderness and propriety' towards them. The resident medical officer not only had more staff reporting to him but also had to maintain a detailed record of hospital patients, monitor all medical equipment and supplies, and vaccinate all patients as needed. Patients came under close scrutiny as the hospital sought to maintain a more orderly and better-regulated establishment. Male patients were never to enter female wards, and vice versa; smoking, gambling, and drinking were prohibited; all able patients were required to assist nurses and other servants in their nursing duties and the cleaning of wards; and all able patients had to be out of bed by 6 a.m. (or one hour later during winter). Patients could receive visitors only on weekdays from 3 p.m. to 5 p.m. These reforms created a more rigid and distinguishable hierarchical structure. Trustees still ruled the roost and were the final arbiters on all matters, but they were trying to limit their role to governance rather than to day-to-day business. The expanded role of the resident medical officer, which was moving towards what eventually would become medical superintendent, meant that he oversaw more of the routine management of the hospital and its staff. Remaining members of staff (and some patients) were responsible for carrying out all other tasks necessary to the proper functioning of the institution. The transition from the old hospital in town to its replacement at the eastern outskirts was effected in less than a week with little trouble. Patients occupied a temporary building before being relocated to the new facility. The original structure was then renovated for its new tenants as it reverted to its earlier use for government.17 Perhaps with as much relief as satisfaction, Christopher Widmer noted in the register that on 26 September 1856 the move was beginning;18 on i October the new hospital received patients.19 New rules, new responsibilities, new rooms - all these changes pointed to a new, positive phase in the hospital's evolution. Yet change of this magnitude can often exact a toll on people working within a significantly altered structure. Unfortunately, such appears to have been the case with Dr Edward Clarke, the hospital's resident medical officer. On 18 December 1856, trustee and local brewer John Doel recorded cryptically in the trustees' register: 4M> Past 12 Dr Clarke died last night at 9 O cl.'20 Ironically, perhaps the first death in the new hospital, after less than two months' operation, was that of the staff physician. At the resultant coroner's inquest, many of the same colleagues who had previously defended Clarke against allegations of insobriety during the 1855 inquiry now came forward telling different tales. While

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acknowledging Clarke's kindness to patients and his attention to professional duties, several witnesses stated that he was subject to fits of insanity that were aggravated by his consumption of alcohol; according to J.W. Brent, secretary to the hospital's board of trustees, a brother of Clarke's had 'died mad.' Other hospital workers testified that on the day he died, Clarke had appeared especially anxious and had behaved peculiarly: he declined receipt of his monthly salary, then claimed that he was being deprived of it. He also remarked that he was leaving the hospital and heading for a nunnery - something that 'no man in his senses would say,' according to coroner Dr Edward Hodder. The results of the post-mortem examination, along with other evidence, indicated that Clarke had consumed a large amount of highly poisonous prussic acid (potassium cyanide) just prior to his death. Based on the facts presented, the jury concluded that Clarke had taken his own life while labouring under temporary insanity.21 The suicide of its medical officer underlined the break between the hospital's raucous past and its more stable future. As symbolic was the death two years later of one who had been inextricably linked to the institution since its inception, Christopher Widmer. After he was found in a cemetery in a state of collapse, Widmer was rushed for care not to 'his' hospital, but to his home. There he died, in the manner befitting a Georgian gentleman.22 The circumstances in which trustees now found themselves required that they take a close interest in the routine management of the hospital. On occasion, trustees on inspection tours deemed the food unfit for human consumption: potatoes were often bad; the bread or dough could be lumpy, sour, or 'intolerable.' If the matron drew the attention of a visiting trustee to the questionable quality of food, such as sour butter, it was his decision that carried the day. Trustees no doubt were vigilant to ensure that they were not being cheated by unscrupulous or careless suppliers. As well, apart from any repulsion at serving tainted food, they would have recognized that proper, wholesome food was vital to the well-being of patients and to their recovery; in many instances, hospital rations probably surpassed what patients were used to eating, in both quantity and quality. On the whole, trustees considered the operation of the hospital to be satisfactory. They typically noted: 'All regular,' 'No complaints,' and 'In good order' in the visitor's book kept for this purpose. In 1861 trustee John G. Bowes, now Toronto's mayor, wrote that he had 'walked all wards' and, characteristically for him, 'found all in excellent order

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enquired in each ward of the patients had any complaints to make all appeared perfectly satisfied. The supplies in a satisfactory state.'23 Sometimes trustees acted to ensure that isolated problems were redressed by the steward - for example, having sufficient hay for doctors' horses, removing a dung heap that had been offensive to patients, and sending a goat 'off the premises/ Trustees were not the only people to inspect and evaluate the hospital. In the event of an accidental death of a patient, for example, jurors would meet in the hospital to review its procedures and interview its patients. Reports of jurors, like those of trustees, generally were encouraging: they determined that the hospital was in 'as good an order & patients as comfortable as possible in consideration of the funds' and that the 'House [was] clean and every thing in the best order and the patients properly attended to.' Jurors were 'quite satisfied that the authorities are doing every thing in their power to conduct its affairs to the satisfaction of the public.'24 Trustees continued to oversee some medical matters, including monitoring the needs of patients and their interactions with doctors. Frequently, trustees' walkabouts led to startling revelations. One patient reported that his medical attendant had not examined his injured foot in six weeks, and eleven other patients said that they had not seen their doctors in weeks. A Mrs Kelly declared that she had not seen Dr Newcombe, her doctor, since she had been admitted to hospital. About Dr Hodder, Charlotte Dalton said that it had been three weeks since he had visited her, Eliza Monk had not seen him in four weeks, and James Madden had not had a visit in seven weeks. Patients similarly complained about another prominent physician, James Bovell, for his lack of attendance: Reuben Abrahams stated that it had been eight weeks since he was last visited by Dr Bovell; Hugh Moore claimed in his case that it had been six weeks. The only known action taken by the trustee was to order that these doctors be informed of these allegations.25 Sometimes trustees and physicians worked against each other, as when trustees might take it on themselves to discharge patients. In one instance, a trustee ordered a patient out for being drunk. Another patient discharged for misconduct was readmitted by one of the attending physicians - incensing the visiting trustee, who fumed that the decision was 'utterly subversive' and should never have been countenanced without the consent of a trustee. Nor were trustees reluctant to second guess a doctor's diagnosis, especially if they felt that the patient was an 'incurable.'26

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The maintenance of discipline and order within the wards also touched on delicate and moral issues. When the matron reported that she had seen one of the house surgeons in bed with a female patient, it was the trustees who investigated. To clear himself of this allegation, Mr Jacques stated that the patient in question was a pregnant woman suffering from syphilis, that he had not interfered with her in any improper way, and that the ward was well lit and occupied by another twelve to fourteen patients at the time of the alleged incident. In adjudicating this matter, trustees' chair William Gooderham noted that the matron's actions were quite appropriate, although there was no solid evidence that Jacques had acted improperly. None the less, the young man received a warning about his behaviour in the wards. The board also decided that in future all pregnant patients in the lock wards (those suffering from venereal disease) would be allowed to walk around the hospital grounds, but they were not to associate with other patients.27 Crisis at Confederation Problems of lumpy dough, truant doctors, or disruptive patients would quickly recede in importance when compared with the challenge that the hospital and its administrators had soon to surmount. At exactly the time in March 1867 that British legislators were passing the British North America Act, which would take effect the following i July, the hospital's trustees were pondering their 'present financial difficulties.' The synchronicity of these events was no coincidence. Among its effects, the legislation that formed the Canadian Confederation in 1867 passed responsibility for such matters as health, education, and welfare to the newly created provinces. It was then necessary for the hospital to apply for a grant from the Ontario government to help offset its expenses yet unfortunately, the required administrative machinery was not yet in place. To his credit, Ontario's first premier, John Sandfield Macdonald, believed that the state should support public charities; he thus began to reform and expand existing aid for welfare institutions. His successor, Oliver Mowat, would see that provincial legislation would come about to guarantee such support.28 In the meantime, however, the hospital fell through the cracks in government funding. As the federal secretary of state in Ottawa replied to the trustees, 'All future payments are in the hands of the local Government of Ontario.'29 The measures implemented by the hospital board were draconian. Doing good meant being bold. In 1867 the hospital housed about

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eighty patients. First, Dr M.B. Hampton, resident medical officer, was instructed to start discharging all patients for whom alternative arrangements could be made. As a result, some patients were returned to the House of Industry; others could not be discharged as they had no other shelter or were still under active treatment.30 Second, if all remaining patients could be accommodated elsewhere (a former jail and also the branch lunatic asylum were actively considered), the board envisaged turning the hospital into a military barracks.31 This plan did not materialize. The third and final measure involved notifying the mayor and people of Toronto that because of the hospital's debt of $5,000 - which was increasing and unlikely to be erased because of the failure of both the city and the province to grant funds - this institution would close its doors on i August 1867. As part of this 'painful duty,' doctors had been ordered to discharge patients who could safely leave, and all members of staff except for those absolutely necessary were to be let go.32 By early October, only a handful of patients remained, along with Dr Hampton, the steward, the matron, a few nurses, and a couple of other persons to maintain the property. A last-ditch effort to save the hospital was initiated by John Joseph Lynch, Catholic archbishop of Toronto. Lynch was extremely active in his efforts to establish and promote a strong Catholic presence in mostly Protestant Toronto, which included, if not creation of a Catholic hospital, at least infiltration of the city's general hospital. When the hospital experienced financial difficulties in 1865, Lynch proposed that it be operated by the Sisters of Charity, who would labour without payment. At an open meeting of trustees, civic officials, religious representatives, and the public, he stated that his plan was grounded solely in the benefits to the sick and suffering and was not to promote Catholicism; none the less, his suggestion was politely but firmly rejected.33 This time, Lynch renewed his proposal, noting that the hospital's difficulties resulted from 'mismanagement.' Widespread consternation emerged among the Protestant ranks of Toronto. At first, the assistant minister of the Church of the Holy Trinity, W. Stewart Darling, tried to strike a conciliatory chord, but ultimately, he, a high Anglican himself, rejected the idea as naive in practice. Although 'women laboring only for the love of God' might keep the pledge of non-interference with the religious convictions of others, interference would be unnecessary, he believed, 'because it is impossible to imagine a more powerful persuasive to adopt the faith of [the Church of Rome] than the loving sympathetic care which the patients would beyond all doubt receive.' In short,

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he wrote to the Leader, 'I can conceive no readier way of turning Protestants whose theories are not sound, into Roman Catholics, than the practical results which would flow from the adoption of Bishop Lynch's suggestion/ Newspaper editorials picked up on the issues that Darling had raised, expressing the hope that trustees and legislators would come up with a plan to keep the hospital open other than by having it run by Catholics - an 'alternative,' declared one, 'which can hardly be acceptable to a large portion of the community.' 'But what is to be done in the meantime?' asked the Leader: 'Bishop Lynch proposed a plan which, were it unconnected with all religious considerations, would be at once adopted. Protestants say they are unwilling that the Hospital should go into the hands of the Roman Catholics. Such scruples are not to be despised, but what are the Protestants prepared to do? It will not do for them to stand by and play the dog in the manger. The Hospital will close in a few days and something must be done.' But nothing was done. By mid-October the hospital was empty except for Dr Hampton, who would leave shortly.34 The wisdom of closing the place can be questioned, but in retrospect it is clear that everyone was 'playing hardball.' In the uncertain economic and political times of 1867-8, it was necessary to do something extreme to ensure that the government and the public focused their attention on the hospital. The tactic had some impact. That this institution, the Canada Medical Journal exclaimed, 'so necessary to the welfare of the public ... located in the capital of the wealthy province of Ontario should have been closed for want of means to maintain it, must be regarded as a disgrace.' And, the journal's editor hoped, when the hospital eventually reopened, it would be under 'auspices which will ensure its successful conduction.'35 To ascertain what could constitute such success and to establish the exact causes of the hospital's closure, the provincial legislature struck a select committee of inquiry in January 1868. Under the chairmanship of Conservative Abraham W. Lauder, the four Liberal and five Conservative members reported their findings the next month, based upon an extensive questionnaire circulated among hospital trustees and physicians. The committee was especially interested in finding out about three areas: hospital income and expenditure, governance, and patients. The official printed report, containing only an edited selection of respon-

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dents' answers, coupled with the original handwritten submissions, indicates that trustees and physicians functioned in different spheres. Trustees held that physicians should not be allowed to sit on the board because they could be disruptive, unreliable, or self-serving. Physicians showed that they knew next to nothing about the costs and administration of the hospital, maintaining that these were the domain of trustees. Yet they often lamented that they were denied the chance to influence hospital matters through the board. Dr Hodder complained that trustees rarely if ever consulted medical staff, while another senior surgeon, Dr W.R. Beaumont, griped that the medical men could not order anything expensive in the way of dietary items such as poultry, fish, or eggs. Worse, for Beaumont, was the lack of medical representation on the board, which, he claimed, erroneously, had 'always three or four senior medical officers of the Hospital on the Board, who of course, knew better than those who are not medical men, the requirements of an hospital, & especially so, of their own.' Incredibly, Beaumont believed that the hospital was better managed during the previous decade because of such medical influence, when in actual fact it had experienced a period of strife, turmoil, and ridicule. Trustees and physicians united in their beliefs that the government's withholding of its grant was responsible for the closure, that the building was in dire need of repair, and that the hospital was inconveniently located for both physicians and patients. They also agreed that physicians' attendance on patients at the hospital was irregular and infrequent - an unacceptable state of affairs. Both recognized that even if no treatments were prescribed for patients, the very presence of their physician had a beneficial effect: 'Nothing is more important in the successful treatment of disease than that the patient should not only have confidence in the skill of the physician, but feel that he is deeply interested in his recovery,' remarked trustee John Macdonald. Echoing this sentiment, Dr W.T. Aikins (since reappointed) stated that the hospital and patients suffered if the physician failed to secure 'the mental curative influence of frequent encouragement.' The hospital's important role in medical education and its potential for development were other areas of unequivocal accord. Dr Berryman was adamant that the institution's failure to reopen would be 'simply fatal* for the city's medical schools and their students. 'The Hospital is an indispensable auxiliary to the existence of Medical Colleges in Toronto,' Dr Green pointed out, 'and no time should be lost in re-

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opening/ Aikins estimated that since medical students spent about $50,000 a year in the city, the closure of the hospital not only would cripple medical education but also would have a significant economic impact. Trustee John Macdonald believed that the loss of medical students would be 'most disastrous' Yet there was an air of hope, too. For Aikins, there was no reason why the Toronto General Hospital could not become 'one of the first in America in the richness of its clinical or practical instructions' and in so doing become an institution of which 'every Canadian would be proud.' In addition to the official report, select committee chair Lauder prepared a holograph report for the legislature that does not appear to have been printed. In it, he reveals that the committee was aghast at the almost $96,000 spent to erect the hospital when a smaller and less expensive building would have sufficed, to say nothing of the remaining $58,000 debenture debt incurred. 'Unless some immediate relief is afforded,' he wrote, 'the balance of the property will be sacrificed to meet the demand of Creditors and the future efficiency and usefulness of the balance of the Trust property, including as it does perhaps the finest Hospital Building in British America, completely suspended and perhaps permanently destroyed.' Lauder's report concluded that the hospital was worth supporting despite its mismanagement, the trustees' loss of public confidence, and the lack of the 'cordial concert amongst the staff as would seem to be essential to a proper and complete care of the patients.' It called for a new and more efficient system of management, under the direction of an experienced medical superintendent who had control of all hospital functions. It also emphasized the 'serious injury' to the education of the province's future doctors that would follow from permanent closure.36 In the spring of 1868, the hospital attempted to get back on track. Trustees initiated discussion with representatives of Toronto's medical schools about educational matters and the hospital. They cleared outstanding debts - though how is not clear - and put out calls for tenders to repair parts of the previously vacant building.37 By August the hospital reopened and Dr Hampton was reinstated as the resident medical officer, assisted by a skeleton staff; initially, only twenty-five patients were to be admitted. However tentative these steps were, the hospital had again 'been thrown open to the public,' as the Dominion Medical Journal reported. In an editorial, this publication urged the new Ontario government to recognize the 'usefulness of this noble institution' and

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take measures to ensure that the hospital would never again close because of lack of funds.38 Spearheading efforts to resuscitate the hospital was Adam Wilson. Though never considered radical, he was imbued with a reforming spirit. As chair of the trustees - an appointment that he held until 1872 - Wilson brought political, legal, and judicial experience to the position. In 1859, ne successfully campaigned against former Toronto mayors and hospital trustees John G. Bowes and W.H. Boulton to become the city's first mayor elected by direct popular vote. During his career he initiated a lawsuit against John A. Macdonald (later Canada's first prime minister) and held a cabinet post in the coalition government of Premier John Sandfield Macdonald. Wilson later became the province's most senior judge, was knighted in 1887, and became known for his 'lucid' and 'prolific'judgments.39 Exemplary of his sagacious approach to hospital affairs was the Toronto General Hospital's report submitted to the government of Ontario in June i868.4° Ostensibly this was an internal document that outlined the financial plight of the hospital, accompanied by a request for government aid. But it was also much more: it was a landmark document in the history of provincial, if not Canadian, health care. In effect, it set out a blueprint for future government funding of hospitals in Ontario. It explained that the hospital had just under $4,000 remaining - a sum that would not take long to exhaust in the light of normal operating costs. In 1866, its most recent full year of operation, the hospital had treated about 600 patients and approximately 4,000 outpatients, adding up to an aggregate number of patient days in hospital of 33,854, with the annual cost per patient being $28; total expenditure for this year was $16,663. Wilson and his colleagues were not interested in a quick financial fix, because the only remedy for the Toronto General's predicament indeed, for all hospitals in the province - lay in fundamental change: 'the conclusion is forced upon us that there is something radically wrong in the present system of hospital management,' the report asserted, 'and that a different scheme must be provided for their future maintenance.' Alluding to provincial support for other charitable institutions, it made the case for continuing support for hospitals. The sick as a class are entitled to quite as much consideration as the insane or the deaf and dumb, and it is very plain that if it be worth while to educate people at an enormous public cost, it is worth while to take care of

Q6

A Public Charity, 1856-1903 them when they are educated and are struck down by sickness. It is a duty which we owe to the community not to suffer dangerous, infectious diseases, to remain among the healthy: their removal and treatment should, in most cases, be at the public expense. The basis of such a system must be public support, continuing regular, always ready for the emergency, and bearing equally upon all: not private alms, inconstant or irregular, too late for the occasion, and pressing too heavily on the liberal, while many who are as able to give go free.

Constructively critical, Wilson pointed out that the existing method of government grants year by year was unsatisfactory: what was needed was a 'permanent self-working plan.' To fund such a program it would not be inappropriate to implement a public tax - and who could reasonably object to such a measure, he asked, for in the long run, everybody in the province would probably benefit: The poor or friendless by hospital care, and the wealthy by the removal from their neighborhood of those who are afflicted with contagious complaints.' Furthermore, because time spent in the hospital and its wards had become an essential part of the training of physicians, the better the hospital, the better their educational experience. The skill and knowledge so obtained re-act for the general good, for the medical man who becomes more expert, or more scientific, becomes better qualified to serve the public.' And in the event that his appeal might appear self-serving, Wilson emphasized that what would be good for the Toronto General would be good for hospitals in Hamilton, Kingston, London, and Ottawa; all needed 'remodelling.' For those who might still be unconvinced, he mounted another argument that might have sounded like institutional hubris but for its undeniable truth: 'At the present time it is notorious that what is called the Toronto Hospital, and which is therefore supposed to be the hospital for Toronto, is not the hospital for this place, but is the receptacle for the sick poor from all parts of the country who flock to it because there is no such place in their own localities.' In concluding this signal report, Adam Wilson highlighted a theme that editorialists of the previous decade had first expounded: public duty. Undoubtedly a man of good Christian character, Wilson subscribed to the tenets of Christian charity. Yet even for him it was no longer adequate to care for the sick, 'merely from benevolent impulse' [emphasis added]; rather, people should be 'bound to act from duty.' 'All the hospitals of the province may be ranked hereafter among those public charities which it is considered to be an honor as well as a duty to

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maintain,' he declared. Public cost, public expense, public support, public duty - the message surely was clear. The Toronto General Hospital had demonstrated its capacity for doing good; the likelihood that other new hospitals in Ontario would similarly contribute to the public good underscored the utility of having the newly formed provincial government assume financial responsibility for all.41 Government Reports and Reforms At first, legislators heard only part of the message. As a result of the tireless efforts of a recent recruit to Ontario's civil service, John W. Langmuir, in time they would all assimilate it. Langmuir entered public service from a background as a small businessman in the eastern Ontario village of Picton. He was elected Picton's mayor in 1864, and at the age of thirty-two he began his fourteen-year service to government as inspector of prisons, asylums, and public charities. Working at first within the Prison and Asylum Inspection Act, which came into force in 1868, Langmuir quickly developed a reputation for his industry, his attention to economy, and his imperiousness. With these traits, and the support of successive governments, Langmuir and his small department developed a system of charitable and correctional institutions that was one of the most complete in North America. Because hospitals, including the Toronto General, were not wholly publicly funded, unlike provincial lunatic asylums and jails, they were exempt from Langmuir's inspection. However, since hospitals had received grants in the past, and probably would again, their inspection soon fell to Langmuir42 - an action prompted in part by Adam Wilson's farsighted report of 1868. Inspector Langmuir's first report formally to include hospitals in 1870-1 ably displayed his inspection style and his penchant for economy. Tacitly criticizing past trustees of the Toronto General for their mismanagement of the hospital land endowment, slighting physicians for their lack of attendance, declaring that wards and beds were unclean, Langmuir concluded by noting that the hospital's expenses were excessive. Although he passed no comment on the salaries of employees, he provided a detailed list of them (Table 3.1) ,43 Langmuir's report drew a public response from the board of trustees in the form of a twenty-seven-page pamphlet, Answer of the Trustees of the Toronto General Hospital to the Report of the Inspector of Prisons Etc., Lately Presented to the Legislative Assembly.^ Its Answer argued that the government inspector's critique was inaccurate, unfair, and based on only an

98

A Public Charity, 1856-1903 Table 3.1 Salaries of employees, Toronto General Hospital, 1870-1 Position Secretary Resident physician Lady superintendent Orderly Dispensary Yardman Cook Laundress Laundress assistant House maid Day nurse (3) Night nurse (3)

Annual salary ($)

Board and lodging

800 600 200 140 120 120 108 108 96 96 96 96

No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

hour's visit during which he made no effort to meet with the lady superintendent. At that time, too, the medical resident officer was in the country recuperating from illness. Equally irksome to trustees was the inexperienced inspector's ignorance of institutional life, his inability to appreciate the effects of daily wear and tear in the hospital, and his reliance on local rumours as much as on his own fleeting examination. 'It is extraordinary,' they exclaimed, 'that there should be any prevailing notion of disorder, neglect and incompetency ruling in the Hospital, when it is considered that it is open every day of the year to all comers.' As to Langmuir's claim that hospital linen was dirty, what did he expect? The hospital's bed sheeting was not to be compared with that of a private family, nor even that of a lunatic asylum, for staining and discolouration from 'all kinds of medical applications, and by blood and ulcerous matter,' were unavoidable in the wards. Then let it be considered what class of persons many of those in the Hospital are,' the Answer reminded its readers, a 'class that is difficult and in some cases impossible to make cleanly or to keep clean, and who are not very considerate as to the use they put any artic[l]e to, whether of bedding or otherwise which is not their own property.' In any case, the trustees rationalized (incredibly), the worst of the bedding was used in the 'Blind ward' (visited by Langmuir), which housed the 'most uncleanly and most troublesome of the male patients.'45 Inspector Langmuir's other major criticism focused on management expenses, set against comparative figures for hospitals in Hamilton and

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Kingston. Trustees again leapt to demonstrate that the government report had presented a distorted image. Comparisons of hospitals were problematic, they contended, owing to differing ward policies; in particular, some of Hamilton's patients were 'Poor House' inmates kept at a minimum maintenance rate. The trustees prepared an elaborate comparative table of patient and cost statistics for all these hospitals that they believed was both fair and accurate. For Toronto, Hamilton, and Kingston's hospitals they calculated the total number of admissions, the duration of stays, and the cost of meat, butter, flour, bread, produce, beer, wine, spirits, and medicinal compounds. In this way, they determined that a patient at the Toronto General cost about twenty-two cents per day, compared with eighteen cents at Kingston and approximately fifteen cents at Hamilton.46 Many of the itemized costs for patient maintenance were higher at the Toronto hospital, the trustees maintained, in a ratio that was roughly proportional to a higher patient load and longer stays. Trustees fully acknowledged, however, that costs for milk, beer, spirits, and medicines were disproportionately higher by any standard: whereas Hamilton spent about $600 and Kingston just over $400 for these items, their hospital spent about $2,500. They explained that the large outlay was a function of the prescribing habits of the hospital's many attending physicians. The Toronto General had 'obtained the best medical advice and skill to be had in the city,' the trustees noted, and so they understood that 'these gentlemen will order that which is right, and not more of anything than is necessary.' Despite this show of support for the doctors, trustees hinted that there were too many in attendance and that a reduction in their number 'would be a check upon any extravagant prescriptions.'47 The hospital's rebuttal reads occasionally like an account of a battle between bean-counters, yet discussion of seemingly trivial matters such as hospital diet, cleanliness of sheets and wards, and the hospital's expenses was important. On this, the hospital's first official inspection by a provincial civil servant, it was vital that trustees defend their credibility in the eyes of both the public and the government. After all, in his report only a few years earlier, Adam Wilson had pleaded for the government to become more active in support of the Toronto General and all other hospitals in the province. This first inspection was salutary for both parties. Langmuir's report and the trustees' Answer can be seen as defining positions. For the hospital, ongoing government funding would probably necessitate a high level of accountability in its management practices - about which trust-

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ees had been remiss for decades. The government and its servant, Langmuir, learned that the cultures and practices of individual hospitals affected performance. During the early 18708 successive reports demonstrated that a working relationship was emerging between hospital and government. Langmuir's reports provide the first collective picture of Ontario's hospitals and their activities. If we judge by the statistics that he employed number of patients treated, staff salaries and wages, hospital expenditures, income, and so on - it is clear that the Toronto General Hospital was the dominant institution. Viewing one year as in a snapshot, Tables 3.2 and 3.3 show that it not only served the greatest number of patients in the province, but it also generated the largest income. It raised approximately $24,000 (almost half from a provincial government grant) - three times more than the hospital with the next highest revenue and many times greater than the provincial average. Not surprisingly, too, the Toronto General had the highest expenditures in the province. As the entire cost of operating the hospital (for food, medicines, salaries, fuel, and so on) was $16,268 in this year, care for 703 patients for 29,574 days (an average stay of 42 days per patient) produced a daily maintenance cost per patient of 55 cents. This figure exceeded that for Ottawa's Roman Catholic hospital (29!^ cents) and several other institutions, but it was lower than that for hospitals in London (69 cents) and St Catharines (732/^cents); the average daily cost for the eight hospitals was 49 cents.48 Whatever else they reveal, these figures show the dependence of the Toronto General and other hospitals on government funding - a point made clear in the hospital's petition of 1872 to the Ontario government in support of its annual grant. In pleading its own case for funds for renovation, repairs, patient maintenance, and facilities to accommodate people suffering from smallpox and similar diseases, Toronto General's trustees made a pitch for hospital funding in general. Throughout the province, this funding had amounted to only $30,000 a year - a small sum for so large an area and population; indeed, trustees believed that there were no charities as 'urgently needed' yet so 'cheaply supported' as hospitals. The good they do may be estimated by the cures which they effect but the evils they prevent [i.e.] the stoppage and eradication of disease ... can never be estimated,' they argued.49 The issue of hospital funding attracted other attention in 1872, as the province obtained a new, Liberal premier, Oliver Mowat. The Liberal

Table 3.2 Patient profiles for hospitals in Ontario, 1870-1 Religion No. of patients Hospital

Under care

Nationality

Sex

Discharged Died Remaining

Male

Female

Protestant

Roman Catholic

Not known or other

Britisht Canadian Other

Toronto General (1829)*

703

562

76

65

502

201

567

134

2

530

139

34

Kingston General (1833)

604

550

20

34

408

196

385

167

52

312

217

75

Hamilton City (1850)

536

436

44

56

347

189

312

224

0

367

116

53

Ottawa Roman Catholic (1845)

250

222

16

12

125

125

9

241

0

56

193

1

London General (1858)

215

186

11

18

120

95

129

85

1

161

42

12

Kingston Hotel Dieu (1845)

200

183

10

7

109

91

9

191

0

109

61

30

Ottawa Protestant (1850)

121

88

16

17

80

41

120

1

0

82

32

7

St Catharines General (1865)

121

105

8

8

91

30

35

82

4

74

31

16

2,750

2,332

201

217

968

1,566

1,125

59

1,691

831

228

Total

* Identifies approximate date that hospital was first operational fFrom England, Ireland, Scotland Source: Data derived from Ontario, Sessional Papers (1871-2), No. 4

1,782

A Public Charity, 1856-1903

1O2

Table 3.3 Receipts ($) for hospitals in Ontario, 1870-1 Sources

Hospital

Total receipts

Provincial government

Paying patients

Municipalities

Toronto General Hamilton City Kingston General Ottawa Protestant St Catharines General London General Ottawa Roman Catholic Kingston Hotel Dieu

23,785 7,120 6,858 4,228 3,382 3,224 2,664 2,092

11,200 4,800 4,800 1,200 1,000 2,400 1,200 800

1,738 218

1,888 2,102

8,959

722 362 0 0

1,336 2,566 1,982

221

0 100 400 824 0 0

Total

53,353

27,400

4,468

5,314

16,171

1,207

Other*

0

0 257

1,071

includes balance on hand, income from property, subscriptions, and donations. Source: Data derived from Ontario, Sessional Papers (1871-2), No. 4

member for Norfolk in the southwest of the province, Dr Clarke, spent his 'spare moments' visiting hospitals, poor houses, and similar institutions to gather information and determine how to build a more 'liberal and permanent basis' for their support. Commenting on his efforts, the country's relatively new, Toronto-based medical journal, the Canada Lancet, hoped that the Toronto General would receive its fair share of any new funding, for it could be made into 'one of the best appointed and most useful of its kind in the Dominion.'50 John Langmuir extended these initial funding activities by exploring in his 1872 report the most appropriate ways for the government to support public institutions such as hospitals. He firmly believed that public hospitals should receive funding because they were central to the education of doctors - and the better-trained doctors were, the better off their patients were. Equally important were the hospital's caring and curing functions, especially its role in addressing the needs of society's less well off, for the majority of patients, 'if not in indigent circumstances,' Langmuir observed, 'were of that class who have to work for the daily bread of themselves and their families, and who, if Hospital treatment had not been open to them, when overtaken by sickness or accident, might have been permanently withdrawn from the working and wealth-producing population of the Province, and placed upon the charity of friends or the public.'

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Having established the worthiness of granting public aid to hospitals, Langmuir reviewed ways to distribute such assistance. Though never mentioning the Toronto General by name, he took a hard swipe at it in dismissing land endowment as a means of support. In established and wealthy countries such as the United States and Britain the system of hospital endowment had largely obtained; in Langmuir's opinion, however, the 'management of the affairs of at least one, originally well endowed Hospital in this city, certainly is not favourable to the introduction of the endowment system in this Province.' Recognizing that the current manner of support was 'entirely devoid of system' - for it was based neither on the number of patients admitted nor on monies received from other sources - he advocated instead that a provincial grant be equal to funds raised by the hospital for its maintenance and support the preceding year.51 (In effect, this was an early form of matching grants.) There was a cost for government support, of course. In addition to being financially accountable to the government, hospitals would have to submit all plans for building, expansion, equipment, and so on for its approval; similarly, the majority of hospital beds would have to be available for indigent patients, and hospital boards would require representatives from local and provincial governments. In the case of the Toronto General, such requirements imposed no difficulty, as they already shaped its board structure. Langmuir's report of 1872 clearly echoed Adam Wilson and his report of 1868. At this time, pieces of legislation were being planned as the province developed an infrastructure. As part of his overall political planning, Premier Mowat worked to ensure that he garnered votes from both Protestants and Catholics, but the increasing organization of Orangeism, culminating in a movement in 1873 to have Orange Lodges legalized in Ontario, presented him with the risk of losing important Catholic support. Behind the scenes many prominent Catholic leaders lobbied hard at both the federal and provincial levels to block any such incorporation of lodges.52 As in earlier decades of its history, the Toronto General Hospital found itself enmeshed in this struggle between politics and religion. A significant player in these manoeuvrings was Archbishop Lynch of Toronto, who took advantage of the situation to embarrass the nondenominational Toronto General Hospital and give pause to Mowat and his proposed Orangemen's legislation. Scenting again the advantage of the moment, Lynch published claims that the hospital was mis-

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managed and in dire straits - whereas if it were placed in Catholic hands, matters would be rectified. Trustees vigorously denied his allegations; they shot back that his statements were at best vague and that they deeply resented his making them public. Even if Catholic sisters were to take over the duties of paid nurses as a cost-saving measure, as Lynch again advocated, that would save only about $1,000 per year, they argued. As for another of Lynch's allegations - that patients' possessions had been stolen - trustees suggested that a rumour had probably originated with a brother of a smallpox patient who had died in hospital: as a precautionary public health measure, the dead woman's clothes and bedding had been burnt on the instruction of the resident physician. After countering these charges, trustees again dealt with the real irritant: religion. Whether Catholic Sisters of Charity would try to inculcate hospital patients with their religious rules and precepts trustees could not say, although they maintained that the general public would think that they would. Such perceptions were unacceptable to the hospital: 'In this community consisting so largely of Protestants of all denominations it would be impolitic, to say the least of it, and perhaps dangerous to the welfare of the Institution.'53 Although Lynch was rebuffed for a third time, in the process he had once more drawn attention to his cause. The tension between the Orange and the Green was not lost on Mowat, who did not wish to jeopardize the majority Protestant vote or alienate the minority - but highly influential - Catholic vote. To extricate himself, Mowat took his time and eventually buried the original legislation for incorporation of Orange Lodges within Bill 139, An Act to regulate Public Aid to Charitable Institutions. In this way, Orangemen indirectly got what they wished, Catholics were not directly offended, and hospitals entered a new era of financial security because of public funding.54 Eventually, Lynch would get his Catholic institution with the founding of St Michael's Hospital in i892.55 Known as the Charity Aid Act, Mowat's legislation of 1874 was the fruit of the seed planted by Adam Wilson in his hospital report in 1868. For the first time government support for the Toronto General Hospital became part of a stable funding program sanctioned by official government policy, in contrast to previous, unpredictable annual grants. The act undeniably signified the government's will to become more involved in the affairs of health-care and other social agencies in the province. Concurrent with Mowat's political deal-making, Langmuir doggedly pursued his inspections, refined his recommended funding formula,

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and pushed for legislative action to implement his plan. The terms of the Charity Aid Act allotted hospitals a basic daily patient grant of twenty cents; typically, however, hospitals received thirty cents per patient per day because of a formula that took into account other hospital revenues.56 In the case of the Toronto General, the daily patient costs hovered around this amount, depending on how it was calculated; this level of ongoing government funding thus greatly aided the hospital's financial health.57 With passage of the Charity Aid Act in 1874 a greater segment of society could benefit from hospital care, while more people endorsed support for the institution. Only a year earlier, a Globe editorial had called for the withholding of government funds until the Toronto General became better organized - sentiments endorsed by the Canada Lancet, which hinted at a lack of community confidence in the hospital. After passage of the act, the Globe had a change of heart. The Toronto General 'years ago lost the confidence of the public, and it is a long time before such a loss can be rectified,' but thanks to 'a marked improvement in its general arrangements,' the public should contribute directly (through taxes) to the hospital 'from genuine interest in the establishment itself, and in the good that it was visibly effecting.'58 The Charity Aid Act had other effects. Not only were more hospitals being built around the province, but existing ones were also able to admit more patients. In an era in which the provincial government promoted institutional growth of all kinds, the numerical increase in hospitals and their patients was seen as good news. John Langmuir reported, almost gleefully, the extended benefits of hospital treatment to more people, which provided, to his mind, unequivocal proof that 'Hospital accommodation of the past would have been quite insufficient for the present wants of the Province.' It was testimony, he hastened to add, to his close supervision and inspection program. Langmuir went further to suggest that every town of over 5,000 inhabitants should have a hospital.59 Many of the earlier issues surrounding hospital management, physicians' activities, and duties, and funding were embodied in another piece of legislation in 1875 - the Act to amend the Acts relating to the Toronto General Hospital. Under this act, three trustees were to be appointed by the provincial government and one by the city of Toronto (who was to be a resident of the city but not a physician); another was to be elected by those who subscribed $20 annually to the hospital. Trustees

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would continue to manage the hospital and its affairs, in addition to appointing and regulating medical staff. Debate on this bill in the legislative assembly was minimal, with Premier Mowat himself roundly supporting it and the hospital. (It was his father-in-law, John Ewart, who had built the original hospital in 1819.) He acknowledged that although the Toronto General had had its problems, it was then in a Very satisfactory state.' Curiously, the most contentious point of parliamentary debate was over the issue of homoeopathy - whether anything in the act would bar its practitioners from being appointed to the Toronto General. One legislator, who claimed that he owed his life to this therapeutic practice, was assured that the act would not present any obstacles for any homoeopathic appointments.60 Doctors, Patients, and Students Grand issues of funding and government involvement in hospital affairs aside, trustees of the Toronto General Hospital in the late i86os and early 18705 had to deal with a host of routine matters. Orders for dozens of new spoons, cups, and tin plates; for numerous bedpans and female urinals; and for thousands of yards of cotton, sheeting, towelling, ticking, and other bedding materials are all reminders of the necessities of everyday institutional life.6' In the light of earlier comments about grossly discoloured bedding, it was probably no coincidence that the purchase of new sheets barely preceded both John Langmuir's inspection and, perhaps more important, the visit of the governor general's wife, Lady Dufferin. Putting its best foot forward during her tour in October 1872, the hospital obviously impressed this dignitary: she declared, recorded the trustees, that the 'pain which the sight of so much suffering, indispensable from an Hospital has given some, has been ... counterbalanced by the gratification with which I have noticed the endeavour to relieve it, apparent not only in the comfort and cleanliness of the wards, but in the skill and kindness with which the patients are treated.' In her private comments, Lady Dufferin observed that she 'went over the Toronto Hospital this morning - a fine building and well managed, but badly off for funds.'62 The upgrading of kitchen and cooking equipment, together with the heating system for the wards and the corridors, added to patients' wellbeing and comfort.63 The hospital, in fact, seems to have developed into such a comfortable place, attracting so many visitors, that trustees

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placed newspaper announcements restricting visiting hours to Tuesday and Friday from 2 p.m. until 5 p.m. The distribution of bouquets of flowers throughout the wards added to the apparently more hospitable atmosphere. While floral decorations and fragrances no doubt cheered many a patient's weary soul, the mounting of this 'flower mission' by some of Toronto's 'ladies' also suggests that the concept of the institution was seeping deeper into the public consciousness. (It also hints at the ceremonial and peripheral role of women in hospital affairs.)04 In a rare moment of enthusiasm, Langmuir himself prophesied that the Toronto General would 'soon become what it should be, not only the Metropolitan, but the model Hospital of the Province.'65 From the time of the hospital's reopening in 1868, government reports provide the quantitative information that we need to develop profiles of patients. As in the past, people hailing from the British Isles formed the overwhelming bulk of hospital patients (Figure 3.3). Most were also residents of Toronto; however, the hospital also served a significant number of residents from surrounding counties and some from other countries. For the years 1873, 1-874, and 1875, f°r which complete information on place of residence is available, 2,795 patients were admitted. The distribution of their residence is as follows: Toronto, 1,989 (71.2 per cent); county of York, 198 (7 per cent); other counties, 516 (18.5 per cent); and the United States, emigrants, or those resident in other countries, 92 (3-3 per cent).66 From 1870 to 1875, 4,815 patients received treatment in the hospital, with an average annual intake of 803 persons. The hospital also provided medical care for many 'externs,' or outpatients. As we see in Table 3.4, in 1870, 1,489 people were outpatients; by 1874, the number had risen to 7,854 before dropping to 4,256 the following year. In each year of this sample, the male-to-female patient ratio was consistently about 2:i; similarly, patients identified as Protestants routinely outnumbered 3:1 Roman Catholics, those professing other denominations, and those whose faith was unknown. The average annual rate of patients who died in hospital as a proportion of those admitted was just slightly over 10 per cent. Despite fluctuations in this figure (for example, 12 per cent in 1872 and 8.6 per cent in 1874), it did remain remarkably constant both within this period and vis-a-vis the 18305. The constant rise of total admissions - by 50 per cent during the fiveyear period - helps explain the concomitant increase in the total number of patient days spent in the hospital. In 1870, 21,348 patient days

108

A Public Charity, 1856-1903

Figure 3.3 Patients' nationality, Toronto General Hospital, 1870-5

were accumulated; by 1875, the figure had more than doubled to 52,414. At the same time, the average length of a hospital stay rose from about thirty-four days in 1870 to fifty-four days five years later. It is not possible to explain this trend adequately other than to note the general increased patient load and to suggest that physicians may have chosen to keep patients in hospital longer to assist their recovery. As the most significant jump happened after introduction of the Charity Aid Act in 1874, however, it is possible that patients were kept in hospital longer than necessary to take advantage of the government's per-diem maintenance rate. (Langmuir himself drew attention to the number of 'incurable' - that is, long-term or chronic - patients whom he had identified in hospitals who should not have been admitted; he believed that they should be removed to houses of refuge. Occasionally, he would penalize hospitals by reducing the official thirty-cent per-diem rate to one of seven cents for such patients.) For the year 1875, John Langmuir gathered data on all diseases and conditions treated in all ten of Ontario's hospitals. Of the 3,915 cases, the Toronto General was responsible for 30 per cent (1,165). Despite probable differences in how institutions classified diseases, 266 diseases or conditions appear; almost half (120) were found on the Toronto General's wards. With respect to surgical amputations, for example,

Table 3.4 Patient profile, Toronto General Hospital, 1870-5 Religion Klrt

r\f rtotiAnto

Cpy

Year

Under care

Discharged

Died

Extern

Male

Female

Protestant

Roman Catholic

Not known or other

Average stay (days)

Patient days

1870 1871 1872 1873 1874 1875

634 703 665 752 1,087 974

486 562 501 597 848 747

63 76 80 88 93 92

1,489 N/A N/A N/A 7,854 4,256

429 502 N/A 509 731 656

205 201 N/A 243 356 318

447 567 N/A 519 738 730

171 134 N/A 167 341 236

16 2 N/A 66 8 8

33% 42

21,348 29,574 28,975 33,165 54,566 52,414

4314

44 51 533/4

Daily cost (e)

80 55 611/2

691/2 731/2 •621/4

Sources: Data derived from Ontario, Sessional Papers (1870-1), No. 6; (1871-2), No. 4; (1872-3), No. 2; (1874), No. 2; (1875), No. 4; and (1877), No. 2

no

A Public Chanty, 1856-1903 Table 3.5 Consumption of medicinal beverages, Toronto General Hospital, 1869-70

Physician Aikins Berryman Canniff Cassidy Dispensary use Geikie Hampton Hodder Richardson Powell Thorburn

No. of patients

Milk (pints)

19 13 22 20 N/A

558 262 712

25 N/A 1 11 9 7

1,057

774 -

24 412 340 389

Beer (pints)

177 74 64 136 124 62 61 102

Whisky (ounces) 810 848 994

1,696 360

3,100 160 990 424 386

Toronto all but secured a monopoly. In 1875, fifty-four amputations ranging from the removal of toes to the potentially life-threatening removal of legs took place in Ontario hospitals, 91 per cent (forty-nine) of them in the Toronto General alone. The single largest group of conditions treated at the Toronto General continued to be fevers, including smallpox and erysipelas (a form of hospital-acquired disease).67 The lack of institutional case records, which would match physician to patient along with specific treatments, makes generalization about patient care difficult. As just one example of variation among doctors, the trustees' Answer to Langmuir in 1871 outlined their individual prescribing habits for medicinal beverages (Table 3.5). The doctors were fairly consistent in their prescription of beer, but Dr Cassidy prescribed twice as much whisky as Dr Aikins, and Dr Geikie ordered copious amounts of whisky and milk. In total, doctors prescribed 566 gallons of milk, 100 gallons of beer, and 76 gallons of whisky in one year alone, with some patients receiving between 2 and 4 pints of milk and 114 pints of whisky daily. The generous portions were consistent with contemporary medical thinking that milk and alcohol formed part of a stimulative dietary regimen for patients. Although there was some discussion as to the merits of alcohol as a medicinal agent, it remained an enduring and widely prescribed treatment. One can only surmise how the sober Presbyterian John Langmuir, who would later manage an asylum for inebriates (including phy-

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sicians), interpreted these data, especially given that Ontario society was then mobilizing its temperance movements. Publicly, he was unimpressed with the excessive cost of these beverages.08 As the available quantitative information demonstrates, the Toronto General Hospital served a broad population. Details of individuals admitted and treated once again appear only in clinical reports published in medical journals. Between 1854 and 1869, when the Dominion Medical Journal was established by Uzziel Ogden and J. Widmer Rolph, Toronto had no publication outlet for reports of the Toronto General. A sign of less charged times, the Dominion Medical Journal (and its immediate successor, the Canada Lancet) routinely included cases presented by Toronto General doctors and their students. Having formed the basis for clinical lectures or bedside instruction, these accounts often were selected for their 'interesting' material; none the less, they illustrate well the nature of patient care in the i86os and 18708. Unlike cases reported fifteen years earlier, these accounts on the whole dwelt less on sophisticated surgical cases. Cancer would be cut out if possible, but this procedure would not effect a cure. A surgeon carefully removed a malignant tumour the size of a man's fist along with 'all suspicious-looking material' from the upper eyelid of a nine-year-old boy, recognizing that the cancer would return sooner or later 'in all its violence, and ultimately secure its victim.'69 Whereas William Beaumont specialized in delicate eye surgery in the 18505, Dr Edward Hodder now undertook neurosurgical operations for treatment of 'epileptic fits' (i.e., seizures). He bored holes in the skulls of young men with seizures, often caused by kicks to the head by horses, to relieve pressure on their brains.70 These cases convey much more than the clinical. Patients ranged from children of nine years to adults in their seventies, and their names begin to disappear in favour of initials. More significant, whereas earlier only inferences about social status were possible via comparison with records of the Toronto General Dispensary, patients were clearly identified here as belonging to the working class. The new Toronto General Hospital cared for those employed as sailor, servant, cooper, cab driver, railway worker, hostler, printer, maid, raftsman, carpenter, stone cutter, labourer, flaxdresser, tavernkeeper, farmer, metal worker, engineer, and canal dredger. That people travelled to the hospital from outside the city, sometimes referred by their doctors, was illustrated in the case of a fifty-nine-year-old woman who had her facial tumour removed at

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the Toronto General after two country doctors 'declined to have anything to do' with the growth, which was i^l/2 inches by 10 inches. Accident victims and people with chronic ailments such as bladder stones also went to Toronto for treatment.71 In contrast to the few cases of chronic skin and eye conditions published in the earlier period, virtually all the cases from the i86os and 18708 reflect the nascent industrialization of the province. Occupational injuries are therefore prominent. In the bush, frostbite affected workers who cleared or transported lumber; one worker eventually lost his foot after being careless with his axe.72 Moving parts of equipment exacted a toll, as in the cases of the printer whose hands were caught in the heavy rollers of his press and the cooper who lost his balance and fell into the fast-rotating belts, pulleys, and fly-wheel of a brewery engine-house. Labourers and construction workers entered hospital for many reasons: slipping on the icy deck of a boat, falling from buildings or down a deep well shaft, having dynamite blow up in the hand, being crushed under a falling case of goods or masonry.73 These kinds of occupational accidents had immediate effects; others were insidious and long term. Having worked the goldmines in the Cariboo and then in a silver smelting plant in Wyoming territory and the Eraser river region for four years, 'T.C.,' only thirty-one, had paralysis of the arms and legs, with no strength in hands or fingers. He had developed chronic lead poisoning, for which he was treated, ironically, with mercury to purge him of the metallic accumulation in his body.74 Everyday life brought violent and desperate acts to the notice of doctors. A man aiming to kick a dog missed it and struck a cast-iron stove instead - obtaining for his just reward a fractured leg. Disconsolate men tried to take their lives by swallowing an overdose of laudanum (opium) or by cutting their throats with an open razor or a tobacco knife. A mistress of a boarding-house borrowed a pistol from a boarder under the pretence of 'shooting cats/ found her husband and her maid together, and shot the maid in the face for having 'obtained an undue share of her husband's attention.' A once-successful man who had suffered several reverses to become a 'common laborer' took a long trek on foot in the midst of a Canadian winter: he developed frostbite of his feet so severe that they 'presented a dark lurid hue,' and within thirty hours of admission to the hospital he died from convulsions. When twelve-yearold 'J.N.' got caught between the buffers of two cars while playing in a railway yard, he was taken immediately to the Toronto General Hospital, where his leg was amputated at the thigh.75

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The railway had been built in Toronto in the mid-i850s. Still, it was the source of many similar accidents among adults and accounted in part for the high rate of amputation reported for the Toronto General. A thirty-six-year-old Grand Trunk Railway worker was removed to the hospital after being run over by a locomotive; amputation of his left arm quickly ensued, and his life was saved, despite the gloomy prognosis offered by surgeons. Another man received treatment for a compound fracture of his arm, which had been struck by a train while he stood on a station platform; a thirty-four-year-old stone cutter had an arm amputated at the shoulder joint after he fell between the moving cars of a train while intoxicated. 'T.S.' had his foot amputated in hospital after being hit by a train and thrown twelve feet onto the tracks. When James F.'s foot was crushed 'almost into jelly' after the wheel of a railway car passed over it, he, too, had it removed in hospital; a year after his accident, he had recovered enough to be able to wear a boot and return to work.76 The features of two highly public, and publicized, cases uncover the risk inherent in all modern operations: general anaesthesia. The inhalation of chloroform to induce sleep and dull the senses was a boon to both surgeon and patient. It became used widely after the mid-i84Os. Many patients were hesitant to become totally insensible during operations and afraid of the real possibility of dying as a result of an unexpected reaction to the drug. Newspapers and medical journals frequently reported cases of patients who had died not from their operation but from the anaesthesia itself.77 In 1863, Richard Humphreys may have had a premonition that he was going to die - or so it seemed when he confided to a fellow patient that he was 'prepared to die as all should be who get operated on under chloroform.' In the Toronto General's surgical amphitheatre, as medical students looked on, 'six of the most eminent men in Toronto' did all in their power to revive their patient with electrical current and other stimulants. The Toronto Globe reported frankly that Humphreys had come to the city to obtain the best medical aid from 'men who are at the head of their profession in Canada,' yet in a matter of minutes he was a corpse. Jurors at the inquest concluded that Humphreys died from 'apoplexy, induced by chloroform,' and that the attending surgeons and the hospital were not to be held responsible. They arrived at their verdict after hearing testimony from all the doctors involved as well as from seven students from Toronto's two medical schools.78 The sudden death of John Gould on the operating table, in the

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spring of 1867, similarly called for an inquest. Newspaper reports described a disconcerting scene at his operation. Assembled on the tiered benches surrounding the floor of the theatre were several Toronto citizens, twenty-four doctors, and 180 medical students. The oppressive atmosphere created by so many people was then increased by the inexplicable behaviour of the students, who started to stamp their feet on the floor when Gould arrived - an action that jury members believed 'must have had a great influence on the mind of the patient/ After the administration of chloroform, Gould's distress became visible. Students - whose stamping may have stemmed from old medical school rivalries - then started to smash windows in order to introduce fresh air to the theatre.79 As with Humphreys's case earlier, jurors decided that Gould's death was accidental as a result of the chloroform. These events reveal how the Toronto General Hospital - especially its operating theatre - formed an arena where doctors, students, patients, and lay onlookers engaged in a kind of public spectacle. Many, if not all, of the operations in the hospital were performed in the presence of a multitude of medical men; furthermore, strict rules applied to patients' behaviour in hospital. Then as now, doctors might hold the power of a patient's life or death in their hands - although this is not to say that patients were entirely powerless. However faint, traces of patients' voices illustrate their effort to maintain some control over medical decisionmaking and clinical outcome. Margaret B., a seventy-five-year-old Irish woman, took offence over her treatment and left the hospital after one month's stay. Despite suffering from a severe, compound comminuted fracture of one of his arms, a male patient strenuously refused its amputation in the face of frequent advice to the contrary; the man recovered with his arm intact. 'T.S.' also staunchly refused an amputation but relented when his foot grew 'colder and colder,' became 'quite black,' and started 'giving off a most horrible stench'; in this case amputation no doubt saved his life. Another patient, too, 'positively refused' amputation; after four days, according to his case notes, he 'at last consented this morning to have his foot removed.' Patients might also demand treatment from hospital doctors. Although it was explained to her that her polycystic ovarian disease was untreatable, 'Mrs T.' and her daughter urged surgeon Hodder to perform dangerous abdominal surgery in an attempt to relieve her. Hodder and five other doctors, with several 'military men' also in attendance, opened the anaesthetized woman's abdomen and removed several cysts - one of which held six to seven

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quarts of 'thick, viscid light greenish yellow fluid/ and another of which filled her pelvic cavity. By noon of the second day after her operation 'Mrs TV began to sink; she died that evening.80 Many of these features of surgery and hospital life have been captured in the only known first-hand account for this period, published years later by a hospital resident serving under Dr Hampton in 1869 and 1870. Dr Alexander Taylor's recollection of his days at the Toronto General displays concern for the welfare of his patients along with frustration over the limits of therapy then available. Apparendy even then he thought that many treatments were useless, if not injurious. He recalled, for example, that chest diseases such as pneumonia, pleurisy, and bronchitis were treated by application of linseed meal poultices, 'as hot as our hand could bear/ for five to six days, followed by a soap-and-water bath and application of a Spanish fly blister. This regimen of heat and irritation might continue with a seton, a strip of linen passed through the exposed flesh to create a suppurating sore and stimulate the body to health; Taylor would turn the seton daily, 'to the great discomfort of the patient, for weeks/ Patients with enteric fevers received milk and limewater as sustenance but then had to contend with indigestion and painful distension of the bowels as a consequence. He regretted the inability to have patients remain in bed, noting that no matter how ill they were they had to get up to use a 'night stool' wheeled from one patient to another. Smallpox and its effects stood out in Taylor's memory. He helped his first case, a frail old lady, up the three flights of stairs to the ward kept for smallpox patients. Despite his best efforts, he estimated that perhaps nine out of ten patients in the hospital had refused 'vaccination' when there. Yet patients, nurses, and doctors took few precautions to curtail the spread of disease - all moved freely among wards and patients without changing clothes and aprons or washing hands. As soon as a patient exhibited a 'few pocks on his face' Taylor marched him or her up to the smallpox ward to convalesce. In only one case did the extreme and hideous 'confluent variety' of smallpox appear, and that in a nurse. Like the three other nurses, she was probably a young, untrained country girl, and she had not allowed Taylor to vaccinate her. With her body 'one mass of sores,' recalled Taylor, 'I think it would have been hard to put a pin point in healthy skin, and the odor of her room was intense.' After she died - the only loss among his smallpox patients - Taylor carried her from the third floor, through all the halls, to the morgue in the

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basement without taking any measures to protect himself, other members of staff, or patients.81 As some cases illustrate, free treatment for patients often involved their bowing to the dictates of instruction and becoming the object of study. For a time surrounding the temporary closure of the hospital in 1867-8, disaffected medical students sought a more stable clinical and educational environment elsewhere. Exactly how many is not known. But the departure of a young William Osier for Montreal's McGill medical school is perhaps the most famous example.82 Because of the hospital's role in clinical education, doctors deemed it vital for the advancement of medical practice to improve the bonds among medical schools, government, and hospitals - especially the Toronto General. Lively debate at the annual meeting of the Ontario Medical Council in 1870 emphasized these concerns. All that remained to complete the excellence of Ontario's medical schools was the greater opportunity for clinical teaching, observed one delegate. The provincial government could not better assist medical education than by aiding hospitals, remarked another. 'The greater number of inmates [hospital patients],' stated another delegate, 'the greater advantage to medical students.'83 The fact that some medical students sought clinical education in Montreal and in neighbouring New York State troubled doctors. Some members of Toronto's medical elite realized that they should help reverse this situation. Doctors who had accepted hospital appointments should honour their obligations by giving regular clinical lectures, for 'one of the primary objects of an hospital, was to train and educate' students. Editors Uzziel Ogden and J. Widmer Rolph drove home their point, along with the related issue of remuneration: 'We hope the time will soon come when the Trustees [of the Toronto General Hospital] will compel every attending medical officer to deliver a certain number of clinical lectures during each and every year. At the same time we think the gentlemen delivering the lectures should be allowed to charge a fee for their trouble, and that all students should be admitted to the lectures on payment of the fee. We care not whether all be compelled to lecture in the hospital free of charge, or all be allowed to charge and collect a fee - only, let us have the lectures.'84 Within a couple of years, a satisfactory system of clinical lectures was in place. Four lectures a week were delivered in the hospital's operating theatre, making this program 'second to no other in the Dominion.' These measures helped counter rumours among McGill doctors that

The city's first general hospital was built in 1819 at the northwest corner of King and John streets in what is now Toronto's theatre district.

The two-storey hospital first admitted patients in 1829 and continued to do so until 1856. This sketch of the building and grounds was made by Toronto physician Norman Bethune (1822-1892) after this hospital site was no longer active.

In 1856 the Toronto General Hospital moved to Gerrard Street East, where it treated patients until 1913. Despite complaints that it was too far from the city and too close to the Don River, the hospital soon became the hub of Toronto's medical activities as medical schools chose to locate around it.

This 1855 architectural drawing by William Hay shows the rear of the Gerrard Street hospital. The central, semi-circular structure is the operating and lecture theatre, which accommodated many generations of students.

Shortly after its construction, the second Toronto General was photographed in the early i86os by noted Montreal photographer William Notman.

•'t

In the late 18705 and early i88os the hospital expanded. The women's pavilion, one of the new facilities, was devoted to the treatment of various gynaecological conditions; it was fully equipped, with its own operating theatre.

Late in the nineteenth century, women admitted to the Toronto General Hospital, including young expectant mothers, seemed to enjoy fairly comfortable quarters. Women's wards were strictly off-limits to male patients.

By the late 18905 the Toronto General was one of the most modern hospitals on the continent. Its many patient pavilions, large wards, well-maintained grounds, and air of progressiveness made it a source of pride for the city.

The new Faculty of Medicine building, opened in 1903, provided excellent facilities to advance medical education in the University of Toronto. Its midtown location prompted the Toronto General to consider moving from its eastern site.

The Burnside Lying-in department of the hospital afforded students experience in maternity cases. This admission ticket from 1902, signed by medical superintendent Dr Charles O'Reilly (1846-1920), certified that the holder had attended six cases of labour.

The creation of the hospital's dispensary soon after 1900 led to free care for Jewish and Italian immigrant men and women, as its notices indicate. This satellite facility, located in St John's Ward, was also a first step in moving the hospital physically closer to the university.

The relocation of the Toronto General to the southeast corner of College Street and University Avenue brought the hospital further west, thereby placing it adjacent to the university and the provincial parliament buildings.

The proposed site for the new hospital contained many immigrant dwellings. Beginning in 1906, as the hospital systematically acquired lots in 'the Ward,' residents had to move elsewhere in the city.

By 1909 the hospital had purchased several city blocks for its purposes. This contemporary sketch by Thomas G. Greene illustrates the demolition of the dilapidated houses at the corner of Centre Avenue and Christopher Street; in the background is the city hall's clock tower.

The construction of the new hospital, well under way by 1911, provided employment for a broad range of tradesmen. It was primarily men of this class and their families who might benefit from the medical services available in the public wards that they were building.

On a site once deemed a public health hazard by authorities, a new temple of health and science began to take form. The project, financed in great part by hospital trustees John Craig Eaton (1876-1922), Joseph Flavelle (1858-1939), and other wealthy Torontonians, was a mammoth undertaking.

Against a backdrop of flags, ferns, and feathers, the official opening ceremony of the new hospital on 19 June 1913 attracted many of the city's well-to-do and provincial politicos. A bird's-eye view of the proceedings was recorded by prominent Toronto photographer William James; in the background is College Street.

.

When completed, the new Toronto General Hospital, designed by Frank Darling, was as handsome as it was impressive. The structure soon developed many teething problems but stood as a monument to the collective forces of philanthropy, capitalism, and progressive thinking. College Street front shown here.

By 1930 the Toronto General was the largest non-government-run hospital in North America. The addition at this time of the private patients' pavilion (centre foreground) allowed select patients a level of comfort hitherto unavailable. The creation of the Banting Institute (top centre) enabled doctors to conduct hospital-related research.

The tens of thousands of patients treated annually came increasingly from all walks of life. Many sought treatment through the outpatient department in the Mulock-Larkin wing, often sitting on hard wooden benches for long periods before being tended by a doctor.

Patients admitted to public wards were subject to strict disciplinary codes to help maintain order in the hospital. In return for their free care, they had to be available to medical students and their teachers for training purposes.

Paying patients (an important source of revenue for the hospital beginning in the late nineteenth century) could choose comfortable suites in the private patients' pavilion from 1930. They could also retain their own physicians and escape the imperatives of medical education.

Beginning in the 19603, the extremes of patient privacy and comfort eased, with the rise of private and government insurance plans. During this penod all patients admitted to the Toronto General Hospital were governed by the same rules and could be required to participate in student training.

A relocated and renovated Princess Margaret Hospital, which began life as the Ontario Institute of Radiotherapy in the Toronto General in the 19305, again became associated with the General sixty years later as a result of amalgamation. To the extreme left is Mount Sinai Hospital, which also has shared resources with neighbouring hospitals such as the Toronto General.

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strife between Toronto's medical schools had 'ruined' the hospital.85 Continuation of this format gave the 'most entire satisfaction to the students in attendance,' as did trustees' decision to allow every student to attend all clinical lectures for the duration of their training on purchase of a single $10 'perpetual ticket.' Thus by the mid-i870s the same Toronto doctors who once worried about their students leaving the city boasted that the amount of clinical instruction available from the Toronto General was 'largely in excess of that of any other institution in America, and cannot fail to be of immense practical value to those who avail themselves of it.'86 The expansion and integration of clinical instruction into the daily life of the hospital brought many advantages. For the hospital, it enhanced its role in medical education, which had first begun in informal ways as early as the 18305; the collection of student fees also was a modest source of income. For doctors and doctors in training, it presented many opportunities to interact and to show and impart their medical knowledge, as indicated in the accounts of patients' cases prepared by clinical clerks and instructors. The publication of their cases as reports from the Toronto General Hospital took their work to a much wider medical audience, both promoting the hospital's services and offering readers a form of continuing medical education. For hospital patients, there were obvious benefits, but at the cost of their becoming the subject of intense medical scrutiny by doctors and students. Patients risked becoming secondary in the hospital's drive to impart knowledge: already they collectively were referred to as 'clinical material' or as the objects of 'clinical study.'87 The reduction of the intense rivalry among Toronto's several medical schools also improved relations between doctors and the hospital. For their part, physicians seemed more willing to raise matters of mutual concern. Trustees made the hospital's amphitheatre available to all medical school lecturers, but they would not tolerate overt signs of favouritism or of squabbles. Trustees also admonished medical teachers to be punctual for delivery of their own lectures to staff and students, since waits of up to two and a half hours, as had happened, were inappropriate. The appointment of hospital medical staff involved both physicians and trustees; trustees complimented doctors on their accomplishments and their contribution to the hospital, but underlying tensions still existed. Because of the competing medical schools in the city, coupled with trustees' desire to appear non-partisan while retaining control over 00

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A Public Chanty, 1856-1903

their own affairs, the hospital had more attending physicians than trustees thought necessary. Commenting on this matter, Dr James H. Richardson, one of the hospital's senior medical officers, defended his colleagues' statements that any proposed change in the number or manner of hospital appointments would harm patients' welfare and interfere - although he never specified how - with the private practices of medical officers.89 Other doctors disagreed. The editors of the Dominion Medical Journal strongly advocated fewer medical officers, with limited terms and rotating duties. They even suggested adoption of a minimum age for assistant staff (twenty-seven years), surgeons (thirty years), and physicians (thirty-five years), as they believed was the practice in France. 'If some system were adopted,' they asserted, 'we would escape the absurdity which now exists, of appointing men on account of their national, sectarian, or political affinities or influence without any reference to, or test of, their professional ability.' These same men also wanted a competitive examination for the post of resident physician. This measure would eliminate favouritism, encourage students to pay more careful attention to hospital work, and better prepare them for their professional lives.90 In 1875, the Ontario Medical Council went as far as to pass a resolution that a formal exam be the basis for appointment of resident medical officers at the Toronto General and at the general hospital in Kingston.91 These hospitals were, of course, under no obligation to implement such a plan. More problematic for trustees at the Toronto General was physicians' request to have medical schools appoint their own men directly to the hospital. In their polite but decisive rejection, trustees reminded doctors in 1873 tnat there still was 'not always the most perfect harmony' between medical schools and their professors. Furthermore, as faculty members often changed medical schools quickly and with little notice, the balance of staff appointments among schools was constantly altering.92 Resolving the method of appointing assistant house surgeons was somewhat easier. These junior positions went to medical students who wished to increase their clinical skills; at the same time, they provided the hospital with cheap labour. Trustees sought the opinions of representatives of Toronto's medical schools on whether these positions should go to needy medical students or be made solely on merit. In response, each medical school simply put forward its own candidate for the hospital's consideration. Eventually, trustees decided that the house surgeon would be either a senior medical student or a recent graduate,

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all subject to an examination by doctors appointed by the hospital board.93 From most internal points of view, the structure and function of the Toronto General Hospital altered little from 1856 to 1875. Its mission, methods of treatment (except for the impact of general anaesthesia), and patient profile did not fundamentally change. But as the largest and most active hospital in the province, if not in the country, it was strengthening its role as the 'province's hospital' based on its technical expertise. The hands on the hospital tiller remained those of the trustees. Among the several permanent members of staff, only one person was employed as a doctor, and no others possessed any formal training. There was no medical representation on the board. That physicians attended the hospital only infrequently made them virtual strangers to its daily routines and procedures, and they did not hold a monopoly on the admission or discharge of patients. Greater stability in medical education in this period brought clear links between doctors, patients, medical schools, and the hospital, but they were still fragile ones. The Toronto General Hospital was very much a lay-dominated institution. The hospital was, however, radically affected by changes external to it. As Canada experienced its first few years of Confederation and began to adjust to the challenges of federal and provincial political life, Ontario prospered, promulgating its own legislation and charting its own course in the provision of welfare. In the decade leading up to Adam Wilson's instrumental report of 1868, calls for a broad approach to hospital support were grounded in the notion of public duty. After the Charity Aid Act of 1874, the state augmented lay authority; its regular funding rendered the hospital and its activities subject to a non-medical inspector. All hospitals in Ontario were being swept along with other public charities on the crest of a broad sociopolitical wave.

4

A Mod*?/ Hospital, 1875-1903

'The spirit of unrest was never more apparent on the surface of human society than at the present time,' declared the Canadian Journal of Medical Science in 1876. 'There is scarcely an institution ... which is not being disturbed by an agitation for reform or change.'1 True for North America, this observation captured the essence of life in Ontario and at the Toronto General Hospital. The Liberal governments of Oliver Mowat (premier 1872-96) - called by one historian an 'instrument' of 'middleclass business and professional elements' - tackled the concerns of an increasingly urban society. From the 18705 until 1905, Liberal governments engaged in 'sweeping campaigns to impose order and rationality' throughout Ontario life, inserting themselves into what had previously been considered 'family and community matters,' including the administration of hospitals.2 Premier Mowat exemplified the belief in improvement through the application of 'humanitarian principles and Christian ethics.' Just before he died in 1903, Mowat wrote that society was 'to render glad and loving service in a special sense to the friendless, the sick, the suffering and the needy.' In his view, as his biographer Margaret Evans has noted, 'the just society, the humane society, the Christian society were one.'3 Because hospitals, jails, lunatic asylums, houses of refuge and industry, and institutions for the deaf, the blind, and 'idiots' - to say nothing of specialized educational institutions - provided special places to render such service, they formed part of the political and social thrust for reform. Accordingly, across the province, more hospitals were built during the last quarter of the nineteenth century than at any other time in its history. In 1870 Ontario had eight hospitals in operation; by the end of the century thirty more came into existence in growing towns.

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The Toronto General Hospital benefited from this boom through expansion and clearer differentiation from other charitable institutions. The men, and increasingly the women, who shaped the hospital were acutely aware of the changing times and the fact that they were helping to change them. They never used the present-day term 'restructuring'; none the less, that was what happened to the Toronto General in the 18705 and i88os. It experienced an internal metamorphosis, with dramatic changes in operation, management, and clinical activities, to emerge as a recognizably modern institution. Expansion, Consolidation, and Modernization That a new game was afoot at the Toronto General in the mid-i87Os becomes immediately obvious in the style and form of its internal records: board meetings were conducted with greater rigour, and minutes for the first time noted movers and seconders of motions; in particular, two trustees, W.T. O'Reilly and Charles S. Ross, repeatedly and regularly supported each other in board actions that reorganized key hospital functions in 1875. (O'Reilly was government inspector of insurance and later would assume John Langmuir's duties as inspector of hospitals and asylums.) In the new system, the resident medical officer, from then on referred to as the medical superintendent, would be responsible for the overall operation of the hospital and would be assisted by the lady superintendent and the steward; this relationship created a new hierarchy, with all subordinate members of staff reporting to the medical superintendent, not to the board as before. Quick on the heels of these changes, the board accepted the resignation of the lady superintendent; suspended Dr McCollum, resident medical officer since 1871; and demoted its own secretary, J.W. Brent. Trustees found cause for their latter actions in a shortfall of about $2,500 resulting from McCollum and .Brent's apparent failure to collect required fees fully and promptly from paying patients and from municipalities during the year i874.4 It is unlikely that at any time in the hospital's history all required fees were ever completely recovered. If the board's actions were close to the irregular, its next move was within a hair's breadth of the legal. As if from nowhere, trustee Charles Ross moved that Dr Charles O'Reilly, then in charge of Hamilton's general hospital, be appointed as medical superintendent of the Toronto General Hospital; right on cue, trustee W.T. O'Reilly (no relation) seconded the motion. A letter went out to

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Dr O'Reilly, who promptly accepted the offer. Board chair John Macdonald was outraged. He protested the lack of discussion over the appointment and the fact that the position was never advertised; he was so disturbed that he sought the counsel of the hospital's lawyer, Clarke Gamble. In his long and careful reply, Gamble stated that the board was within its legal rights to have acted as it did, but it really was not proper procedure. It did not look good, and trustees should in future follow a less irregular path. In great part vindicated, Macdonald none the less resigned from his chairmanship. With the appointment of Ross as his successor, the hiring of A.F. Miller as 'assistant' secretary to the board who in effect took over the duties of secretary J.W. Brent - and that of Miss Harriet Goldie as the new lady superintendent, the coup of 1875-6 was complete.5 The speed and decisiveness of these bold moves set the tone and pace for the era that followed. Dr Charles O'Reilly, who would remain the hospital's medical superintendent for the next three decades, graduated from Montreal's McGill medical school in 1867. He had returned to practise in his native Hamilton, where he became the city's first medical officer of health in 1873; later he would oversee the city's hospital. When he assumed his new appointment in Toronto in 1876, he married a niece of Dr John Rolph. Just as the board's chair and the hospital's counsel had warned, O'Reilly's appointment was controversial. A provincial politician declared, with 'blundering recklessness' according to the Globe, that Charles O'Reilly was the brother of board member W.T. O'Reilly, who had vigorously supported his appointment. The Canadian Journal of Medical Science decried the manner in which the appointment was handled, since few people outside Toronto knew of the vacancy. Public and medical contemporaries, however, agreed that O'Reilly's move to Toronto was the result of the Very high opinion' that Inspector Langmuir had formed of his abilities. They also agreed that the choice was a good one; from it, the Canada Lancet predicted a 'future of much usefulness' for the hospital.6 As O'Reilly was responsible to the board, with all staff members reporting to him, he exercised almost unlimited control over the hospital's operation. This authority, coupled with his undoubted skills and legendary parsimony, helped shape the modern hospital in Toronto. Neither the sudden death of board chair Ross later that year nor the unexpected resignation of Ross's successor, William Elliot, within a matter of months could deflect O'Reilly or 'his' hospital off course. (Elliot was perceived to be in conflict of interest because of the hospital's ten-

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dering practices with his firm, which supplied drugs and medicinal agents.)7 An early outcome of the hospital's 'full steam ahead' approach was expansion of its physical plant. First came new outbuildings to accommodate a laundry, coal rooms, and post mortem/dead house, followed by permission to erect a separate fever hospital on the grounds. Financing for expansion came from the public purse, whose strings were readily untied, and from efficiencies within the hospital, such as the recovery of all fees from paying patients. Most important was a hithertounexploited source of hospital revenue: philanthropy. Up to 1875, private donations and bequests totalled $5,000; between 1875 and the early iSgos, the figure rose to over $70,ooo.8 The hospital formally recognized philanthropy by placing tablets inscribed with donors' names in its entranceway; the hospital was constantly enlarging or replacing them to add more donors' or benefactors' names. It also named wards after those who gave money generously.9 The readiness, if not eagerness, of prominent Toronto families such as the Cawthras, Gooderhams, Macdonalds, and Worts to donate to the hospital reflects both the rise of an affluent merchant class that could afford to do so and improved popular perception of the Toronto General. The sky appeared to be the only limit during these years of philanthropy and public funding. Another sign that 'dough' was no longer a problem - lumpy, sour, monetary, or otherwise - was the decision to build a hospital bakery. In addition to all this construction, a further $19,000 was targeted for an eye and ear infirmary to be established within the hospital in 1878; $10,000 of this amount was allocated by the provincial government from the estate of Andrew Mercer, who had died without a will. As well, countless renovation and repair projects updated the main building itself.10 In 1877 the Toronto General amalgamated with the Burnside Lyingin (maternity) Hospital, with a completely new facility for mothers-to-be and their newborns to be built on the site of the general hospital. An independent institution dating back to the 18508, the Burnside had strong connections to the general hospital through its Anglican origins and the overlap in medical staff. Discussion on amalgamation proceeded smoothly. Toronto General trustees acquired the Lying-in Hospital's assets, notably its building and land; in return, they would erect a forty-bed pavilion conforming to Inspector John Langmuir's requirements. Trustees also conceded to the request by the ladies' committee, allowing it to provide 'moral and religious instruction' to unwed moth-

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ers. To offset operating costs, trustees agreed to lease the grounds and former hospital to the Toronto Mechanics' Club for the development of a library, reading room, and billiard room to 'entice young men away from the snares of the bar-room.' (Within a year the Mechanics' Club must have realized that its program was flawed, for it sought the.hospital's blessing to sell ale and lager to members.)11 The public welcomed the anticipated savings from hospital mergers. The Globe recognized that the 'consolidation scheme' was by no means a 'chimerical movement,' for it was based on 'good economical as well as common sense principles, and it bids fair to prove a success.' With this movement 'fairly set on foot,' the paper sincerely hoped that no party interests would get in the way of its ultimate success.12 Professional responses, in contrast, were mixed, reflecting concerns other than financial. In a letter to the Globe, 'Medicus' raised a 'note of warning' about a lying-in hospital on the grounds of a general hospital: to bring parturient women and their puerperal diseases into contact with other patients was the 'acme of folly.' Citing authorities from British lying-in hospitals, who claimed that pregnant women increased six-fold their own chances of dying by entering such institutions, 'Medicus' suggested that the new building be put to 'some more beneficial purpose than the propagation of disease and death.' Dr 'R' countered these 'alarming statistics': from 1867 to 1877 only 8 of the 1,108 women confined in Toronto's lying-in hospital had died; and only twice in eleven years had childbed fever erupted, both times when the disease was already widespread in the city and surrounding area.l3 Apart from this warning, other commentators were ecstatic over the changes. After a visit to the hospital during their annual meeting in 1878, members of the Ontario Medical Council heartily endorsed its 'excellent and efficient order' and congratulated Charles O'Reilly on his efficiency in managing it. In an enthusiastic editorial, the Canada Lancet exclaimed how unrecognizable the Toronto General had become: never before in its history had it been in 'such perfect working order.' Management was to be congratulated on its 'high state of efficiency': the hospital would be propelled to the 'front rank of institutions' in North America, as the result of the 'scheme of amalgamation ... so energetically carried out' by trustees and of their having 'boldly grappled' with difficulties in breaking down monopolies and dealing out 'evenhanded justice to all.' Another contributing factor was the 'entire confidence' that the public now placed in the hospital.14 Six months later doctors would describe the Toronto General, in an

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echo of Langmuir's prediction, as 'our model Hospital of Ontario.' Even a visiting surgeon from England, who had previously worked in the Montreal General Hospital, 'expressed some surprise to find such a well appointed hospital in Canada' as the Toronto General. For several years, the hospital was touted as 'one of the best on the continent' and 'the largest and best ordered Hospital in Canada.'15 Indeed, by the end of 1878, the construction dust had settled to reveal the most complete Toronto General Hospital ever. Although no other period during the nineteenth century would match the hospital's construction boom of the late 18705, its expansion did not abate. In the i88os an extension to the main building provided a nurses' residence; a separate structure, known at first as the convalescent building, then later as the women's pavilion, increased bed space. The 'Pavilion' quickly transformed itself into a section devoted to 'special diseases' of women. The two-storey, brick structure was self-contained, consisting of examining and operating rooms, kitchens, pantries, a dispensary for extern patients, and public and private wards to accommodate up to forty women.16 In the 18908 the hospital expanded again, beyond its original boundaries, to set up an emergency hospital in the heart of the city to tend to accident victims before their removal to the main general hospital.17 Also in the 18905 the board planned to acquire another institution, the city's isolation hospital, then under the direction of the Board of Health and of Toronto's medical officer of health, Dr Charles Sheard. Located at the easternmost limits of Toronto on land abutting the jail, this hospital was designed to accommodate sufferers of diphtheria, scarlet fever, and similar infectious diseases. The transfer of responsibility to the Toronto General was grounded in assurances from the mayor and Sheard that the isolation hospital would be properly equipped and furnished and that it would fall under the rules existing for the Toronto General Hospital. Within weeks of this plan being made public, it was scrapped. Fear, professional indignation, local politics, and moral outrage among doctors and residents caught city and hospital officials off guard. Galvanizing so many people, so quickly, was the fact that all patients admitted to the isolation hospital would be treated only by doctors on staff of the general hospital. Family doctors would be denied access to their patients, many of them children with terrifying diseases. The perceived medical need to isolate these patients was not disputed indeed it was the law - but to deprive them of care from a physician whom they trusted was deemed unreasonable. The flood of adverse

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newspaper editorials, letters to the editor, and a petition signed by over 120 physicians made clear the argument against the proposed amalgamation. When the Board of Health met to vote on the issue, the many doctors who spoke against the motion guaranteed its failure. Toronto's isolation hospital would remain a civic institution and would not become a branch of the city's general hospital.18 The centralization of so many other medical services and the development of branch operations under the umbrella of the Toronto General Hospital greatly enhanced its prestige and importance. To ensure the smooth operation of an increasingly complex and multifaceted institution, the hospital had to stay abreast of late-nineteenth-century trends in technology and systematic management. Examples of its modernization abound. The move from gas lighting to electrification beginning in 1898 - and the installation of an elevator - marked changing eras in utilities.19 The application of strict business accounting practices, along with the introduction of the typewriter, double-entry bookkeeping, and standardized patient forms and charts, reveals its bureaucratization.20 The maintenance of communication across the burgeoning and sprawling organization similarly required new technologies. The hospital's first intercom system involved electric bells in private wards, in the medical superintendent's office, and in some public wards, as well as a network of whistles and speaking tubes. Augmenting this system was the telephone, introduced on a six-month trial basis in 1879; before long a separate line was strung between O'Reilly's office and that of Walter Lee, board chair. Soon telephones linked all hospital buildings.21 Matters of efficiency and communication were vital to the operation of the hospital; at the same time, they show how business methods influenced its affairs more and more. Another borrowed practice involved corporate and staff identities - one that could as easily have been adopted from the military as from business.22 In 1884 the hospital took its first step towards institutional 'branding' when it acquired hundreds and hundreds of bed covers, together with pieces of cutlery and crockery, that bore the monogram of the Toronto General Hospital.23 Easily identifiable hospital items would help to discourage theft while giving a sense of institutional awareness to staff, patients, and visitors. With the increased number of staff and the creation of new job categories, the hospital began to provide work clothes. In addition to practical benefits, this action helped delineate the hospital's employment hierarchy, especially as the clothes often were uniforms. House surgeons first started to

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wear white coats around 1890, a habit that may also be viewed in the context of uniforms and identity, notwithstanding any other considerations associated with cleanliness.24 As the hospital's complement expanded and fragmented, knowing who was who and where they fit in became crucial. Central to the formation of the modern hospital was the 'new' nurse.25 In 1876 Eliza Storrie became head nurse and deputy matron, reporting to Lady Superintendent Harriet Goldie. Trained at King's College Hospital in London, England - an Anglican institution that played a significant role in the development of modern nursing - Storrie was well aware of changes in her field. Goldie, though not a nurse herself, seemed also to be imbued with the spirit of reform; shortly after becoming lady superintendent, she asked the board to consider outfitting nurses with 'uniform dresses,' and the next year she suggested that it establish a training school for nurses. Initiated by these women, the training school was in fact established by their male superiors. After a board subcommittee had reviewed Goldie's plan and sent Dr O'Reilly to visit the principal nurses' training schools in Boston, Hartford, New York, Rochester, and other large cities in the United States, it circulated by-laws and promotional information to announce the Toronto General's nursing school. Admission was restricted to women between twenty and thirty-five years of age. Initially, the course was two years long, with trainees receiving board and lodging and a stipend of $6 per month in their first year; in second year, they would receive $9 a month. Technical instruction included the dressing of blisters, burns, sores, and wounds; the application of fomentations, poultices, and leeches; the administration of enemas; and the use of female catheters. Trainees were also to report to physicians any abnormal developments in patients' secretions, pulse, appetite, or body temperature. Instruction on patient care included how to prepare food and drinks for patients; how to move helpless patients and give them baths in bed to prevent bed sores; and how to make beds and change sheets while patients were still in bed.26 During 1881, Goldie and Storrie prepared the hospital and themselves for the task ahead; by year's end the lady superintendent prepared her first report on the school. Of the seventeen women enrolled, including previously employed nurses and new 'probationers,' nine remained; of the eight who had left, two married, three were incapacitated or suffered from ill-health, one returned to her family, and two

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were dismissed for insubordination. Continuing students spent three months each on the medical and the surgical wards, including day and night duty. Goldie and Storrie gave lectures, and attending physicians occasionally explained details of their cases to trainees; in later years, nurses were required to attend formal lectures given by physicians. The use of a skeleton, a manikin, anatomical charts, and other educational material supplemented this course of instruction. Goldie reported that the first trainees were 'intelligent, competent women' and that, as the demand for skilful, trained nurses was 'daily increasing,' more pupils were needed. Successful students received a medal and certificate.27 A series of resignations of head nurses and lady superintendents during the early i88os because of ill-health or marriage did not severely affect the progress of the school. Then, the appointment of Agnes Snively as superintendent of nurses in 1884 assured stability for the next couple of decades. A Canadian, Snively had just graduated from New York's Bellevue Hospital; she returned to Canada to take up this position, where she would remain until 19io.28 Such innovation in nursing affords a powerful indicator of the changing face of the hospital. Another was the rising importance of technology in medical practices. Beginning in 1875,tne hospital constantly purchased surgical instruments and appliances and upgraded its surgical facilities.29 Twice O'Reilly was granted three-month leaves to visit the medical centres of Europe to purchase equipment; instruments also came from the major New York supplier, Tiemann & Co. The adoption of new methods to induce general anaesthesia can be traced in the purchase of mechanical chloroform and ether inhalers. Designed to regulate the flow of anaesthetic agents, this equipment was more economical for the hospital and safer for the patient. By the later nineteenth century, anaesthesia by chloroform and, by the 18905, ether became a routine part of almost all operations. So much so that doctors had to complete a standardized printed form before administering an anaesthetic agent. Introduced by O'Reilly, this document recorded information about any factors that could interfere with the anaesthetic, such as a patient's addiction to cocaine or alcohol or the presence of disease; it also charted the patient's vital signs before and after an operation. The purchase of a mechanical 'Lister' steam sprayer for carbolic acid, along with large instrument sterilizers, complex operating tables, and other specialized surgical furniture, signalled the introduction of surgical technique that accepted the role of bacteria in causing wound infec-

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tion. Unlike the Montreal General and many British hospitals, the Toronto General was not the site of great debate over the topic of whether or not germs were a factor in post-operative infection. The appointment of Dr Fred LeMaitre Grasett to the hospital in 1878 may help explain the hospital's smooth transition to this new surgical era. A fourth-generation physician, Grasett trained in Edinburgh under the originator of the antiseptic surgical system, Joseph Lister. As a firm believer in the existence of bacteria and their role in causing disease, Grasett was an eloquent advocate of the germicidal properties of carbolic acid when applied directly to wounds or used to purify the atmosphere of the operating room through the use of a 'Lister' sprayer.30 The origins of laboratory medicine in the hospital can be traced to this era, with the acquisition of microscopes, glass slides, biological stains, and an incubator - all designed to aid in the culturing and identification of disease-causing bacteria. Other equipment such as a centrifuge and a haemocytometer heralded the beginnings of blood analysis. Hypodermic syringes and needles, crutches, fracture boxes, gauze, thermometers, stomach pumps, catheters, patient weigh scales, a typhoid fever bath, a laryngoscope (for examining throats), and an oculist's chair were all purchased during the last decades of the century.31 The advent of electricity to the hospital was especially noticeable, not just in the replacement of gas illumination with incandescent lighting, but also in an array of electrical devices used for therapy. On several occasions the hospital purchased galvanic batteries, electro-cautery apparatus, and an electro-medical 'cabinet.' Such equipment widened the scope of clinical practice available, especially in the treatment of skin conditions and the temporary relief of pain; it also allowed Dr C.R. Dickson, who took charge of electrotherapeutics, to become one of the hospital's earliest specialists.32 In early November 1896, soon after Rontgen's discovery of X-rays, the Toronto General acquired an 'apparatus for the Rontgen Rays for use in surgery, comprising coil, tubes, cells, etc.' Subsequently, it purchased more powerful radiology apparatus as the applications for this new and lasting technology grew.33 The hospital also adopted other forms of Victorian technology. The idea of using a special vehicle for transporting Toronto's sick was first suggested by Dr Lucius O'Brien in 1847. At the time, regular cabs ferried smallpox victims to hospital - a practice that O'Brien thought sure to spread this 'fatal and loathsome' disease. It was not until 1881, however, that the Toronto General introduced an ambulance service. Combined with the downtown emergency hospital, which was functioning by

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the end of the century, this service inaugurated in Canada a feature of the modern hospital that would remain familiar to the present. It differed in this early period through its operation by another agency - the police force. Through a series of telephone links, police constables alerted their headquarters about any medical emergency and the need for an ambulance; in turn, police headquarters informed the hospital and dispatched the dark-green horse-drawn carriage, which sounded its gong to warn other vehicles and pedestrians. Patients who travelled in the ambulance had the most comfortable ride possible because of its sophisticated suspension system and rubber pneumatic tires; a tubular-rubber air-bed stretcher afforded additional comfort. The ambulance's interior could be readily disinfected and was well ventilated. It contained a speaking tube to connect the driver with the patient's attendant, and it also had a reading lamp. The ambulance and its crew, which might include a nurse, could be called for all manner of emergency, including childbirth; it therefore had a 'surgical box' with a selection of medicines - stimulants, emetics, antiseptics, anodynes (pain relievers), sedatives, antispasmodics, and astringents. Other supplies included splints, cotton and gauze dressings, bandages, lint, needles and sutures, scalpel, haemostatic forceps, tourniquet, hypodermic syringe, stomach pump, stethoscope, probes, and ligatures indeed, everything that might be required in an emergency. The ambulance driver was required to keep a log of information on the patient and details of pick-up and delivery to the hospital.34 The typewriter, telephone, miscellaneous laboratory equipment, and diagnostic devices, considered collectively, impressed the mark of early modernity on the hospital. From this perspective, the whole had even greater impact than its individual parts. Though still rooted in the tenets of Christian charity and care of the sick poor, the institution began to be associated with things new, technological, and 'scientific.' It mattered little that the laboratory and its equipment may have been rudimentary, perhaps some of the apparatus even being unused or used incorrectly;35 what was significant was that the whole complement conferred a progressive image on the hospital.36 Like the city of Toronto, which in the 18905 saw itself as modern, with its new electric streetcars and other examples of late-nineteenth-century 'tumultuous transformations,'37 the city's hospital was seen to be a trendsetter. X-ray technology, which the hospital quickly procured, serves as the best example of medicine reflecting modernity. The ability to photograph inside the living human body without disturbing it became a sen-

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sation and media event.38 One Globe editorial suggested that photography using cathode rays (that is, X-rays) will 'awaken a popular interest such as has greeted no invention of recent years.'39 The Mail and Empire drew a tighter connection between the 'new photography,' technology, and modernity. Noting that the 'scientific world' was 'moving with the speed of this age of express trains and rapid transit generally,' the newspaper was gratified to learn that Toronto scientists were not 'behind the times.' Their use of X-rays for scientific and medical applications brought credit to everyone involved.40 The Toronto General Hospital, too, could claim some of this glory. Two other contemporary portrayals highlight the hospital's progressive image, through its rising technological connections. An engraving of the hospital and its grounds on Gerrard Street East depicts the grand buildings that comprised the Toronto General at the end of the century. In front of them, an electric streetcar - 'rapid transit' - has stopped to give way to an ambulance rushing to the main hospital driveway, in a manner suggesting the meeting of modern society with the modern hospital. A detailed newspaper feature described the Toronto General in 1896 as a 'noble and philanthropic' institution of'interest to all classes of the community.'41 Consisting of six buildings, it could accommodate up to 400 patients; an underground tunnel connected the three main buildings. Just as the modern world outside was being moved by rapid transit, so too cargo moved inside the hospital via its own tramway, circulating through the basement of the main hospital building. The largest electric elevator in the city could readily carry a patient on a stretcher or a bed. The extensive precautions to control fire - escapes, ladders, hydrants, chemical extinguishers, and telephones - rendered the hospital the best-protected public institution in the city. Both the ambulance service and the training school for nurses reflected the hospital's commitment to good organizational practices: among its fleet of three vehicles was a 'modern model ambulance'; the school was touted as a model of efficiency, where women learned that 'simple obedience must ever be their watchword.' Photographs of rows of beds, their patient occupants, and nursing attendants portrayed a state of orderliness. Although it would be inaccurate to describe the care of patients at this time as a 'team effort,' the advantages of formal cooperation among members of hospital staff were beginning to be appreciated. A photograph of the 'Throat and Nose Department' further illustrates the forging of links between medicine and technology and

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between physician and nurse. The scene is a large, high-ceilinged room, where many surgical instruments adorn a long table draped in white cloth; against one wall stands an electrotherapeutic cabinet. Two seated physicians examine their male patients, while a white-uniformed nurse and a white-jacketed male (either a senior student or medical resident) stand by ready to assist. The tableau, though probably staged for the photographic record, conveys a real sense of purpose, the message clearly one of clinical activity. The hospital's coming of age was marked in late August 1897, when it drew the attention of international visitors. From 18 to 25 August, Toronto hosted a major event - the annual meeting of the British Association for the Advancement of Science (BAAS). Meeting only for the second time outside Britain, the BAAS attracted to Toronto many luminaries of nineteenth-century science and medicine. Among the visitors was John Shaw Billings, an American surgeon who had masterminded several leading medical institutions in the United States - notably the library of the Surgeon General's Office in Washington and the Johns Hopkins Hospital and Medical School in Baltimore (where he had hired William Osier, among other top-flight physicians). Billings had acquired an international reputation as a designer of hospitals and creator of the Index Medicus, the first major tool for access to the world's burgeoning medical literature. Toronto physicians eagerly planned for his visit, putting him up at the home of J.E. Graham; on 24 August, he toured the Toronto General and signed the visitor's book.42 Another guest who signed the hospital's book was Joseph Lister, the English surgeon lauded as the originator of antiseptic and later, aseptic, surgical methods. Deemed one of the greatest doctors in the Englishspeaking medical world, Lord Lister received an honorary doctoral degree from the University of Toronto during his visit; he was also feted at the BAAS conference and, separately, by Toronto's medical elite. Attending the more intimate medical affair was the hospital's superintendent, Charles O'Reilly, and other hospital physicians (former Toronto medical student William Osier was also there). Given Lister's stature, it is not surprising that his visit to the hospital, and his comments about it, were recorded in both the medical and the popular press. The Canadian Practitioner reported that he toured both the Toronto General and the Hospital for Sick Children with Dr F. LeMaitre Grasett (a direct descendant of one of the hospital's early trustees and a former house surgeon of Lister's in Britain), noting that he remarked

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favourably on both institutions. The Mail and Empire reported his public comments more fully: both hospitals impressed him with their efficiency, but he spoke of the Toronto General 'in the highest terms of praise' for 'excellence of management.'43 The Modern Hospital at Work: Staff, Physicians, Patients

What was the net effect of these extensive changes for the people who worked in the hospital and who were treated there? How did staff, nurses, students, physicians, and patients fare within the 'model' hospital? From 1880 to 1901, the number of employees tripled, from 47 to between 152 and 166; total wages and salaries quadrupled.44 Hospital positions also were becoming differentiated. In addition to key administrative appointments of medical superintendent, secretary, lady superintendent, superintendent of the training school for nurses, and assistant lady superintendent, a host of other jobs ranged from housekeeper to laundry staff, from gardener to fireman. Workers had well-defined duties; it was also made clear both to whom they reported and who reported to them. Regardless of the job, obedience and good conduct were paramount. The housekeeper had responsibility for the 'general oversight and charge of cleanliness of the whole establishment,' including the operating theatre, lobbies, and corridors. Except for the head cook, who was mistress of the kitchen and all that pertained to it, all porters and female servants were under the housekeeper's 'immediate charge ... and subject to her control.' She had to conduct morning prayers with servants and was to ensure that staff began work at 7 a.m. and had retired to their rooms by 10 p.m. She had to keep detailed records of supplies along with staff time worked, holidays, and time off, and she could hire and discharge staff. Female servants were forbidden to engage in loud talking, laughing, or any unnecessary noise or to communicate with hospital patients; disobedience in any form resulted in instant dismissal without the customary two weeks' notice. While male workers were subject to the same rules of hospital conduct, the overt disciplinary action that applied to women does not seem to have been so explicit in their case. In keeping with gender norms of the period, and the growing technological sophistication of the hospital, men held jobs involving machinery or other equipment. These skilled male employees, too, worked within a well-defined sphere, typically reporting to the medical superintendent or to the steward. The hospital engineer looked after every-

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thing relating to heating, fire prevention, laundry, and bathing equipment. He was required to keep the wards heated to a constant 65°F and to ensure that coal purchased for furnaces was of the correct weight and quality. The janitor had to be at his station in the main hall from 7 a.m. onwards and to ensure that this reception area remained neat. He attended visitors and handled incoming communications (letters, telegrams, and telephone calls). He also regulated the comings and goings of people visiting patients.45 Nurses occupied an important but ambiguous role within the organizational hierarchy. The night superintendent of nurses and the head nurse were considered part of hospital staff, employed to oversee other nurses and ward-tenders; in turn, they were responsible to the lady superintendent. These women ensured safe, courteous, and economical day-to-day care of patients and the recording and strict implementation of doctors' orders. Most nurses, however, were not truly members of staff because they were pupils in the hospital's training school for nurses - although they did receive a modest stipend for their ward duties as trainees or nurse probationers. Each first-year nurse-in-training received $3 per month; second-year trainees received $6 per month. Women who completed the full course of study became entitled to a bonus of $25. After the spring of 1895, the bonus was eliminated, but it was offset by a raise in monthly stipends of $i.46 Upon their retirement, key nurses appear to have been treated with kindness. In 1881 Eliza Hutchinson, who had been employed in the hospital since at least 1867, received a monthly retirement allowance of $1 and a 'home in the Hospital.' When Miss Goldie resigned as lady superintendent because of ill-health in 1883, after over seven years' service, the board granted her a lump-sum allowance of $5OO.47 The nurse of the late Victorian era thus differed from her typical antecedent in being much younger, unmarried, and trained in the elements of anatomy, physiology, and disease causation, in addition to possessing practical nursing skills. Rigorous selection for her character and perseverance, too, separated her from earlier nurses at this hospital, some of whom had harassed and intimidated patients. Prevalent ideals and goals of new womanhood, however, often were submerged in deeply entrenched Victorian values, which still characterized nurses as domestic servants. When male civic officials and their wives visited the hospital in 1882, for instance, they were struck by its brightness, neatness, and spotless nature: The key to the cleanliness everywhere appar-

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ent is furnished in one of the instructions given in a circular for the information of nurses in training. This instruction reads: - "That no part of the hospital is clean if it can be made cleaner." That this injunction is carried out to the letter the spotless coverlets, floors, and walls testify. No housekeeper could keep a kitchen in better order.' Another reference to the 'training of young ladies as nurses' was juxtaposed with a discussion on the efficiency of the hospital laundry.48 The nurse-probationer was also subject to the discipline and culture of the hospital. When board chair Walter Lee opened the convalescents' ward and addressed members of the graduating class of 1883, he acknowledged that earlier nurses in the Toronto General Hospital were of a 'class far different' from them. During this event, Dr Charles O'Reilly also recognized the recent progress of nursing but maintained that the good nurse was the woman who knew her place and was obedient.49 The continuing ambivalent perception of women as nurses is clear in the Canadian Practitioner's report of the 1896 nurses' convocation. On the one hand, Agnes Snively extolled the virtues of the newly expanded three-year course, which aimed to produce graduate nurses who were self-reliant, intelligent, and efficient and who demonstrated executive and administrative abilities. Its rigorous entrance requirements were reflected in her announcement that out of approximately 600 applications in 1896, only 28 were accepted. On the other hand, the medical editorialist seemed struck less by the accomplishments of these women and the merits of the nursing program than by the 'pink ribbons,' the 'pleasing nature' of nurses dressed in their 'pretty blue and white uniforms,' and the 'tasty decorations.' From a medical perspective, this graduation day was one of 'most pleasant entertainment,' rather than a dignified occasion for celebration of achievement.50 The gendered nature of nursing at the Toronto General Hospital was a microcosm of the 'dilemma' of modern nursing. As historians have shown, nurses were 'ordered to care'; as women they were believed to have intrinsic talents for nurturing and caring, yet they were expected to be wholly subordinate within a male hierarchy.51 Even Agnes Snively could not escape this situation. A senior institutional administrator and the top woman in the hospital, she was none the less required to sit with junior house surgeons at meals. Her appeal to the board for permission to sit at a separate table was politely deferred - indefinitely.52 The hospital had been a feature of medical students' life since the 18308, but from the 18705 it played a crucial role in the shaping and pro-

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duction of new doctors. Medical schools simultaneously underwent major changes. John Rolph's school affiliated with Victoria College encountered administrative difficulties that forced it to close in i875.53 Its successor was the separate Toronto School of Medicine, spawned in 1856 from his eponymous institution; like his, it had operated as a proprietary school (where the professors were shareholders) until this time. It continued to function in this way until 1887, when the University of Toronto absorbed it as its medical faculty. This absorption of the second Toronto School of Medicine, which received adequate provincial funding, caused Trinity Medical School to falter. Trinity had been newly constituted in 1871, following its dissolution after the strife of the mid-i85Os; during this hiatus, the regulation requiring the Anglican religious test was relaxed, shortly after Bishop Strachan's death. Six years later, in 1877, Trinity Medical School became a fully incorporated body independent of Trinity College, although the institutions remained closely connected through a variety of business arrangements. In 1903, after considerable discussion, the Trinity school was again dissolved in order to merge with the university's Faculty of Medicine.54 Another of Toronto's medical schools was the Ontario Medical College for Women, which was founded in 1883 and then expanded and renamed in 1894 after the demise of its sister institution in Kingston. Because this college was wholly dependent on donations and fees from its few women students, faculty members were rarely, if ever, paid during the years when the college was active. When the women's college, too, was forced to cease operation in 1906, the ever-strengthening University of Toronto absorbed its students.55 With these amalgamatiAns, the era of proprietary medical schools in Toronto came to an end. In this more-moderate educational climate, the hospital assumed the role more of a meeting place than a battleground. With the city's medical schools relocating in the 18705 within a brief walk of the hospital at Gerrard and Sackville streets, every year hundreds of medical students passed through it to become subject to its culture and rules. The purchase of hospital 'tickets' allowed students to view operations, attend lectures in the hospital's theatre, and interact with patients under the supervision of their professors. Clinical training illustrated the closer connections that were being drawn between the hospital, medical education, and the newly formed Faculty of Medicine of the University of Toronto; for example, the student judged to have the best clinical note-

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book was to receive an attendance ticket for Toronto General Hospital. By the close of the century, the sale of student tickets became the responsibility of the university, with any valid ticket allowing the possessor access to all of the city's hospitals. More indicative of the ties between clinical training and the hospital were calls to reform teaching of medical students. In several editorials, the Canadian Journal of Medical Science criticized both instructors and students for continuing the tradition of didactic lectures, making inadequate use of post-mortem demonstrations, and favouring the rare over the routine condition. Although the expanded Toronto General, with between 150 and 200 patients, afforded 'abundant opportunities' for clinical study - rendering it * second to no place in Canada' - students were still 'too much lectured too [sic], and too little taught.' After hearing a few remarks by a professor about a patient's condition, the editors explained, students received a didactic lecture only 'by courtesy called clinical because delivered in the presence of the (bedridden) patient'; they then took a 'perambulation' through the wards. Similarly, although the death rate at the Toronto General was 'up to the average,' typically making about three to four cadavers available for study in the mortuary, post mortems were not always performed on them or were performed in an incomplete manner. Finally, students would 'eagerly crowd around to see a rare and difficult surgical operation,' which they would probably never perform themselves, while turning their backs on such cases as pneumonia that they would probably meet in everyday practice. In short, for these editors it was a matter of 'vital importance' that the hospital be utilized to the utmost in teaching pathology and morbid anatomy, and they called on medical instructors to review their methods and implement new teaching techniques to match the advantages of the new hospital.56 Clinical training highlighted a growing tension between the hospital and medical schools in the light of their basic functions - caring and instruction. Both institutions did what they could to accommodate and balance the needs of patients and students, but with the advent and strengthening of the university's Faculty of Medicine the demands of medical education grew. In 1892 Edward Blake, the University of Toronto's chancellor, chaired the medical faculty's select committee on hospital facilities. This group's recommendations, which it submitted to the hospital's board for consideration, called for a complete overhaul of clinical instruction. Its main conclusion was that the hospital, its patients, the advancement of medical knowledge, and the improvement

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of medical education could all benefit by an increase in the facilities for clinical instruction. The most famous and most frequented Hospitals in the world are just those where the most Clinical teaching has been done, and the best use has been made of the opportunities presented,' the report stated. After outlining the facilities of the 'most famous and most frequented' hospitals in the United States, Britain, and Continental Europe, as well as hammering home the point that clinical teaching was perhaps the most important component of medical education, the committee made its case for more clinical instruction at the hospital and for smaller bedside classes. The report made it clear that Toronto presented special difficulties because there were three medical schools to consider when selecting staff, although it was wholly dismissive of the Women's Medical College; none the less it believed that a satisfactory formula could be worked out. Other issues to be considered related to autopsies, maintenance of good clinical records, and laboratory and theatre space. Also contained in the proposal was a list of possible chiefs of medical and surgical services and their likely assistants. The facts of the university report were true, its recommendations sound. The hospital's board implemented such as were practicable.57 The short-term effect of these changes was improved clinical instruction. In the longer term, however, these reforms signified the increasing interdependence of the hospital and university-based medicine, even though, legally and financially, hospital and university were independent institutions functioning within their own regulatory frameworks. Within the hospital, student activity was rigorously regulated; rules in place by 1895 were explicit on matters of personal and professional conduct. Students could enter the hospital only through its rear door under the operating theatre and were forbidden from entering other parts of the hospital unless they were accompanied by one of the medical officers. While attending lectures in the theatre, students were not allowed to use tobacco, to spit, or to cut, disfigure, or injure its walls and seats; infringement of any of these rules led to expulsion. Only third- and fourth-year medical students had the privilege of sitting in the theatre's first two rows of seats, thereby allowing them a better view of all operations and proceedings. Similarly, only senior-year students were admitted to bedside clinics within the wards; during these clinics students were forbidden to sit or stand on patients' beds, required instead to assemble in an orderly manner around them. Indeed, the continuation of bedside instruction was conditional and dependent on students

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preserving 'perfect order and discipline' in the wards. Generally, students were prohibited from engaging in conversation with nurses or patients. Even more stringent were the rules in the Burnside Lying-in Hospital. Only fourth-year students could attend maternity cases and then only when accompanied by the medical superintendent or one of the other doctors on the Burnside staff; through the purchase of an $8 ticket, students could to be present at six births. A unique stipulation recognized that students and doctors could be hazardous to the health of their pregnant patients (in contrast to the earlier belief that pregnant women spread disease to others). In keeping with the growing medical awareness that disease could be spread by bacteria through human touch, all students signed a solemn declaration that they would not visit or be present at cases of confinement (pregnancy and birth) when 'engaged in pathological operations, when recently engaged in dissecting, or when dressing putrid sores'; the penalty for breaking this rule was also expulsion.58 Enforcement of rules and the meting out of penalties for their infringement were the responsibility of the hospital, especially its board, and not that of the sundry medical schools - demonstrating again that, despite its close links to the schools, the hospital remained autonomous. On one occasion, trustees suspended a medical student from the hospital for several months for writing profanities on the notice board at the Burnside.59 The increasing number of students using hospital facilities created pressure to accommodate them, including the addition of more lecture space in the already expanded operating theatre. When women medical students were introduced in the 18905, the hospital made alterations to its physical structure and procedures to ensure segregation of the sexes. In his reviews of the Toronto General, the provincial government inspector nodded approvingly at its good laboratory facilities, with one lab for the 'special use' of women medical students, and at 'improvements' to the theatre that arranged seats for the women in such a way as to 'afford a good view of the operations, while at the same time [securing] the greatest privacy.'60 In addition to attending lectures in a section designated for women only, women students were taught in separate post-mortem sessions and met patients during special hours.61 It was the prerogative of any operating surgeon or physician to deem a case 'improper for consideration in the presence of students of both sexes'; under this circumstance, the presiding doctor had the power to demand the withdrawal of all male or all female students. It is unknown

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how often, if at all, this power was exercised.62 The measures taken by the hospital to maintain the segregation of women students, while remarkable, were consistent with prevailing social norms about the place of women in society, to say nothing of the male-dominated world of medicine in Canada and beyond.63 Somewhere between the ranks of medical student and full-fledged hospital medical staff were resident medical assistants. This group expanded from two positions in the 18708 to ten by 1900; for the duration of the nineteenth century, all incumbents were male. Beginning in the early 18905 candidates were selected on academic standing from an ever-widening pool of applicants recommended by instructors of Toronto's medical schools.64 For the hospital these medical men provided competent medical assistance to Dr O'Reilly, medical superintendent, as well as to the visiting and consulting physicians on staff; as they were 'residents' of the hospital they also were available day and night. Residents received no remuneration during their one-year internship, only board within the hospital. More valuable to them was the clinical experience that they gained while there. Their duties were whatever Dr O'Reilly assigned them to do; specific tasks included visiting and keeping notes on the progress of all patients at least twice a day, communicating any information concerning patients' comfort or their neglect by attendants to the medical superintendent, assisting in the admission of outdoor patients, and cooperating in 'promoting harmony, discipline, and the general efficiency and good name of the Hospital and the [nurses'] Training School, by every means in their power, and particularly by their own conduct, demeanor, and example, whether on or off active duty.' Residents' fraternizing with nurses was of special concern to authorities and could result in instant dismissal for residents. It was feared that any familiarity between these young men and women on or off hospital premises could compromise a nurse's professional integrity and prejudice her personally.65 Breaches of discipline by resident medical assistants were taken seriously by the hospital board, which, as with medical students, was the authority that meted out punishment. On a summer's evening in June 1897, several of these young doctors were partying in their hospital sitting room so noticeably that the lady superintendent complained of their noisy and disruptive behaviour, especially the loud music. The trustees banned additional social gatherings in the hospital and withheld residents' certificates of attendance until later in the autumn of that year.66

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The hospital was central to both the personal and the professional lives of its resident medical assistants, and as such it took on a greater role in moulding them as doctors. The collegiality of an (occasional rowdy) evening or time spent around the hospital's billiard table became an essential part of their training. In many respects the year that these men spent in the hospital became a rite of passage as they graduated from being medical students to becoming professional medical practitioners with all the attendant responsibilities. It also marked membership in an informal fraternity, one element in the process of 'male bonding' central to medicine then and a feature that would endure. Those who have recorded their memories of this stage in their medical careers emphasize this benefit. In the early 18905 the hospital admitted recent graduates Lewellys F. Barker, Herbert A. Bruce, and Thomas S. Cullen as resident medical assistants; all of them went on to illustrious careers. Barker and Cullen established themselves as leaders at Baltimore's Johns Hopkins Hospital and Medical School (Barker would succeed William Osier as professor of medicine when Osier was called to Oxford in 1905), while Bruce developed a successful career in Canada in both medicine and society, culminating in his becoming lieutenant-governor of Ontario in 1932. All these men remarked on the utility of rotating between different medical and surgical services and getting first-hand experience of patients with a variety of ailments. Spending time in the Burnside section of the hospital held a particular fascination. Bruce remembered three women from Quebec because they had collectively given birth to sixty living children. Barker and Cullen occasionally amused themselves in off moments by having 'wash-and-dress-the-baby' races to see who performed these tasks the fastest: Cullen could never break the eleven-minute mark and usually lost to Barker. Smells of the typhoid fever ward and carbolic acid and sounds of the hospital's whistle system lingered in their memories. All remembered, too, the cost-conscious medical superintendent who chastised residents for burning too much gas to light their rooms.67 Challenges to the 'maleness' of medicine were being mounted, one of which was the acceptance of women as medical students. Another came with the request to appoint a woman resident medical assistant in the Toronto General Hospital. In June 1897, August 1898, May 1899, July 1899, and June 1900, the dean of the Ontario Medical College for Women, Dr R.B. Nevitt, or secretary Dr J.G. Wishart, applied to have one of their school's graduates accepted along with those from the other Toronto medical schools. On each occasion, the board declined,

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noting that there was 'no accommodation' for a female resident medical assistant.68 The conclusion that the board discriminated against women physicians is inescapable. As the hospital was the residence of many other women, such as nurses and the lady superintendent, the board's stated reason for rejecting women medical assistants rings hollow. While there was no accommodation for them specifically, it made no effort to create quarters for them either. Two of the requests from the women's medical college named specific candidates; one, Jean Cruikshank, later accepted a post at Boston's New England Hospital for Women and Children, one of the most important all-women hospitals in the United States.69 With the onset of the twentieth century, the hospital's barrier against women was lowered with the appointment of Dr Helen MacMurchy to the hospital's house staff in July 1901. MacMurchy's appointment was a first step towards the acceptance of women as physicians in the hospital, yet it was a very cautious and tentative one. Unlike her male colleagues, who were customarily appointed for one year, MacMurchy's term was for six months only, and the board's minuted caveat, 'as may be found convenient,' betrays a sense of hesitation.70 MacMurchy went on to a successful career, undertaking postgraduate study at Johns Hopkins University before returning briefly to the Toronto General a decade later; she then became one of Canada's top-ranking physicians in child health policy, first with the Ontario government and then with the federal government.71 Whether servant, skilled worker, nursing student, nurse, or young physician doing a one-year stint at the Toronto General, whether remunerated in cash or in kind, these positions made up the hospital's staff. Physicians were vital personnel, too, but because they never received salary from the hospital they cannot be considered its employees. From the mid-i870s until the beginning of the twentieth century physicians none the less placed their mark on the hospital, if only through their growth in number. In 1876 sixteen physicians were associated with the hospital; by 1901 the figure had increased six-fold, to ninety-six. As with other occupations in this era, they became more specialized. The distinction between surgeons and physicians (who cared for medical cases) was emphasized. By the close of the century, hospital doctors identified themselves as pathologists, gynaecologists, obstetricians, electrotherapeutists, and eye and ear specialists; there was also a dentist affiliated with the hospital.72

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Other distinctions among doctors included their status within the hospital's hierarchy. As they were not employees, hospital doctors held their positions at the pleasure of the trustees; every year they were eligible for reappointment. In the past, hospital appointments had been subject to much debate and strife. The issue continued to be of concern in the last quarter of the century, though discussed less stridently. For young doctors it was extremely useful to acquire a hospital appointment as a 'desideratum for eminent professional success': the collective ailments of the hospital's several hundred patients afforded information that could not be gained in private practice. In the opinion of one medical writer, scarcely a day passed 'without the occurrence of a case in which we feel the want of the kind of experience obtained in a General Hospital only.' Doctors on 'Active Staff dealt with the bulk of the patients admitted; doctors with at least six years of service on active staff could be appointed by trustees to the consulting staff. These senior doctors were invited to attend all capital (major) operations and to examine and give advice on all critical or special cases within the hospital. Yet another classification was that of 'Extern Staff,' which cared for outdoor patients. Outdoor patients recommended for admission to the hospital became the responsibility of the active staff member on duty. Doctors, too, were bound to a host of hospital rules, many of which were specific to their function and duties. Capital operations were not to be performed without the agreement of the majority of doctors in attendance at the hospital at the time; an exception was allowed if the case was believed to be an emergency. (Previously, the entire hospital staff had to be consulted before a decision to operate. Some senior surgeons considered this situation insulting; their judgment would be questioned by those junior and/or inferior to them 'a monstrous absurdity.') A physician was also to see only patients belonging to 'his own department,' such as ophthalmological, gynaecological, and obstetrical. Attending physicians were to ensure that their pupils did not alarm or injure patients and that clinical bedside classes did not exceed twenty students. Only paying patients had the right to appoint which doctor would attend them, and only under these circumstances could physicians arrange to collect a fee for attendance; all other patients were attended free of charge.73 Doctors could undertake regular operations in the theatre only on Tuesdays and Fridays beginning punctually at 2:30 p.m. Abdominal sections and other major operations on women took place in the hospital's

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other operating theatre, located in the Pavilion, usually only between 10 a.m. and noon. No surgeon was to perform two operations consecutively; the seniority of the surgeon greatly influenced priority in .scheduling, with juniors giving way to their senior colleagues.74 Physicians, then, had a hierarchy within the hospital culture that was grounded in the larger world of medical etiquette. The care and treatment of hospital patients - the focus for staff, students, and doctors - changed in this period too, inspired by the provincial inspector of charities, prisons, and asylums. Beginning in the 18705, John W. Langmuir and his successors transformed Ontario jails and prisons into institutions dedicated to incarceration and punishment of lawbreakers rather than 'cheap and convenient all-purpose facilities' with a 'congregate population' of vagrants, the insane, homeless, and criminals.75 In a similar manner they pushed the hospital away from its roots as an institution that was just as likely as these to cater to a pauper, a homeless immigrant, or a sufferer of a chance affliction. In report after report government officials emphasized that the Toronto General Hospital was not a place for the aged, the incurable, or the chronically ill and that the length of stay of patients was to be controlled. Langmuir increasingly became frustrated over the number of 'improper cases' kept in hospitals, especially as the institutions' purpose - and the reason they received government aid - was to 'restore, as soon as possible, to the working community, those who have been withdrawn from it by sickness and disease.' He was glad, however, to see the decrease in the number of chronic and incurable cases who had found a 'home in the Toronto General; others remained who could receive care more cheaply at the House of Refuge or the Home for Incurables or as outdoor patients. The names of patients so designated by the inspector found in institutions receiving government aid at the higher hospital rate were struck off the list; the medical superintendent was also informed of this action.76 The Toronto General's trustees willingly complied in removing unfit or improper cases, an action which suggests that fiscal imperatives might easily override clinical ones.77 By the early i88os government policy began to have its desired effect. Reporting on the Toronto General for 1882, W.T. O'Reilly found on his visit 'comparatively few of the old chronic cases who make the hospital their home - and there is ground for the hope that that class will soon disappear entirely'; out of 163 patients then under treatment, only seven were deemed to be of 'that class.' Even when the inspector encountered

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Figure 4.1 Revenues, Toronto General Hospital, 1876-1903 Source: Data derived from Ontario, Sessional Papers (1877-1903)

an unsuitable patient who clearly suffered from a medical condition and was not simply old or infirm, government policy still took priority over clinical circumstances. In the case of a twenty-five-year-old man who had been in the Toronto General for several years owing to paralysis of the legs, and who had no money or relatives willing to do anything for him, the medical superintendent was requested to arrange for his removal to the Home for Incurables.78 The constantly decreasing average length of stay attests to the success of this policy: in 1876 it was fifty-four days; in 1885, thirty-two days; and in 1903 twenty-six days.79 The patient population changed in other ways, especially in a dramatic rise in the number of paying patients. Although this trend may well have been consistent with the provincial government's aim of having hospitals raise their own funds, Toronto General trustees themselves certainly initiated and maintained it. Announcements placed in Toronto newspapers actively sought paying patients and informed them of the benefits offered:80 'It is perhaps not as well known as it might be that in the private wards [available for $8 per week] ... sick persons can have all the advantages of the best medical attendance coupled with as much comfort and privacy as they could enjoy at home, while the cost is, of course, much less than it would be in their own houses.' As Figure 4.1 shows, between 1876 and 1903, revenue from paying

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patients became a sizable source of hospital funds. In 1876, just over $2,8oo came from paying patients, as compared with over $15,000 from the hospital's provincial grant. In 1897, revenues from the two sources were about equal, at just under $20,000. Between 1897 and 1903, while grant income declined to $12,524, paying patients' share more than doubled, to about $44,000. Given total revenue of $92,280 for 1903, paying patients accounted for about 46 per cent, and the provincial government, about 13 per cent.81 (Other revenue came from property and house rents, philanthropic gifts, and grants from municipalities, including the city of Toronto.) Since the hospital first opened its doors in 1829, there had been an expectation that those who could pay for their care would do so; rarely, however, had any great number paid. That so many Torontonians and others paid for hospital care by 1903 again illustrates their changed perception of the institution. This trend also suggests that patients were from different social sectors - that is, those people with sufficient income to spend it on hospital care, including a private room. Recorded trades and occupations in 1890-1 support this contention. Of the approximately 3,000 patients admitted for that year, only one was identified as a pauper, and nine as unemployed or of unknown trade. As in the past, the single largest group of male workers comprised labourers (263, or 8.8 per cent), and for women it was domestics (312, or 10.4 per cent). Many of the remaining patients belonged to occupations such as farmers, shopkeepers, and railway workers or to a host of skilled trades such as building (bricklayer, brickmaker, carpenter, gasfitter, joiner, mason, painter, plasterer, plumber, roofer), manufacturing (boilermaker, boltmaker, cooper, carriagemaker, draughtsman, ironworker, leadworker, mechanic, machinist, wheelwright), and printing (bookbinder, bookseller, compositor, engraver, lithographer, printer, stereotyper). A small but important new group appeared - nineteen nurses, eight 'gentlemen,' seven 'ladies,' six lawyers or barristers, six engineers, five schoolteachers, four physicians, three clergymen, and one government officer. Clearly, more genteel and educated people sought out the hospital for treatment.82 The patient population swelled dramatically. In 1876, 974 were admitted; in 1886, 2,504; in 1896, 3,008; and in 1903, 3,700. This four-fold increase over three decades reveals the growing role and use of the general hospital as a place for health care. Between 1876 and 1903, with the boom in hospital building across Ontario, the total number of patients actively admitted each year rose about ten-fold, from 3,893 to 35,912; the

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percentage of the province's patients treated at the Toronto General declined from 25 per cent to 10.3 per cent, although the hospital also treated tens of thousands of others annually as extern, or outdoor, patients. These outpatients received advice and treatment free of charge but were required to supply their own clean bottles and gallipots (ointment jars) for any medicines received.83 Reports critical of patient care surfaced in the i88os and 18905. The author-editor of a weekly Toronto pamphlet, Medical Criticism, an ardent supporter of free trade in medicine and of a host of sectarian medical practices (such as Eclecticism, homoeopathy, and hydropathy), attacked the Toronto General and the practices of its doctors. In his view, the doctors needlessly harmed patients, and the hospital encouraged a medical monopoly by not allowing the practice of other than mainstream medicine in its wards. Another, particularly truculent, anonymous article of 1884 inexplicably harkened to the strife-ridden 18508 with its complaint of patient neglect, vermin-infested beds, shorttempered nurses, and medical students and physicians who paid attention only to the 'interesting' cases. Perhaps easily dismissed as the work of cranks, these critiques nevertheless raised a minority voice against the rising power of the hospital. A decade later a report of patient neglect, this time internal, was dismissed by the board after an extensive investigation. (Supplied with liquor by friends, a patient had become noisy and troublesome; to avoid disrupting others, staff moved him to an attic ward. Shortly afterwards, against the advice of his physicians, he signed a release and left the hospital accompanied by his wife.)84 Along with the bureaucratization and 'modernization' of the hospital, the sharp increase in numbers of people treated, the drive to raise revenue from patients, and differences in type of patient, there surfaced a novel reaction from some dissatisfied people. Beginning in the 18905, trustees contended with several threatened legal actions from former patients or their families. A father demanded compensation for the death of his daughter, which occurred while she was in hospital; a patient contemplated suing over 'improper treatment' for a broken jaw; a family sought to sue when a daughter contracted typhoid fever while living in a house rented from the Toronto General; and another action arose over the hospital's refusal to admit a person believed to have diphtheria (such cases were admitted not to the Toronto General but to the city's isolation hospital). For one patient whose stay had been pro-

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longed by injury from a fall out of bed, the board did refund a portion of the bill.85 Doctors reacted to this trend by seeking the hospital's support. Dr G.S. Ryerson sought reimbursement for costs of a malpractice suit brought against him by a patient whom he treated in the eye and ear department. Other hospital-affiliated doctors supported his request, maintaining that the board should assume liability when patients unjustly sued members of staff. The board, however, thought otherwise. A coaxing letter from Ryerson's lawyer failed to persuade its members to interfere in this matter. The board saw no precedent for it to act; indeed, as a charitable institution the hospital apparently had no responsibility to physicians.86 This incident neatly underscored the tenuous relationship between hospital and doctor: no formal legal tie bound them, while the board retained the power to regulate their conduct. Doctors remained independent practitioners. Their concerns over these kinds of incidents eventually led them in 1901 to found the Canadian Medical Protective Association, to provide funds for physicians to cover legal costs if sued.87 It is open to debate why patients contemplated suing physicians or the hospital - because they had higher expectations of a successful outcome, or began to feel alienated from those who cared for them, or because society just became more litigious? Whatever the motivations, these actions signalled yet again that the hospital had entered the modern era. Undoubtedly, there would be examples of disgruntled patients, but the majority of evidence suggests that the Toronto General Hospital had become a more comfortable institution. Three main indicators the thousands of dollars spent annually upgrading hospital plumbing, ventilation, heating, wards, and kitchens; the numerous hospital expansions; and the increase in staff and its members' improved deportmentall augured well for patients' care and comfort. Given the constant vigilance of both the medical and lady superintendents, it seems hard to believe that management and patient welfare could revert to practices tolerated in an earlier era. Similarly, successive provincial government inspectors were casting a watchful eye over the hospital. Langmuir and his colleagues routinely drew attention to the constant improvement of the Toronto General. Almost every aspect of patient care, comfort, safety, maintenance, and well-being came under scrutiny at one time or another - typically with no adverse comment. According to official reports, inspectors interviewed every patient available at the time of their hospital visits. Their

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impressions are presumably reliable: food was good; air was pure; beds and bedding were clean, tidy, and comfortable; and the discipline of staff was commendable. The wards were in the best possible condition,' reported Langmuir, 'both cleanliness and order being scrupulously observed in them, and many of the rooms were rendered bright and cheerful looking by pictures, flowers and other inexpensive ornaments, which must add much to the comfort of the patients and at a certain stage largely conduce to cure/ At Christmas, wards and halls were decorated festively. A small library of donated books and magazines was also available for patients' use.88 Provisions were made as well for the spiritual needs of patients. The hospital gratefully received a donation of 170 copies of the New Testament for patients; the operating theatre was available on Sundays for any denomination to hold services; and clergy could visit the hospital daily between 3 and 5 p.m. None the less, religion remained a sensitive issue. Hospital rules dictated that patients were not to be subjected to any religious services or reading that they did not want; similarly, pastoral visitors were to talk on religious matters only to patients of the same denomination. To aid in the implementation of this policy, a card at the head of each bed identified the religion of each patient. Despite the Toronto General's lack of religious orientation, denominational tensions still simmered below the surface. In 1893, T.F. Chamberlain, inspector of prisons and public charities, wrote to both the Globe and the Mail newspapers and published a pamphlet to explode a series of falsehoods circulated in the public press and by printed 'flysheets' about favouritism to Catholic hospitals. Citing data derived from his annual government reports, he showed that all Catholic hospitals accepted Protestant patients - in some cases the latter outnumbered the Catholic patients. Similarly, non-Catholic institutions accepted Catholic patients. Using the Toronto General Hospital as an example, Chamberlain noted that, for every one hundred Protestants admitted, twenty Catholics received treatment. Chamberlain freely admitted that Catholics preferred their own institutions, and Protestants, hospitals 'controlled by Protestants, whether called Protestant or general,' but that was a matter of personal choice and not government policy.89 As with the other members of the hospital community, patients' conduct was monitored and regulated. They had a high degree of responsibility for their own recovery. Tobacco and liquor were prohibited; indecent or immoral behaviour was not tolerated. Patients were not to

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endanger their own recovery in anyway, such as by interfering with their own diet cards or charts. When physicians were scheduled to visit the wards, patients had to make themselves available and assist by sitting on the chair in front of their bed and remaining there until the visit concluded. During this period all patients were forbidden to talk, make any noise, or wear a hat. Generally, patients could not lie in bed without being undressed and could not talk in the wards after 8 p.m. Most of the hospital was out of bounds to them, except for private ward (paying) and female patients, who had access to the front grounds. All patients who were able were expected to render whatever assistance they could in the wards on the request of nurses. Pregnant women admitted to the Burnside branch of the hospital were subject to additional regulations, including making their own beds, keeping the wards in order, and wearing only clothes provided by the hospital. A strict injunction against mothers leaving the hospital without taking their babies existed, reflecting concern that a woman might abandon her newborn in the hope that someone else would take care of it.90 Over time, economic status, or more generally social class, came to exert a more pronounced effect, and the hospital evolved a two-tier system of care. Initially, this situation was cause for celebration: the rich, along with the poor, actively sought the medical care and comforts of hospitals such as the Toronto General, noted the 1894 government inspector's report. With the increase in paying patients it was anticipated that hospital administrators would spend more on the care of those who were unable to pay - members of the latter group now identified as public ward or poor patients. 'Under the system of management that prevails in this Province,' the government inspector reported, 'all classes, creeds, and nationalities have free access to the hospitals ... they all receive rich and poor alike, those who are able to pay and those who are not.' A decade later, however, celebration had given way to concern. In the government's eyes, it was then regrettable that 'poor or ward patients' were not receiving as much attention as was necessary. Some hospital boards were concentrating on the care of private patients who paid a 'goodly sum' for their accommodation and, worse, tending 'towards an extravagant expenditure in providing rooms and fittings which might to some extent be avoided.' It is impossible to gauge the extent to which care of the poor may have been compromised in some hospitals, or whether paying patients actually received better care. In theory, as paying patients paid only for accommodation, there is no reason to expect

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that they would have had additional medical benefits. In some hospitals (not identified) patients were neglected or subjected to overcrowded conditions: attics became wards, both ill-ventilated and unhygienic. The Toronto General certainly employed its attic space as patient wards, but the government report noted that Toronto was overdue for a large central hospital that could accommodate its expanding patient burden.91 Gender and health were inextricably linked in the activities of the Burnside hospital and the women's Pavilion. During the nineteenth century and for roughly the first third of the twentieth, hospitals were not the primary location of childbirth in Ontario; not until 1938 was there an equal number of births in and out of hospital. None the less, even if the majority of births - over 40,000 annually - took place in the home, attended by family, physician, or midwife, the trend towards hospital births became clear in the late nineteenth century.92 Between 1879 and 19O3> births in hospitals throughout Ontario each year quadrupled, from 280 to 1,173. In Toronto from 1879 until 1889, births at the Burnside rose steadily from 159 to 195 annually; beginning in the 18908, they decreased because of the founding of other local hospitals (such as the Grace Homoeopathic, St Michael's, and Western hospitals), all of which had maternity sections. Even so, the Burnside was still the busiest lyingin hospital in the province, with an average of 137 births annually between 1890 and 1903. Between 1878, when the Burnside amalgamated with the Toronto General, and 1896, 2,748 babies were born there.9'^ Lack of complete records and inconsistencies among those that have survived inhibit further analysis. However, Dr Adam Wright, a Burnside physician, reported in a medical journal that between 1888 and 1897, out of a total of 1,259 deliveries, eight women had died, five from septicaemia; for an unspecified period ending in 1897, there had been 565 consecutive births without the death of the mother. Perhaps about 10 per cent of all infants died at birth or shortly afterwards. Such statistics suggest a better performance than that of similar institutions elsewhere in Canada; when compared with data from non-hospital births attended by doctors, the Burnside's record remains a favourable one.94 The length of stay for women at all of Ontario's maternity hospitals was regulated starting in 1882 by government order. In this instance, as with the regulation of chronic and incurable patients, policy was influenced more by morality than by medicine. Often, pregnant women admitted to maternity hospitals were prostitutes, unmarried, or of especially low social class. It was deemed unjust that such women should be

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able to take advantage of 'comfortable quarters, with nothing to do' for extended periods, while other responsible working-class women who gave birth were 'seldom away from their duties for a longer period than two or three weeks.'95 Between 1878 and 1882, a period for which records were once available, 80 per cent of the women admitted to the Burnside were unmarried; over 50 per cent of them were under the age of twenty-one. Girls might be admitted as young as fifteen.96 Accordingly, the government restricted the stay of pregnant women to thirtyfive days; thereafter any hospital would receive only a reduced per-diem rate for their support, unless the longer stay was absolutely necessary for medical reasons. The Toronto General itself would not admit any woman more than two weeks before her 'expected accouchement.' With the cap of thirty-five days' stay, a typical new mother could expect to stay in hospital for up to three weeks after giving birth. This pattern seems to have been followed in the majority of women cared for.97 The admission of pregnant women to the Toronto General and their care there stood in contrast to previous hospital policy and practice. The involvement of hospitals in a domestic event such as childbirth was another sign of the expanding world of medicine and of institutions in the lives of ordinary people. Once admitted to hospital, mothers-to-be became patients and were subject to the hospital's many rules, the demands of doctors, and the inexperienced hands of senior medical students. Even if the notion of 'medicalized' childbirth was beginning to take shape, its pursuit in the Burnside at the close of the century was not overtly meddlesome or interventionist. Despite the advent of general anaesthesia and its increasing employment in surgical operations, this technique was used sparingly for women experiencing pain during childbirth. Similarly, the use of obstetrical forceps as an aid in delivery, though debated and frequently resorted to beginning in the 18705, was discouraged at the Burnside; in 500 cases by the close of the century, forceps had assisted labour in only three of them. The health of women who had recently given birth improved materially through the observance of good antiseptic/aseptic technique to limit the spread of infectious bacteria. The necessity of absolute cleanliness and sterility in dressing materials, clothing, hands, surfaces, and instruments was fully appreciated by the early 18905. Dr Wright could testify that they were practised assiduously in the Burnside: owing to her 'intelligent appreciation and conception of the virtues of practical asepsis and anti-sepsis' the hospital's head nurse and matron, Miss MacKellar, he declared, 'is the most skilful midwife and the best teacher of

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aseptic and anti-septic nursing in midwifery that I have ever met.'98 Wright's praise for MacKellar's skills also nicely reveals the interconnections between physicians, nurses, new medical knowledge, hospital practice, and patient care that were fast forming in the modern Toronto General Hospital. In 1881, three years after the Burnside Lying-in Hospital had joined the Toronto General, one doctor bemoaned the fact that the hospital still ignored gynaecology as a separate specialty. Despite the abundance of 'material,' he claimed, many medical students had never seen a speculum, a probe employed, or a pessary introduced." Within a year the hospital's new Pavilion addressed this lack, and it quickly became a busy place. Data available for 1890-1 show that over one-third of all 'special diseases' of women in Ontario were treated at the Toronto General; as well, the second-largest category of all operations within the hospital itself was performed on women (15.6 per cent). Conditions treated included recto- and vesico-vaginal fistulas; ovarian disease; prolapsed, inverted, anteverted, and retroverted uterus; womb cancer and fibroids; and cancer of the breast. The development of gynaecology at the Toronto General illustrates another aspect of the often-uneasy gendered nature of medicine. In many instances, surgical procedures for the removal of large ovarian cysts and for other internal disorders brought relief and allowed women to live longer. In others, operations were often, at best, unnecessary or, at worst, ill-advised and dangerous. The unclear rationale behind, and high frequency for, Battey's operation (the removal of ovaries), for example, indicate how some doctors - including those on the gynaecological service of the Toronto General - probably did more harm than good.100 Significant here is the role played by the hospital itself. Physicians' drive to ameliorate specific disorders was supported by the hospital's making available facilities for the well-being, comfort, privacy, and care of women. As many cases involved complex abdominal operations, it was considered more appropriate to perform them in hospital, which could provide aseptic conditions and professional nursing care. By the same token, the availability of these facilities permitted and sanctioned the interventionist actions of physicians. In this way, the hospital acted as a catalyst in the creation and rise of the specialty of gynaecology. The Toronto General was also instrumental in advancing at least one other specialty as a result of its facilities and the skilled personnel associated with it. Since the 18508, with the appointment of William Beaumont,

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the hospital had a reputation for treating ophthalmological conditions; the creation in 1878 of the Mercer Eye and Ear Infirmary greatly enhanced this reputation. By the early 18905, over half of all eye treatments in the province's hospitals took place at the Toronto General. In 1891 cataract removal and other eye operations constituted the largest category of all surgical procedures in the hospital (19 per cent).101 Gynaecological and ophthalmological procedures accounted for about 35 per cent of all those performed at the hospital. In keeping with its role as a general hospital, the Toronto General admitted and treated an extensive list of other conditions. As in the past, it dealt with environmental circumstances that could erupt into epidemics. Although fevers still dogged Torontonians at the dawn of the twentieth century, the scourge of intermittent fever that had incapacitated so many original York settlers had subsided. Only a dozen cases were admitted between October 1890 and September 1891, and there were no deaths. Similarly, there was only one case each of cholera and typhus - the diseases that had decimated Canada's earlier immigrants and caused so much concern to medical and municipal authorities alike had disappeared. Exploding on the scene, however, was typhoid fever: in the early autumn of 1890 and the summer of 1891, the hospital admitted 375 cases, of which 49 ended in death.102 Caused by a bacterial cousin of cholera, and spread similarly by contaminated drinking water or food, typhoid was a sign of the congested urban times. In this period, the city's water was drawn from the harbour - the same place into which the city's sewage flowed. Breaks in the wooden intake pipes for drinking water, as often occurred, resulted in widespread contamination and disease; in Toronto's growing slum areas, overcrowding and poor hygienic living conditions accelerated the course of disease. (Not until 1915, with the development of chlorinated drinking water and an active program of inspection by the city's public health department, was the threat of typhoid fever reduced.103) Overall, and over time, the Toronto General's patients increased their chances of surviving their stay. Since the hospital's opening, the number of deaths of patients relative to those admitted constantly hovered around 10 per cent. In 1876, of the 974 patients admitted, 92 (9.5 per cent) died. A decade later, however, this figure dropped to 8.1 per cent; in 1903, 262 (7.1 per cent) of the 3,700 patients admitted to hospital died.104 Although this crude index suggests a positive trend in hospital care, other factors should be taken into account. Some diseases might

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still have alarmingly high death rates, or their outcomes might be different for men and women. For example, between 1878 and 1891 the number of cases of typhoid fever treated annually increased fourteen-fold, yet for all hospital patients the death rate from this disease declined from 20 per cent to 12.5 per cent. In male patients, the pattern was one of general decline, from 26 to 11.8 per cent; however, for unknown reasons, that of women was more irregular, showing ultimately a net increase, from 10 to 13.7 per cent.105 A selection of the published case reports again reveals a spectrum of patients differing in age, sex, and nationality and a familiar tale of the successful, the commonplace, the tragic, the bizarre, and the catastrophic.106 Miss McA. gained relief from her fibroid tumour of the uterus after a series of hypodermic injections of ergotamine (an extract of a fungus found on rye); 'W.B.,' a fifty-two-year-old man, died after he mistakenly consumed oxalic acid; Mrs E. had her inguinal hernia corrected with a truss; Mr McN. could urinate normally again after the removal of a iV4-inch bladder stone; Wm. Davie suffered from a bladder stone measuring 21/£-inches by 2 inches but died after failed attempts to crush it; James T. was treated for 'barber's itch' after being cut by the barber who shaved him; Robert T. suffered from diabetes and soon died after passing nine pints of urine in twenty-four hours; and W. Chapman had a large melanoma on his abdomen removed. Other cases suggest the drama of everyday hospital life. Katy B., twelve years of age, who probably was suffering from a form of leprosy, used to entertain her friends by inserting a needle into the deadened yellowbrown patches of skin on her ear and face; her hospital doctor, J.E. Graham, assessed her condition dispassionately: 'If the patient should live long enough it will be interesting to watch the further development of the disease.' Thomas G., nineteen years of age, sustained serious injury after ten railway cars passed over him. Two physicians at the scene of the accident suggested amputation of one arm and one foot. After the patient was admitted to the hospital, Dr Aikins felt that he could save both limbs; within six months, Thomas G. had indeed fully recovered. 'J.V.,' a healthy twenty-year-old - though 'somewhat addicted to masturbation' - suffered from convulsions and partial paralysis of his left leg and arm. After three weeks' treatment of warm baths and arsenic solution in hospital, the young man was sent home 'apparently cured'; he later was readmitted after his fits resumed. Enoch Baker, thirty years old, married and healthy, received a blow from a crowbar when he was lifting a large stone. Six months later, he was admitted to the Toronto

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General complaining of pain and stiffness in his right inguinal region; his leg was greatly swollen down to the foot. While under hospital care Baker suffered a paroxysm, and, according to the writer of his case, he 'placed his hand between his legs, lifted it up, looked at it, and exclaimed, "I am bleeding to death!" and in a few minutes he was no more.' A postmortem revealed a sac filled with a clot that 'filled a large wash basin/ Some cases, though successful in the end, show starkly that doing good often involved a great deal of medical delay and interference. After two-year-old 'M.E.' accidentally swallowed a glass bead, she and her parents received varying opinions and procedures. A local doctor first advised her parents that she would cough up the bead in time. When the child continued to cough over the next week and ceased eating, another doctor recommended that they take her to the hospital. Eleven days after she had swallowed it, she was admitted to the Toronto General for a tracheotomy to remove the 14-inch by V4-inch bead from her windpipe. Unfortunately, the wound in her throat became infected, it became difficult to keep the trachea free from an accumulation of mucus and pus, and she became feverish and weak. The child fully recovered within two weeks of her operation, her wound healed, and she finally returned home. The medical tribulations faced by twenty-two-year-old 'C. McD.' were remarkable. Her ordeal began in January 1876 when she was admitted to the Burnside Lying-in Hospital. In labour for six days, she eventually gave birth with the aid of forceps, not to assist delivery but 'merely to correct some malposition of the head/ Eight days after giving birth, the woman became incontinent; during her six-week stay at the maternity hospital she was then given a prescription containing Spanish fly, nux vomica, ergot, and iron - all to control her flow of urine. At the beginning of May she was admitted to the Toronto General, where the same treatment was prescribed until July. Because her condition did not improve, her prescription was modified to include chloroform, and later turpentine and bella donna (deadly nightshade). Additional treatment included electrical stimulation direct to her sphincter and forcible dilatation - all unsuccessful. Suspecting a vesico-vaginal fistula, her physician, Dr Fulton, undertook 'a most searching examination, by means of the speculum and the injection of warm milk into the bladder.' Following the path of free-flowing milk, he was able to locate a half-inch opening from the bladder into the vagina; the case was deemed no longer medical, but surgical. In early October, in the presence of several

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members of hospital staff, the house surgeon, a few assistants, and some senior medical students, the delicate and long operation to repair the tear was successfully performed. In three weeks' time, 'C. McD' was 'moving': she was discharged from the Toronto General at the end of October, after ten months of almost-continuous treatment. The peculiarities of the human body and of human behaviour also came under the gaze of hospital doctors. The celebrated contortionist who could dislocate every body joint, except that of the elbow, left no doubt in the minds of those who examined him at the Toronto General that the 'dislocations were complete in every case.' Similarly, the case of Thomas D. contained the stuff of doctors' stories. This thirty-eight-yearold man was admitted to hospital complaining of pains in the bladder and problematic urination. He sought medical aid after learning from a friend that while he was in a deep alcoholic stupor some time previously two men had inserted a pipe stem into his penis. An operation for lithotomy successfully removed a three-inch-long gutta-percha (hard rubber) pipe stem, which, at its widest, was one inch in diameter because of a build-up of uric acid. The patient left hospital relieved. If the hospital acquitted itself well in the treatment of many individual cases, it distinguished itself on at least one occasion. Just before 7 a.m. on 2 January 1884, a freight train slammed head on into a suburban passenger train carrying over forty men to their jobs at the Toronto Bolt and Iron Works. The impact killed just over half of the passengers instantly. The scene, wrote one reporter, was a 'carnival of death.' Local physicians arrived promptly at the site, just west of the centre of the city, but the seriously injured needed more than their care. The Toronto General Hospital was telephoned, and emergency procedures were rapidly put into effect. Beds were prepared; extra bandages, dressings, medicines and stretchers assembled; and members of staff placed on alert. Soon the ambulance arrived with the first patient, and then a convoy of omnibuses, wagons, and cabs brought more. A crowd of anxious family and friends descended on the hospital, and the telephone line was constantly in use as others called in to inquire about the injured. Meanwhile, hospital doctors and nurses sewed and dressed wounds: many of the men were burned from 'head to foot,' their faces scarcely recognizable to friends, and several died within hours. Superintendent O'Reilly, acting perhaps for the first time as what would now be called public relations and media officer, released daily reports of the half-dozen patients with fractures, lacerations, and scalds who were making satisfactory

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recoveries. Soon, they were sitting up in bed and able to play checkers or to describe their ordeal to reporters and friends alike. Torontonians responded to the tragedy by organizing a relief fund for victims' families, many of whom were left destitute. Standing as a beacon amid the 'deep gloom' that hovered like a 'large pall over the Queen City' had been the Toronto General Hospital. Quick telephone communication, ambulances, and trained nurses had enabled Dr O'Reilly to marshal his forces so effectively that he, his staff, and the hospital received glowing praise in the popular press for the 'magnificent manner' in which they responded to the disaster.10? The Cost of Success

Success came with a cost. From 1876 to 1903 annual expenditures almost doubled, from just under $52,000 to over $95,000. More significant was the absolute and relative rise of both salaries and the cost of medical, surgical, and related equipment and supplies. Salaries rose four-fold, from $6,573 (!2-7 per cent) in 1876, to $12,328 (23.9 per cent) in 1886, to $17,816 (26.1 per cent) in 1896, and to $25,857 (27.2 per cent) in 1903. Similarly, medical and surgical supplies accounted for only 3.5 per cent of the hospital's annual expenses ($1,794) in 1876 and over 10.5 per cent in 1886. For the remaining years of this period the proportion for supplies levelled at just over 11 per cent, while the cost rose from just over $5,400 in 1886 to $10,573 by 1903. Other expenses such as heat, lighting, food, and miscellaneous supplies also increased, though proportionately not as quickly.108 While not alarmed at the rising cost of running the hospital, trustees sensed that the bountiful years could be coming to an end. In 1900 the board reviewed its financial situation, especially in the light of drops in revenue from provincial and municipal grants. At this time the hospital borrowed $12,000 from George Gooderham to clear its bank overdraft.109 The Toronto General's situation at the turn of the century reflected a province-wide state of affairs, as the government realized too that success did not come cheaply. In the early 18708, when the governing Liberals promoted the growth of hospitals as part of their larger agenda of social welfare and state support, only a handful of institutions existed across the province. Two decades later the program had been so successful that about thirty general hospitals were receiving government support - and the number continued to grow. Provincial officials approved of this trend but wondered if the 'Government ought not to

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assume greater powers than it has hitherto exercised as to the necessity for increased hospital accommodation in any locality before a new enterprise is undertaken.' As government grants to hospitals rose towards $100,000 annually, the government inspector's level of concern also rose.110 By 1895, the annual grant for hospitals alone was $110,000, shared among thirty-five institutions. To control costs, new legislation reduced the grant available to hospitals over ten years old; they would not receive the government's per-capita allowance for patients who paid $3 or more per week for care and treatment. The legislation also forbade communities to establish new hospitals without receiving prior permission from the government. The government tried to contain unbridled expansion and to encourage 'younger' hospitals to make an effort to become selfsufficient.111 Its plan also aimed to stop duplication of hospital facilities in the same location, for 'one hospital, well equipped and supported, will do much better work than two or more, and at much less expense to the community.'112 Despite these efforts, the number of hospitals receiving government funds grew, and the 'disposition to multiply hospitals in some localities' continued; in response, in 1898 the government froze its annual grant to all hospitals at $no,ooo.113 Even so, officials continued to sound the alarm:114 It is to be regretted ... that there is a tendency in many small places and even in some cities, to establish more Hospitals than the requirements of the population demand, thereby dividing the work to such an extent as to cripple the efforts put forth for their proper maintenance. ... Consequently, great care should be exercised in establishing new Hospitals on the assumption that they will always continue to receive Government aid, as in the event of its withdrawal at any time they might be placed in embarrassed circumstances, and to a great extent rendered useless. Just as meaningful for the Toronto General's operation were the government's warnings about duplication of institutions 'even in some cities.' By the turn of the century, Toronto had seven hospitals. Overlap in services was offset somewhat by ostensible differences in orientations (clinical and otherwise). The Hospital for Sick Children cared for infants, boys and girls; St Michael's was open to all but cared primarily for Catholic patients; the Grace was founded to provide homoeopathic

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medical care; the Orthopedic dealt with selected surgical cases; the Western, a small general hospital, served a community far from the General's eastern location; and St John's was oriented to Anglican patients. None the less by 1903 one-third of the total provincial grant of $110,000 went to these seven institutions, and, despite its declining share, the Toronto General continued to receive the largest portion.115 The multiplicity of hospitals in Toronto caused concern for the city's board of control, which gave a municipal grant to all of them. Medical Officer of Health Charles Sheard advocated eliminating some hospitals to reduce costs and to avoid the 'evil' of medical men 'soliciting patients to accept hospital charity who otherwise would not have thought of applying.' Echoing the provincial government, Dr Sheard advised the city to limit the proliferation of hospitals and the indiscriminate dispensation of hospital relief at the city's expense:116 There is a strong leaning in all large cities towards the organization of special hospitals, and I am confident that this municipality will, unless it adopts some policy of protection, have strong pressure brought to bear upon it, to furnish grants towards the maintenance of such institutions, as, for instance, a special hospital for the diseases of women, a hospital for orthopedic surgery, a hospital for consumptives, a hospital for cancer, a hospital for chronic nervous diseases, and a hospital and dispensary for teeth, each of which might do a great and beneficent work in itself, but the total result of these efforts would be decentralization, increased expense, a demand for and a tendency to attract paupers from other municipalities for the sole purpose of receiving such relief. Sheard's warning would be prophetic. The general worry over uncontrolled expenses, proliferation, and decentralization of hospitals was grounded in the success of the hospital idea. Even when the largest and the oldest hospital, the Toronto General, had had no competitors, its survival had often been a matter of concern; the fact of so many other institutions in the province vying with it for support could hamper its future development. Ironically, the provincial inspector himself offered a solution to this potential problem. Reviewing the province's hospitals in 1903, he concluded that Toronto actually required an increase in hospital facilities; in particular, there was a 'great need for a large central hospital convenient to the university.'117 These few words presented an opportunity and a blueprint for the Toronto General in the twentieth century. It would require

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a person of great vision, commitment, and the right connections to translate such a program into action. In 1902, such a person, Joseph Wesley Flavelle, was appointed to the hospital's board. When Flavelle became chair in 1904, the hospital's ability to do good intensified, and he steered it for the next few decades, guided by his Christian values, business acumen, and social vision.

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PART THREE A Major Academic Hospital, 1904-2000

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5

Millionaires, University Doctors, and Their Hospital, 1904-1930

Early in the new century, an editorial in the Canada Lancet on 'Hospitals and City Life' captured just how important hospitals had become to Canadian society. Appealing to the 'imagination of all classes,' it suggested, hospitals were centres of education for medicine, nursing, and the public. Through their 'union of science, art, business skill, and charity,' they had evolved into 'great industries conducted for the purpose of making people well, prolonging life, and relieving suffering." Inspector of Hospitals and Public Charities Dr R.W. Bruce Smith had shared this idea with listeners at the inaugural meeting of the Canadian Hospital Association in Toronto in 1907.2 Civic pride and local philanthropy had teamed up to drive hospitals' progress, he told them, and the time had passed when the public looked on the institution as a 'chamber of horrors.' With all classes regarding it as devoted to patient care and education, it could assume a larger role in society: The hospital should ever spread a gospel of health and right living throughout the community where it exists. Not only should the institution be a model of sanitary housekeeping, but the doctrine it inculcates should do much to demonstrate the best and truest hygienic truths. The beams of light from a hospital should shine forth and enter every home within the radius of its influence, so that the superstitious and baneful influences that shadow many lives may disappear as mist before the morning sun. The hospital in its greatest mission of teaching people how to live, in order that they may keep healthy, has a field of ever enlarging usefulness.

In step with the times, those responsible for the Toronto General Hospital tried to uphold the goals of caring, education, and charity that

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had marked its development up to the twentieth century. Over the next three decades, they also strove to increase its business efficiency and strengthen its part in spreading the 'gospel of health,... hygienic truths [and] beams of light... within the radius of its influence/ Most important, they, along with their employees, completely reorganized, relocated, and rebuilt the hospital, forging a crucial and intimate link with the neighbouring University of Toronto, and then steered it through a world war and a period of economic expansion. Throughout this era, one man dominated the hospital's affairs. From 1902 until his death in 1939, Joseph Flavelle served on the board of trustees, chairing it from 1904 until 1921. After the hospital's relocation downtown in 1913, its extensive physical plant of medical, surgical, and private patients' buildings and nurses' residences came to fill two city blocks on fourteen acres; by the 19305, it had over 1,000 beds and cared for tens of thousands of outpatients annually. During the 'Flavelle years' the Toronto General became North America's largest privately directed (i.e., non-governmental) hospital and Canada's major academic hospital. Toronto itself emerged as the principal industrial and commercial centre in Canada. By 1930 it boasted both the tallest building and the largest hotel in the British Empire. As well, the city's population was growing and diversifying noticeably through an influx of Italians, Jews, Poles, Ukrainians, other eastern Europeans, and some Asians, although it did not challenge the dominance of the British population (over 80 per cent of the 631,000 residents by 1931). Rising with the population were costs for the city's upkeep. From 1900 to 1930, municipal support for public health activities grew by a factor of twenty-four and for welfare by a factor of thirty-one, to just under $1 million and just over $2.5 million, respectively. About $25,000 spent annually on sewers increased to $1.7 million; similarly, the costs of garbage collection rose from $84,000 to $1.1 million. With all this growth, Toronto matured as a city - even if a dull and parochial one in the eyes of Toronto Star reporter Ernest Hemingway.^ Linking Hospital and University The well-to-do and genteel referred to Toronto as the 'Queen City of Canada'; non-residents and those of more modest means usually called it 'Hogtown,' thanks to its concentration of pork-packing plants. When he became chair of the hospital's board in 1904, Joseph W. Flavelle lived in both these Torontos. He had amassed a considerable fortune as man-

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aging director of the largest pork-packer in the British Empire, William Davies Company, and from his numerous directorships in firms such as Canada Cycle and Motor Company, National Trust, and Simpson's Ltd. During the First World War, Flavelle's work as chair of the Imperial Munitions Board consolidated his relationship with top politicians and bureaucrats on both sides of the Atlantic; this war work was recognized with a baronetcy in 1917. Although he himself never attended university - never completed high school, in fact - Flavelle headed up the commission that revamped the entire academic structure of the University of Toronto.4 Truly a captain of Canadian industry, Flavelle was wealthy, astute, diplomatic, and well-connected - characteristics vital to his successful management of the Toronto General Hospital. The source of his greatest strength, however, was his Methodism. From its founding in the eighteenth century by John Wesley, Methodism has as a fundamental tenet the connection between religion, healing, and health. Rev. Wesley himself wrote a medical guide, Primitive Physick: Or, An Easy and Natural Method of Curing Most Diseases (1747), which enjoyed widespread and long-lived publication. Affluent Methodist philanthropists in the United States pursued this tradition in the nineteenth century building hospitals as 'deeds of mercy' for society.5 That Joseph Wesley Flavelle would devote so much of his life and a considerable portion of his personal wealth to the Toronto General Hospital similarly reflected his religious obligation. His mother neatly alluded to his sense of duty in 1906 when she supposed that Joe was 'doing all the good he can.'6 During Flavelle's tenure at the Toronto General, doing good involved three grand projects, based on ideas from Europe and the United States about medical education, about research and practice, and about the concept of a university hospital. Flavelle oversaw the reorganization both of the medical staff within the hospital and of its relationship with that of the University of Toronto and its Faculty of Medicine. The hospital also had to continue to provide the best possible care to the city's growing and diverse population - a goal hindered by an ageing midnineteenth-century building that badly needed another round of renovation. Flavelle took it on himself to plan, finance, and build an entirely new, modern, twentieth-century hospital to supersede the 'Old General.' Fulfilling any of these goals would be reason enough for him to feel satisfied, but the fact that Flavelle accomplished all in one decade is truly remarkable. In 1903, one year after Joseph Flavelle joined the hospital board, the

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University of Toronto opened its * thoroughly up to date' medical building, which housed lecture theatres, laboratories, a library, pathological museum, and quarters for the dean.7 The erection of such a new facility on the university's campus testified to the new spirit of consolidation and cooperation within the city's medical teaching community. With the Faculty of Medicine's absorption of Trinity Medical College that same year, the university undeniably became the intellectual and geographical focus of medical education in the city and in the province; the expected registration of over 600 students also made it one of the largest medical schools in North America. (The small Ontario Medical College for Women would be amalgamated within the Faculty of Medicine three years later.) So important were these developments that they attracted leading medical educators from North America and Britain to the official opening in October 1903. William Osier was among those who received an honorary doctorate from the University of Toronto on this occasion. His address to students and faculty, entitled The Master-Word in Medicine,' had both an immediate and a long-lasting influence. Seldom had medical students 'listened to words so eloquent and so appropriate,' they recalled, 'and seldom, too, has any speaker had so receptive an audience.'8 Medical professors in Toronto received Osier's congratulations for having united into a 'harmonious body.' He urged the province's two smaller medical schools, in Kingston and London, to 'commit suicide' and affiliate with the central university in order to create a school of the 'first rank in the world.' Such a school should have hospital facilities under its control. Osier's remarks about the city's main hospital, the Toronto General, would reverberate through its affairs for some years to come. 'It should be an easy matter,' he suggested, 'to arrange between the provincial authorities and the trustees of the Toronto General Hospital to replace the present antiquated system of multiple small services by modern wellequipped clinics - three in medicine and three in surgery to begin with. The increased efficiency of the service would be a substantial quid pro quo, but there would have to be a self-denying ordinance on the part of many of the attending physicians.'9 In these few words, Osier called for a total reorganization of the role of physicians within the Toronto General, a redefinition of the hospital itself, and the creation of a new relationship between the hospital and the university. In effect, he sought a Canadian Johns Hopkins. The medical school and hospital in Baltimore had set the new standard for clinical education, scientific research, and

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patient care; combining German and British ideas, it had consolidated the management of medical and surgical services in the hands of a few full-time paid hospital doctors who were specialists, rather than in a group of generalists who derived their income from private practice. It also encouraged medical students to be more actively engaged in the day-to-day care of patients and promoted laboratory research within the medical school hospital. The ideal to be pursued was the melding of patient care, clinical instruction, administrative plans, and the pursuit of medical knowledge, more or less under the same roof and by the same people. Other medical dignitaries visiting Toronto reinforced the need for cooperation while stressing laboratory research. In particular, W.W. Keen of Philadelphia's Jefferson Medical College and William H, Welch of Johns Hopkins - both of whom joined Osier in receiving honorary doctorates - endorsed the view that the university needed to acquire its own teaching hospital. Toronto University,' Welch pronounced, 'will not reach the height of its endeavors unless it has a hospital under university control.'10 Within only a few weeks of these ceremonies, hospital trustees were receiving demands for change from senior members of the university's Faculty of Medicine. Joseph Flavelle himself was soon engaged in cordial but pointed correspondence with the dean of medicine. His great respect for doctors and the selfless work that they undertook, and his efforts to further their goals, did not allow him to understand their inability to overcome their own self-interest to appreciate a 'problem from every side.' Writing to Dean R.A. Reeve in November 1903, Flavelle admitted: I cannot claim to be a careful student of Hospital matters. I cannot claim either general or accurate knowledge of what is being done in the Hospital world, what are the ideal conditions under which such institutions should be conducted, nor do I possess any one of the many expert qualifications which you and other gentlemen of the Faculty possess for the individual consideration of such matters. I have rather brought to the small consideration I have given to the Hospital, the common sense view of a business man, inexpert in the field in which he finds himself. Flavelle outlined his views about hospital-university relations and his frustration over criticisms coming from the medical profession:

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I thought it would be well to establish closer relations between the gentlemen who constituted the Board and the gentlemen who lent their medical and surgical services to the Hospital. I have thought, rightly or wrongly, that such association would lead to good results, would be of service in better relieving the suffering sick, better provide teaching facilities for the work of the Medical School, and perhaps be the first step in setting in force a movement which would ultimately result in the establishing of a very great Hospital with modern buildings and appliances, and administered by a Board composed of gentlemen who are qualified by experience to efficiently direct its operations. ... These views may be visionary, impossible, and mistaken, but they will indicate to you, however, that I have at least been endeavoring to consider Hospital matters on broad lines, and that I have had particular thought for Toronto University Medical Faculty having a Hospital second to none on the Continent, in direct association with their work.11 This was not the ideal of the university hospital sought by physicians. But after his election as chair of the trustees in May 1904, and his appointment in 1905 to chair the provincial commission on the reorganization of the University of Toronto, Flavelle quickly became the pivotal figure in the shaping of each institution and uniquely placed to foster the strong relations between both that he so desired. The political culture of Ontario supported change. Wishing to make the university more financially and administratively secure, James P. Whitney, who became the new Conservative premier in 1905, was prepared to direct much-needed funds to the then-fractious and beleaguered institution. Over the next few years, various interested parties actively pursued parallel studies on how best to integrate the university's medical faculty with the general hospital. By 1906, Flavelle and his fellow commissioners had submitted their own blueprint for university reform across all colleges and all faculties - including medicine, which they acknowledged as a special case, 'intricate, and not free from perplexity/ They believed none the less that this faculty should be placed on a similar footing as others and receive state support. Acting on the commission's report, the legislature passed a new university act in 1906, assigning administration of the University of Toronto to a board of governors appointed by the provincial government; executive power would reside in the university's president, who would become its chief officer. The timely resignation of the unpopular president

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prompted consideration of such possible successors as William Osier (who, it was thought, would ably represent the science and humanities constituencies of the university) and William Lyon Mackenzie King, then a high-ranking official in the federal civil service. A period of rapid growth, stability, and achievement for the University of Toronto began with the appointment of Robert Falconer in 1907.lij The process of university reorganization, together with Osier's call for reform, spurred the Faculty of Medicine to review its own affairs, especially as they related to the Toronto General Hospital. Between 1903 and 1908, a torrent of deputations, memorials, meetings, and memoranda occupied trustees and doctors. Accounts in both the medical and the public press - favourable and otherwise - intensified negotiations. At the root of all the discussions lay the issue of who should control the 'clinical material' (patients) and medical appointments to the hospital. To present the strongest case for hospital reform, members of the Faculty of Medicine undertook a fact-finding mission to New York, Boston, Philadelphia, Chicago, Montreal, and Baltimore. Afterwards, Dr J.F.W. Ross and his colleagues, with the support of the university's vice-chancellor, its president, and its dean of medicine, met with Toronto General's trustees to make preliminary requests. They sought more house appointments for the faculty so that the wards could turn more towards medical education and so that some staff members could focus on laboratory work. While specifically restricting access to charity patients to those already on staff, they wanted all patients placed under the charge of university clinical staff. They also wished to introduce a cycle of junior and senior appointments, with senior staff members retiring after six months. Finally, they hoped that a university advisory committee could be struck to guide intern staff and admit hospital patients. At this point, early in 1904, the board proceeded cautiously, agreeing only to expand the house staff by the appointment of an assistant pathologist and promising that additional meritorious final-year medical students would be considered. Not content, the faculty continued to press its case, so that by spring the board acceded to most of its requests in principle; the net result was that university doctors could exert greater influence over the hospital's day-to-day clinical affairs as well as over who was appointed to its staff. '3 While these negotiations were going on, the faculty's secretary, Dr A.B. Primrose, sent a questionnaire to twenty-one leading hospitals in Britain and twenty-four in the United States inquiring about size and details of staff, method of allotting beds to surgeons and physicians, out-

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door and pathological departments, anaesthetists and pathologists, and house staffs and registrars. The resultant Very elaborate tabulated statistical report' provides a veritable snapshot of the Edwardian hospital in Britain and the United States, although its purpose was purely informative. In the spring of 1906 Primrose submitted the report to the trustees for their review, believing that it spoke for itself. He did highlight, however, a single conclusion - that the Toronto General was overstaffed relative to its number of beds: only Chicago's Cook County Hospital, with twice as many beds available (986), had more medical practitioners proportionately, with a ratio of i66:ioi.H Meanwhile, a committee of hospital doctors also met to gather information and formulate policy on reorganization of the Toronto General. It early on recommended a prohibition on staff doctors serving on the staff of any other general hospital, a limit to age and years of service for medical staff, strict rules for charity patients so that doctors would not be deprived of fees, and formation of a medical board of senior hospital doctors to set rules and regulations 'respecting all persons, matters and things connected with the medical and nursing department of the hospital.' In a more conciliatory tone, a later series of recommendations from the committee sought the best possible treatment of patients and training of students while scientific and clinical research developed. The medical staff assured the board of its cooperation and the submersion of personal interests if the board would agree to do the following: open the positions of chiefs of services and assistants to the whole profession and consider applications for them on the basis of merit; allow physicians-in-chief to devote all their time to teaching and consultation in hospital wards; provide adequate technical and clerical support for clinical record-keeping; provide research assistance for scientific departments in the form of laboratory technicians, artists, photographers, library and journal materials, and an annual appropriation of $10,000; and give members of the general profession admission and treatment privileges to private and semi-private wards. The hospital doctors repeatedly invoked William Osier's name in support of these recommendations. They quoted his admonition from the 'Master-Word' that doctors practise a 'self-denying ordinance'; they cited his thoughts on the proper bed-to-physician ratio, physicians' visitation hours and procedures, and 'local conditions.' They canvassed prominent doctors at Montreal's McGill University and at American and British universities - Cornell, Harvard, Johns Hopkins, Michigan, Cambridge, Edinburgh, London, Oxford - about the reorganization of the

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hospital. Not surprisingly, those doctors favoured greater control by physicians over clinical matters, advancement based on merit, and provision for specialization and laboratory work. In the summer of 1906 the committee of hospital doctors submitted its final series of recommendations. Building on the requests previously circulated, this report outlined how to accommodate medical and surgical services within a new framework. In addition to three surgical services, each operated by a senior surgeon and assistants, there should be four departments for obstetrics, gynaecology, ophthalmology and otology, and laryngology and rhinology.15 Not everyone was enthusiastic about the direction of these various sets of proposals. The Canadian Practitioner and Review observed that hospital organizational matters had become very complex and hoped that the centralized Johns Hopkins model, especially if it involved importing powerful departmental heads 'from abroad,' would be avoided.16Joseph Flavelle was being portrayed, in public and medical press alike, as antagonistic to doctors. The Canada Lancet differed 'in totd from Flavelle's view that Toronto doctors were selfish or self-seeking, for it was only right that the 'medical men of Toronto should have hospital facilities at their command/17 For its part, the hospital took no official action. Regardless of Flavelle's opinion about doctors, the hospital's lack of reaction derived from a much larger set of imperatives. As Flavelle was engaged in restructuring the University of Toronto, complete with new legislation, a separate bill pertaining to the administrative structure of the Toronto General Hospital and its operation was being drafted. Until the hospital bill became law in 1906, it was neither prudent nor appropriate for trustees to approve such radical changes as university doctors desired. The repeal of previous acts and the passage of the 1906 bill transformed the hospital's executive structure. The number of trustees expanded to twenty-five, of whom five were to be appointed from the University of Toronto. As well, sections of the new act paved the way for relocation and the construction of a new hospital.l8 Internal administrative change, another hallmark of the early Flavelle years, further postponed discussions with doctors. With paternalistic nudging from Flavelle, key members of staff retired, ending a period of stability that had lasted since the last reorganization thirty years earlier. Early in the agitations for this round of reorganization, just a year after Flavelle became chair of the board, Charles O'Reilly tendered his resig-

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nation. Although he asked to leave at the end of the year, trustees made his resignation effective June 1905, with the remaining months to be taken as paid leave of absence; they also granted him a pension of $1,000 annually for the next five years. Because O'Reilly himself was virtually an institution, linked inseparably to the hospital through his many decades of service and his mentoring of a whole generation of doctors, over one hundred came from near and far to mark his retirement. They believed that he had been the 'right man in the right place'; they told stories of the old days; they noted the number of patients - over one hundred thousand - treated in the Toronto General during his time there. For his part, 'visibly affected' when they presented him with a sterling silver loving cup engraved 'And We'll Remember You O'Reilly, 1876-1905,' O'Reilly told them that he had lived only in three houses: his father's and the Hamilton and Toronto hospitals.19 The need for a new medical superintendent triggered discussion over what should be the appropriate background for the position and who would therefore be suitable. In the opinion of the Faculty of Medicine, the position should not go to a medical man. Flavelle had lunch with Johns Hopkins professor Thomas Cullen, in town for O'Reilly's banquet, who emphasized the dignity and importance of the position.20 Perhaps acting on these comments, though more probably following their own instincts, trustees Flavelle and Cawthra Mulock began to recruit William Lyon Mackenzie King. This action was extraordinary, yet wholly sensible. Grandson of William Lyon Mackenzie - newspaperman, first mayor of Toronto, Reformer turned rebel, and vocal critic of the General Hospital's administration during the 18305 - King had studied arts and law at the University of Toronto, then political economy at Chicago and Harvard. King had impressed Mulock's father and his own family's longtime acquaintance Sir William Mulock with his research and writing on sweatshop labour in Toronto. King had become Canada's first deputy minister of labour under Sir William and, after moving to Ottawa, had developed a reputation for his skill in labour relations.21 Writing to Mackenzie King on 12 July 1905, Flavelle indicated that he was 'very anxious over the appointment and very desirous of a wise decision' and, further, that he had no one else in mind. King consulted his physician-brother, 'Max' (Dougall McDougall), who thought the offer of $4,000 a year plus a house financially attractive. Still, a non-medical man doing the job 'would seem,' he wrote, 'comparable to the management of a department store.' King evidently agreed and politely declined Flavelle's offer. When Flavelle tried again to entice him to Toronto, King

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admitted that he was attracted to the 'academic side' of hospital work but considered himself 'too much of a layman' to be of adequate service; he was also fully committed to his 'serious study of the industrial problems of our day/ With this, Flavelle accepted his decision and wished him well.22 Within two years, indeed, King was planning federal legislation on dispute resolution in strikes, and he then entered federal politics. Minister of labour in Sir Wilfrid Laurier's cabinet from 1909, leader of the Liberal Party from 1919 until 1948, King served as prime minister for much of his twenty-nine years as party leader. The only person apparently considered seriously for the medical superintendent's position, King had asked his brother to keep the details of the offer secret, since it probably would not be made to another. In the meantime the board, probably because it had built in a transition period to allow time for someone of King's stature to join the hospital, had appointed a medical man to the post. This move surprised observers, not least the appointee himself, who thought that the position would go to an accountant. Yet the fact that Dr J.N.E. Brown brought to the role experience in medicine and government won praise from the medical community. A Toronto graduate and former Toronto General house surgeon, Brown had been both territorial secretary and medical officer of health in the Yukon Territory. As well, he had just returned to Toronto from a 'season of experiment and study' at Johns Hopkins - suggesting that he might have caught Cullen's eye as a possible successor to O'Reilly. Despite his initial one-year appointment, Brown would remain with the hospital throughout planning for its reorganization, until 1911.23 As with Charles O'Reilly, Flavelle smoothed the way for Agnes Snively to retire - at her twenty-fifth anniversary as lady superintendent. Those with whom she had worked marked the event. Known equally as a disciplinarian and as one of the figures who transformed Canadian nursing, Snively 'feared no man nor no set of men,' the Canadian Practitioner and Review recalled, 'and the man or men who thought otherwise for a time, and acted accordingly, almost invariably failed to win out.' Snively received a $700 annual pension, and a few years before her death the hospital provided her with rooms, where, Sir Joseph Flavelle observed, 'she had the loving care, and companionship, and attention' of the nurses. When she died in 1933, Sir Joseph acted as a pallbearer.24 It was only after the longstanding medical superintendent had retired, both the university and the hospital had received new rules of governance, and the university had appointed Robert Falconer as president

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that Flavelle was prepared to deal with the doctors and their concerns.25 Months of reflection on all sides culminated on 10 October 1907 when Flavelle, Falconer, and Mayor Emerson Coatsworth met with thirty-nine members of the medical faculty. The lengthy transcript displays the participants' mutual respect and genuine desire to cooperate, notwithstanding any difference of professional opinion.26 The central question for resolution, Flavelle noted, was the general 'method' on which to base reorganization - German or English. The German approach, which had influenced Johns Hopkins, was authoritarian and centralized power: it had a chief for each department, with junior colleagues responsible for patient care, teaching, and administration. The English method decentralized authority and was described as the 'establishment of as many services in each department as might be considered wise, with the head of each service co-equal and co-ordinate in power with his associates.' Doctors at this meeting criticized this system, owing in part to dissimilarity in application between English and Scottish hospitals. The ensuing debate dwelt mainly on the intrinsic drawbacks of the German method. Dean Reeve, for example, believed that the appointment of a 'sort of autocrat such as the physician or surgeon is in a German hospital' would not be appropriate for Toronto. Others noted that the entire educational process in Germany was different: medical students were all but expected to travel among several medical schools for their training, not just attend one as was usual in Canada, and even Johns Hopkins had modified the German approach to suit local conditions. Only Dr Alexander McPhedran spoke vigorously - and at some length - about the success of the German system, especially the resulting great strides in medical research. He described the hospital's educational role as that of an 'intermediate university'; by contrast, London's institutions following the English system were 'practical failures.' For these reasons, McPhedran adamantly maintained that each department must be under the central control of a supreme head, one who promoted continuing study among his subordinates. Despite McPhedran's defence, the German system could not survive the evening's attacks. 'I hope the Trustees will not be led away with the idea that Germans are such wonderful fellows as you have been led tonight to believe,' Dr J.F.W. Ross commented: T consider that good work is done in English countries -just as good work as is done in Germany. If you go to Germany, among the Surgeons at any rate, you will find that the work is extremely sloppy; that the work is done somewhat

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after the abattoir style in Chicago, where the patients are brought in and operated on one after the other, and where they are not treated like human beings but like so many dogs. Such a system as that would never do in this country, would never work, and we don't want to introduce it.' Ross's allusion to the abattoir surely would have made an impression on Flavelle, whose business was the meat-packing trade. The American offshoot of the German system, Johns Hopkins, then became Ross's target. What had Hopkins done? he asked. It had given Osier a magnificent position in England and had allowed other physicians to operate within a private hospital and charge 'enormous fees.' 'That is what Johns Hopkins is doing,' Ross fumed: 'It is putting those men into positions in which they remunerate themselves very, very handsomely; and then when they begin to get such handsome remunerations, the work begins to fall off, and it is deputed, left to assistants, although nominally under their headship. The assistants are greedy for fees, and greedy for the surplus that flows over from the rich man's table. (Laughter.) That is exactly what is happening in Johns Hopkins, and we don't want to establish Johns Hopkins here. (Hear, hear).' As happens with many things Canadian, the meeting saw a gathering consensus for compromise. Dr W.B. Caven reminded all present that they neither lived nor worked in Germany or England - 'it is our country, and our conditions here are entirely different from what they are abroad.' Dean Reeve suggested combining elements of the two systems to address Toronto's needs by establishing medical and surgical services operated by heads who were senior, yet who would freely consult with colleagues and trustees. Mount Sinai Hospital of New York functioned successfully in this way and thus could act as a model. Reeve's 'compromise - in the better sense of the term' (his own words) closely resembled, in intent, the final recommendations submitted to the hospital's trustees over a year earlier. In December 1907, trustees released a series of interim reports on reorganization; they prepared their final report in January 1908, and it was approved in March. Copies of the report also appeared in the medical press. The reorganization was indeed a study in compromise, with departments created for medicine, surgery, obstetrics, gynaecology, ophthalmology, and otology, rhinology, and laryngology combined. It divided medicine and surgery into three services each. The doctors appointed as heads of service were already prominent practitioners and included Caven, McPhedran, Primrose, Reeve, and Ross; each head of

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service would be responsible for associates and assistants as need required. All appointments, theoretically open to both sexes, were to be made annually; doctors appointed to the Toronto General's visiting staff could not serve on the staff of any other general hospital. Surgeons had to retire at sixty, and physicians at sixty-five. There was to be a medical advisory board consisting of the heads of services; these heads were also responsible for students' clinical instruction in all the public wards.27 The hospital's immediate implementation of this plan involved controversial decisions. The most biting criticism came from Dr George Elliott, managing editor and publisher of the Dominion Medical Monthly. Elliott was incensed over those doctors who had had their 'heads pole-axed.' He considered the actions to be 'unsavory ... [and] abominable': 'If this sort of slaughtering is to be a feature of hospital work every few years ... then it is high time reform, thorough and lasting, should be inaugurated in all hospitals which receive governmental and municipal grants ... There are a great many medical men who do not care for hospital appointments. There are others who will pull out tooth and evulse nail to get them. Is their success in life so dependent upon this disgusting wire-pulling? We trow not.' Elliott later took sole responsibility for these unsigned remarks, acknowledging criticism of his 'too strenuous' language and exonerating others on the editorial board.28 Editors of the Canada Lancet may have approved of the list of appointments, but they too were perturbed that a number of doctors with long service to the hospital were no longer to be on its staff: not only had the 'policy of pruning' gone too far, but it appeared that there had been a 'good deal of "the friend-at-court'" in the making of appointments. With his characteristic wit, W.A. Young, editor of the Canadian Journal of Medicine and Surgery, poked fun at the reorganization. Congratulating the new 'Crowned Heads where the headgear fits,' he observed that some actually had 'had greatness thrust upon them.' He wished well for the 'Bald-headed row' - senior doctors of the 'Old Brigade' who had been placed on the consultants' roll; acknowledged the passing of the 'Dead Heads' - 'over-the-age' doctors and those who simply did not make the grade; and cast the whole in verse: The arrangement of Toronto General Hospital staff Has but resulted in making some men laugh. Others have been treated in a way that is rough Don't you think that their lot is decidedly tough?

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'Now that the game is over,' Young mused, 'whether it be worth the candle or not remains to be seen.' None the less, urging everyone to wish that the hospital be 'a greater credit to our city than even in the past,' he added slyly, 'in the good old days so many love to remember.'29 The daily press had sharply criticized hospital reorganization and appointments. Young similarly counselled that 'Father Time' would 'adjust all differences.'30 Central to this media criticism had been 11 articles of May 1908 in the Evening Telegram. This series in the newspaper published by John Ross Robertson, who also chaired the board of Toronto's Hospital for Sick Children, set top hospital and university administrators against each other over the process of reorganization and the clinical appointments.31 At first the Toronto General's trustees decided to take no action over the 'mis-statements' in the press.32 Soon afterwards, W.T. White spoke out on behalf of both the hospital and the university, on whose boards he served. He stated repeatedly that all parties had been kept informed at each step of the process, and he quoted liberally from the several reports prepared by doctors themselves regarding reorganization and proposed conditions for appointment. Although it was regrettable that some doctors had been dropped, White declared that there had been no intention of slighting anybody or any institution. The only tangible result of this public exchange was a minor amendment to the 1906 hospital act which made it the responsibility of the lieutenant-governor-in-council to ratify all of the board's recommendations for hospital appointments and removals.33 This amendment did little to change the normal course of events, but it remained a conciliatory gesture. The airing of concern in both the professional and public press drove home the realization for many doctors that their medical community had split into 'haves' and 'have nots.' Specialist practitioners who held formal appointments at the University of Toronto as well as the Toronto General Hospital had become a super-elite within the fraternity. Those who held hospital appointments in the city's other hospitals occupied a lower rung; those who did not hold any hospital privileges or who disdained hospital treatment ran the risk of being pushed to the margins of the profession. Medical editorials referred to this last group as 'unattached physicians' or the 'non-hospital class.'34 Similarly, the demarcation between hospital and non-hospital doctors underscored the institution's growing role. It was the place where more people were being treated by their doctors, while it was transforming itself into a vital

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academic setting for career advancement and peer recognition. The formalized relationship between the hospital and the university bound these institutions together as never before. In the past the clinical education of doctors had been at the discretion of the hospital. In 1908, the Toronto General became, in all but name, a university hospital, in which medical education was another of its integral obligations. External encouragement of this development came from an unexpected American visitor to Toronto: Abraham Flexner. In 1908 the New York-based Carnegie Foundation had commissioned Flexner, a former school teacher, to survey all 155 medical schools in the United States and Canada to evaluate their facilities and quality of performance so that it could identify those that might benefit from philanthropic support. Flexner used the Johns Hopkins Hospital and Medical School as the model for comparison, and so well-equipped laboratories, extensive clinical facilities under the control of the medical school, and a plentiful supply of operating funds became the benchmarks. In 1909 Flexner visited Canada's seven medical schools, the majority of which he declared unsatisfactory in his report, published the next year. Western University in London, Ontario, was as bad as the worst American schools; Quebec's Laval and Nova Scotia's Halifax schools were 'feeble'; and the medical colleges in Kingston, Ontario, and in Winnipeg, Manitoba, tried hard but fell short of the mark. Only McGill University in Montreal and the University of Toronto scored excellent ratings. To Flexner's mind, Toronto's new laboratories were among the best in North America, and he also drew attention to the school's library and pathological museum. Of equal importance, the medical school had 'recently perfected a very intimate relationship' with the Toronto General Hospital, which allowed its faculty control of patients and its students access to wards, clinical laboratory, and dispensary. This evaluation indicated that Toronto was on the right track for scientific advancement. Even if the medical school and hospital had not fully embraced the Johns Hopkins ideal, many changes placed their collaborative educational endeavour in the top rank in North America. Creation in 1909 of the Joint Relations Committee, composed of hospital trustees and university faculty members, which approved all clinical appointments, made the institutional marriage seemingly irrevocable.35 Tangible outcomes of this relationship were laboratory medicine and biomedical research. Although these scientific ideals were not unknown in late-nineteenth-century Toronto, their pursuit had been rudimentary. Around the turn of the century, the method of the laboratory took

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precedence over the previous art of clinical medicine as universities and medical schools changed their orientation. As Dean Reeve explained to alumni in 1901, 'Practical Universities are the Universities of the future' - and a lab that could produce useful, practical results epitomized this view.36 A few years later Medical Superintendent Brown regretted to inform hospital trustees that, from a 'scientific standpoint,' the Toronto General had accomplished 'little of permanent character.' 'Suitable laboratory accommodation must be provided for the scientific study of medicine,' he advised; 'without efficiency here, the work of the hospital will be deprived almost entirely of scientific value.'37 The equipping of a clinical pathological laboratory was a first step.38 During its first partial year of operation in 1906 it completed almost 3,500 examinations of various excretions from patients (blood, urine, stomach contents, sputum, vomitus, faeces). All patients had urinanalyses on admission as well as before and after surgical operations. The Widal reaction for the identification of typhoid fever was performed 272 times on 156 patients; patients also had tests for the presence of bacteria causing diphtheria and tuberculosis. Successive years saw the number of microscopical, histological, and bacteriological tests rise inexorably as hospital staff came to rely on the laboratory. In 1912 the Wassermann test for syphilis was introduced and performed 242 times. In addition, there were 1,328 bacteriological examinations, 980 histological slides viewed, and over 1,500 surgical diagnoses, many of which were 'Rush' tests to determine the nature of tumours during or just prior to operation.39 Patients may not have fully appreciated the impact of laboratory medicine other than to note perhaps the discomfort or embarrassment of having to supply numerous samples of body fluids and waste. It did, however, make a difference to their clinical histories, which started to include a host of details previously unavailable. Personal and family narratives were still noted, and the results of traditional diagnostic techniques such as inspection, palpation, auscultation, and percussion still gathered, but objective data helped to characterize the patient's condition. Figures relating to a patient's red- and white-blood cell count, percentage of haemoglobin, and the amount of urea, ureates, phosphates, and chlorides in the urine all became vital elements of the clinical record.40 The narrowing of the gap between hospital bed and laboratory bench also aided physicians in forming more accurate diagnoses. Dr O.R. Mabee, the hospital's assistant pathologist, reported in 1909 that in some cases laboratory examinations alone had led to the correct diagnosis, while in many others they had provided valuable confirming evidence.41

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Another laboratory venture marked the entry of the hospital into scientific medicine. In October 1906, the noted Anglo-Irish physicianresearcher Sir Almroth E. Wright delivered to Joseph Flavelle and other trustees a very 'brief, but lucid' account of his 'inoculation' work at St Mary's Hospital in London.42 Wright would have charmed and impressed the likes of Flavelle because of his command of numerous languages, training in both literature and medicine, recent knighthood, and election as a fellow of London's prestigious Royal Society. Flavelle would probably have been most impressed with Wright's explanation of the principles and practice of his medical research, for they blended science, business, hospitals, and patient care in a unique way. As a spokesman for scientific medicine, Wright would have also underscored the importance of hospital-based laboratories for his lay audience of trustees. Wright had developed a vaccine therapy for the treatment of acute diseases by harvesting bacteria from sufferers and then subcutaneously injecting cultures of the same killed micro-organisms back into the patient. He developed a range of vaccines that were popular for several decades and formed the basis of a lucrative business. His initial small laboratory in St Mary's Hospital became self-supporting; his later, larger quarters became a vaccine factory that generated healthy profits. Because of Wright's personality and reputation for innovation, his London laboratory quickly became a mecca for young scientists, including several from Toronto.43 In the spring of 1907 the Toronto General engaged Dr George W. Ross, a Toronto graduate and former intern (1902-3) who had studied with Wright in London the previous year. In addition to a $1,000 salary, trustees supplied Ross with a suitably equipped laboratory: other than the St Mary's Hospital laboratory and another at the London Hospital, no similar undertaking was then in operation. Ross set about purchasing and housing rabbits, guinea pigs, and sheep for experimental purposes and the production of vaccines. His lab was first called the Department of Immunization and Medical Research, later Therapeutic Inoculation.'44 Unquestionably, it was the scientific centre of the hospital, reflecting its marriage with the university and research. Subscriptions to international periodicals devoted to research issues, such as the Journal of Infectious Diseases and the Journal of Experimental Medicine, together with publication of the hospital's research results in other journals and at scientific societies, began to offset J.N.E. Brown's earlier assessment that the hospital had contributed little scientifically. The constant attraction of postgraduate students, mainly from the

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United States, added to the fledgling reputation of the Toronto General as a research-oriented hospital. Fees paid by these students, revenue generated from the sale of vaccines, payment by paying patients who received vaccine therapy, and the philanthropic contributions of men such as wealthy merchant John Craig Eaton all supported the operation of the laboratory business. Year after year George Ross extolled the virtues of the treatment of bacterial diseases by therapeutic inoculation with his bacterial vaccines. Cases of acne, boils, carbuncles, and barber's itch seemingly responded well and quickly to treatment; others such as gonorrhoea and tuberculosis showed variable and ambiguous results. His research lab produced vaccines for local outpatient and hospital cases as well as for cases across the province and country. Most notable was the production of an antityphoid vaccine. Not only were nurses and medical students vaccinated - occasionally experiencing severe reactions - but the lab distributed thousands of doses across Canada to National Transcontinental Railway workers free of charge, on the condition that data concerning the effectiveness of the vaccine be recorded.45 Eventually bacterial vaccine therapy and the underlying action of opsonins - blood substances that Almroth Wright believed made bacteria more palatable for destruction by white blood cells (phagocytosis) fell into disrepute. None the less, although the research lab closed around 1913, it was a precursor to the University of Toronto's Connaught Laboratories, which began to produce antitoxins and other vaccines in 1Q14.46 During its operation, the laboratory testified to the hospital's willingness to emulate Wright's British establishment. It offered a blend of research, business, practicality, and medicine that fitted nicely with new goals of the reorganized university, medical faculty, and hospital. Ideas about mixing business methods and health matters did not circulate just between Britain and Canada; they also involved the United States. In 1907, administrators attending the annual meeting of the American Hospital Association first discussed the possible effects of shortening the regular twelve-hour day for nurses. Within a few years many nurses' training schools in the United States had adopted this plan; in California in 1912 it became a state law.47 In 1908, fifty nurses at the Toronto General Hospital signed a petition in favour of an eighthour workday. They were told that financial reasons made it impossible. Flavelle himself intervened, telling nurses that they did not understand

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what their request involved. An arrangement allowing up to two hours off within each shift placated them, and the twelve-hour shift remained intact.48 The American Hospital Association (AHA), however, soon became the authoritative voice in hospital management on both sides of the border. 'Economy of Administration and Efficiency of Organization. This is our slogan,' it proclaimed, To the newly-elected superintendent it spells success or failure.' Founded in 1899, the organization had over 450 members by the end of its first decade of operation, of whom 10 per cent were Canadian. J.N.E. Brown was its secretary from 1910 to 1913 and served on its committee on hospital progress; several Toronto General trustees became members when the annual meeting was held in Toronto in igo8.49 Discussion of administrative issues at AHA meetings reveals how other American trends affected the management of the Toronto General and how Americans viewed Canadian hospitals. At one meeting, Dr Brown indicated that he had visited the New York Hospital about 1906 to study its system of cost accounting; after he had 'borrowed' its accountant for a few days, he had implemented the method in the Toronto General. This system allowed Brown to keep track of all requisitions of food and articles on a daily and monthly basis, to eliminate duplication, and to effect savings on the bulk of hospital purchases. Brown's business efficiency (and perhaps Flavelle's influence) became clear, too, in his plan to sell waste food from the hospital to hog farmers. At another meeting, Dr R.W. Bruce Smith, inspector of hospitals and public charities for Ontario, extolled the Toronto General's inventorying methods, which used a card index system: the hospital had borrowed this accurate approach to stock-keeping and guide to expenditures from New York as well. Brown and Smith looked to American business practices and 'scientific management,' which promised savings through the elimination of wasted time, material, and human effort. The Toronto General seems to have avoided the excesses of this movement, however, which required detailed time-and-motion studies of all staff and clinical functions. Indeed, Canadians were sceptical about too much American efficiency and 'factory'-style medical practices in hospitals.50 At the same time, American hospital executives recognized that they could learn much from Toronto and the Ontario hospital system. Dr D.C. Potter, New York City's chief of charitable institutions, addressed those attending the 1908 Toronto meeting of the AHA on the advantages and problems of private and city-run hospitals. On learning how

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the Toronto General functioned - as a non-municipal hospital operating on a mix of private patients' fees and public support- he hoped that New York would some day 'have wit enough' to follow a similar path. Furthermore, he would advise others to 'go and look at the system in Toronto, and you will have the essence of a system that can be applied, and should be applied everywhere.' Dr S.S. Goldwater of New York's Mount Sinai Hospital similarly believed that Ontario's 'conservative and well-ordered system' deserved 'careful consideration'; its chief peculiarity was a moderate per-capita allowance for 'all classes1 of patients during the first ten years of a hospital's operation. These American observers found intriguing the successful blending of private philanthropy, support by the province, and contributions from the city that permitted both sick poor and patients of means to receive quality care in the same institution.51 This arrangement contrasted with the typical U.S. situation, in which municipal funds - subject to the changing imperatives of local politics - supported city hospitals for the sick poor only, while the well-to-do went to privately operated institutions.52 From this early date, Americans noted a more egalitarian spirit north of the border and, in Ontario at least, a sense of system and organization that underpinned hospital care. Moving to College and University Although Toronto had grown in all directions, adding hospitals such as the Grace, St Michael's, the Western, and the Hospital for Sick Children for different communities around the city, the General remained dominant in the early twentieth century. Year after year it cared for more people than any other hospital in the province. Superintendent Brown considered 1906-7 the busiest year ever in its history: on average, three hundred of the four hundred beds were occupied every day, and on one particular day the hospital operated at near full capacity. As usual, it also in 1906-7 treated several thousand people through numerous clinics of the outpatient department. The average stay per patient was 23.3 days, with an approximate daily cost of $1.38. As well, the hospital treated all classes of patients, for all manner of conditions. Medical registrars recorded and classified the thousands of cases. Rearranged in descending order of frequency, their records identified diseases that were infectious, nervous, genito-urinary, constitutional, alimentary, respiratory, cardiovascular, cutaneous, and blood or glandular. Surgical registrars recorded 1,541 operations for abscesses, fractures, gunshot wounds,

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amputations, hernias, and tumours. The most frequent operation was for the removal of the appendix.53 The somewhat-dilapidated state of the Gerrard Street East building complicated the task of coping with such an ever-expanding workload. Efforts to control the infestation of rats in nurses' residences and hospital wards were unsuccessful until the hospital hit on the best method: paying a night watchman a bounty (five cents) for every rat that he caught.54 It cost substantially more to correct underlying structural problems. A concrete floor needed to be poured in the basement to help combat the rat problem; in addition, electrical wiring needed updating before it caused a fire, and the leaky roof required repair, the plumbing refitting, and the telephone system updating. The elevator had become an accident waiting to happen. (Trustees even considered taking out insurance in case it caused injuries.) City officials complained about the smoke belching out of the hospital's powerhouse chimney, a problem that could be corrected only by the purchase of better-quality and hence more expensive - coal.55 Clearly, Flavelle and the staff of the hospital had to go about their business in a structure that was rapidly ageing. It would not be accurate to portray the Toronto General as a ramshackle, down-at-the-heels institution, however. Only a couple of decades earlier it had been widely viewed as a model hospital, and while it edged towards shabby gentility, it remained dynamic and respected. Operating the hospital within its budget did present challenges, as revenues declined and expenditures increased for maintenance and repair. Rent income from the many homes that the institution owned also declined; as newer residential areas sprang up around the city, these older properties became unattractive. In many cases, the hospital lost rent altogether as the city condemned its houses: they no longer conformed to public health standards because they lacked indoor plumbing and sewer connections.56 The rising deficit in hospital finances - $11,000 by 1908 - placed extra pressure on Superintendent Brown to keep costs in line. In 1906 the emergency branch downtown was closed, and the property rented to a private club. Other cost-cutting measures included the replacement of male workers in the kitchen by women, who could be hired for less, and use of women inmates of the Mercer Reformatory to wash and iron the more than 60,000 pieces of linen monthly at a rate lower than that charged by the commercial laundry.57 The strains placed on the facility on Gerrard Street East had been evident to all for some time. In the spring of 1905, Flavelle wrote to new

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Premier James Whitney that the 'man on the street, who after all represents an immense body of robust opinion in the criticism of Government acts,' would probably be impressed with a 'great Hospital Building.' To bolster his request for provincial funding, Flavelle explained that Toronto's mayor and board of control favoured the idea and would ask council to share in the costs.58 Dr R.W. Bruce Smith similarly threw his support behind a new 'great hospital' for Toronto.59 Flavelle's initial goal was to raise $1.3 million for both the hospital building and the purchase of property at College Street and University Avenue, diagonally opposite the university's new medical building, just south of the legislative buildings at Queen's Park, and beside the Hospital for Sick Children. To raise this sum, trustees sought subscriptions from philanthropists and the public, along with grants from the city, province, and university. By October 1906, just over $1.2 million had been subscribed: special grants from the province, county, city, university, and medical faculty amounted to $565,000, with the remainder coming from corporate and private donations. Toronto's wealthy Methodists responded readily: George Cox and the estate of Hart Massey each subscribed $100,000; Timothy Eaton, $50,000; and Flavelle himself, $25,000. Cawthra Mulock also pledged $100,000; Edmund Osier (elder brother of William), and many other well-to-do Torontonians, $25,000 each. Ordinary people donated, too, among them employees of Flavelle's pork-packing plant, who contributed $1 each.60 At this early stage of his campaign, Flavelle had to address some of the many obstacles that would lie ahead. He had to overcome conditions of the city grant so that he could placate non-university doctors who feared loss of income if they were denied access to private paying patients admitted to the proposed hospital.61 He also had to ensure that subscribers made good on their promises. In the case of the young multimillionaire Cawthra Mulock - the richest man in Toronto after George Cox, John Craig Eaton, and Edmund Osier - it took decades and the threat of litigation to recover funds eventually from his estate.62 While Flavelle would learn that $1.3 million fell far short of the hospital's needs, by 1906 he had amassed sufficient collateral to proceed to buy the desired property. The site was at the northern limit of St John's Ward, an area containing Toronto's worst slum. Home to eastern European immigrants and a fast-growing Jewish community, the densely populated warren of rundown houses and back streets of 'the Ward' was deemed a disgrace and a threat to public health. Neither the city's medical health office nor its other social agencies offered imaginative solu-

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tions to the plight of Ward dwellers, other than to recommend that the worst areas be torn down.63 Armed with the power to expropriate property under the 1906 hospital act, along with an arbitrator and National Trust as purchasing agent, the hospital systematically set about buying lot after lot. By the autumn of 1906, it had acquired most of several city blocks. It soon had plans in place to ensure that houses were vacated and then razed. The final step involved removing material from the outdoor privies and ploughing the ground to * disinfect' it.64 Although the stated purpose was sanitary, the ritualistic overtones are apparent. A journalist, Augustus Bridle, astutely assessed that there was a 'sort of symbolic race drama' going on in St John's Ward. In the Canadian Magazine of Politics, Science, Art and Literature, he referred to Toronto's Jews collectively as * the Jew,' noting how they were modern and progressive but dealt in dirt and 'somewhat' lived in it (an allusion to their rag and scrap-metal dealings). The Ward had a reputation for 'dirt and disease and diligent microbes,' but the hospital would be the 'enemy of all.' With a Methodist, Joseph Flavelle, as head of the hospital, 'capital and philanthropy, hand in hand,' would bring 'modern methods and daylight' to this disreputable section of the city. 'So with the Jews crowding out the Gentiles in one part of the "Ward," and the Gentiles driving out the Jews and the Italians in another, the drama of the slum as they have it in Toronto - by some old-country critics considered worse that [sic] the ghettos of Europe - is in a fair way to begin working itself out.' The clearing of this section of the Ward helped to eliminate a real public health problem; at the same time, the dislocation of so many Jewish and other immigrant families addressed latent concerns of those in better circumstances. This was a time when Flavelle himself could write in private from a ship that the 'Jew' aboard was so 'disturbingly disagreeable' that their 'complete removal' would be 'highly satisfactory.'65 The hospital itself was not openly anti-Semitic: it admitted Jewish patients and accepted funds raised by groups such as the Hebrew Ladies Aid Society and the Hebrew Ladies Sewing Circle.66 It was not, however, especially accommodating to Jewish patients or doctors. Requests by rabbis to have language translators and Kosher food it dismissed as 'impracticable ... and very inconvenient.' Toronto's third Jewish doctor, Dr Abraham Isaac Willinsky, steadfastly maintained that his rejection as an intern at Toronto General in 1908 was the result of his being a Jew.67 Two decades later, anti-Semitic issues resurfaced when the rabbi of Holy Blossom Temple, Ferdinand Isserman, charged that Toronto's general hospitals refused to employ Jewish interns and nurses. Hospital

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trustees dismissed the allegations outright, yet an unofficial policy of exclusion clearly existed. Flavelle's own correspondence reveals that a recommendation from the president of the Robert Simpson department store for one of his salesmen, a 'young medical man, of Hebrew birth,' failed to win him an internship at the hospital. As one medical editorialist mused, the issue was a 'matter of expediency for although Jewish students usually ranked high in their medical studies,' 'internes in any large hospital must walk together, room together, meet at meals practically associate together for one or more years. Effort is made by the hospital authorities to select those who by birth and training will be congenial to one another as well as to their chiefs during these months of close contact.' Such discrimination may not have been ethically justifiable, the editorial continued, but such was the way of the world in which the 'exceptional one suffers for the average many ... Old walls must fall in time; but until then expediency is often wisdom.' The old walls would remain at the Toronto General until at least the 19605, but in 1929 a crack appeared when the hospital began appointing one Jewish intern per year.68 Concurrent with land acquisition came the many stages in designing and building the new Toronto General. Trustees and doctors visited hospitals in the eastern United States and Britain to interview hospital superintendents and architects.69 Trustees also chose the Toronto-based architectural firm of Darling & Pearson to prepare plans. Frank Darling had a national reputation for designing banks and innovative commercial and public buildings. His local commissions included the Home for Incurables, the Hospital for Sick Children, the new university medical building, and Joseph Flavelle's mansion (Holwood), just north of Queen's Park. When completed, the hospital was hailed by colleagues as an exemplary structure and a credit to Canadian architecture.70 The path to this success story, however, was marked by confusion, aggravation, the threat of litigation, and unforeseen expenses.71 It was one thing to make grand claims about erecting a thoroughly modern, efficient hospital; it was another to articulate this vision into a coherent set of plans that building contractors could implement. Besides, in the intervening years since William Hay had drafted his plans for the old General in the mid-i850s, many innovations had appeared in architectural design, building technique, and medical and surgical practice. As architectural historian Annmarie Adams has indicated, in the first decades of the twentieth century the design and building of hospitals

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developed into a specialized field of study.72 Contemporaries insisted that promoters, physicians, and architects collaborate to ensure that the needs and expectations of all could be met. The mammoth 1913 book The Modern Hospital: Its Inspiration, Its Architecture, Its Equipment, Its Operation, written jointly by a physician and an architect, testified as well to the art and science of hospital planning and construction.73 Although he was one of the most experienced architects in Canada, Darling was not expert in^hospital design. Early on trustees declined the assistance of American architect Edward Stevens, who would become North America's premier hospital designer, but the contributions of Frederick C. Lee, later Stevens's partner, and J.N.E. Brown, medical superintendent, helped to correct matters.74 Much-needed money came from the estate of the Shields sisters, to put up what would be known as the Shields Emergency Hospital; from John Craig Eaton, who promised approximately $300,000 towards the building and equipping of the new surgical wing; and from the university, which agreed to construct its own pathology building on hospital grounds and underwrite its cost.75 On a bright, chilly day in April 1911, five years after fund-raising had begun, the governor general of Canada, Earl Grey, laid the cornerstone of the new Toronto General Hospital on College Street. To make sure that the new hospital might receive blessings from all quarters, Rabbi Jacobs, Bishop Sweeney, and the general superintendent of the Methodist Church of Canada were invited to the proceedings. Also present were Premier Sir James Whitney, President Falconer of the University of Toronto, the mayor of Toronto, philanthropic board members, and throngs of the public. For Falconer, the hospital provided an excellent example of the union between science and philanthropy, and it connected harmoniously with the university.76 Just days earlier, Dr J.N.E. Brown had left the employ of the hospital. His departure surprised colleagues and was a 'matter of extreme regret,' especially as it was understood that it was the result of the board's decision not to grant him a well-deserved raise. 'Vague rumors' circulated in newspapers, and medical editorialists exploited these circumstances to emphasize that medical men in public administrative positions should receive appropriate compensation. Colleagues praised Brown for his devotion to his duties twenty-four hours a day, every day of the week, with few holidays - and those usually spent attending conferences. They chastised hospital trustees for paying Brown only $3,000 per year and a 'little scrub cottage rent-free.' Those who attended Brown's retirement

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banquet at Toronto's York Club paid him even greater tribute for his superb administrative skills, tact, and diplomacy. Brown reacted graciously in thanking his fellow doctors and hospital staff but could not resist declaring that the latter were often over-worked and underpaid. Then everyone joined in the toast to the great institution of the Toronto General Hospital.77 As none of the twenty applicants, including a medical superintendent of a major New York hospital, seemed suitable as Brown's replacement, 'it naturally suggested itself [to trustees] to look round on those occupying somewhat similar positions in this city.' This introspective gaze resulted in the appointment of Dr Charles K. Clarke in May 1911. Then dean of the university's Faculty of Medicine, Clarke had been medical superintendent of several of the province's asylums, including the largest one in Toronto. His skills as an administrator were well known; so too was his relationship with William Hanna, provincial secretary and registrar general, with whom he had collaborated on health policy. With this appointment, the marriage of hospital and university was formally consummated; Clarke's training as a psychiatrist would also have an impact on the administration of hospital services during his term of office.78 As both dean of medicine and hospital superintendent, Clarke shouldered a heavy burden, but Flavelle and a building committee of other hospital trustees assumed responsibility for erection of the new hospital. By the autumn of 1911, projected costs of the new facility had increased to $2.2 million. To raise money, trustees did what their predecessors had done over fifty years earlier: they floated debentures, worth $1.5 million, to a consortium of banks.79 The actual construction seemed to present a new problem every day: suppliers did not fulfil orders, the refrigeration system had to be scrapped and replaced by more appropriate equipment, plumbing for ward areas and private rooms required expansion, a projected classroom for nurses was inadequate and needed redesign, the provision of washrooms for women staff had been overlooked, the electrical requirements for X-ray and other medical equipment had been underestimated, the arrangement of doctors' consulting rooms was not suitable, the design of ambulance sheds had not taken into account the actual height of vehicles, and a backup emergency power supply for operating rooms needed to be installed.80 Because private paying patients had become a major source of reve-

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nue, the hospital paid special attention to furnishing the separate pavilion for this class of patient. While floors in the rest of the hospital were to be covered with battleship linoleum, those in the private patients' pavilion were made of oak. Individual telephone jacks were planned for each patient room, as were marble slabs to cap central heating radiators. (The radiators themselves then had to be relocated because they interfered with the beds.) One room was to be specially insulated and refrigerated to store paying patients' flowers.81 A functional but incomplete building was ready by late spring 1913. Prior to its official opening in June, Sir William Osier toured the premises with his brother Sir Edmund. Sir William, who had urged the creation of such a hospital a decade earlier, was delighted with what he saw and believed that the new hospital could not be improved on.82 The opening ceremony on 19 June 1913 was marked by military bands, visiting dignitaries, and appropriate speeches. Premier Whitney vowed that his government would do everything reasonable to help carry on the 'great work' of the hospital and to cooperate with its trustees. Flavelle carefully explained to the gathering why the hospital's final cost of $3.5 million greatly exceeded the original estimate of $1.3 million. The costs of labour and material inevitably had risen; more important, the plan for a 4OO-bed institution had grown to 670 beds. Flavelle thanked those who shared the financial burden of the project: the Cox, Eaton, Mulock, and Shields families for their generosity and the university, province, and city for their support. Even so, the new hospital still faced a shortfall of about $800,000. Flavelle made a direct appeal to those present to help reduce this amount and was able to raise $50,000 that day. (Not until 1918, with Flavelle's personal contribution of $250,000 along with donations from his meat-packing associates and Methodist business colleagues, was this deficit finally cleared.) The opening day was filled with the promise of the future while it acknowledged the past. It coincided with the birthday of former superintendent Charles O'Reilly; he attended the ceremony, cheered on by his medical colleagues. A newspaper reporter mused over the 'story of suffering' that the walls of the old hospital could tell - how they could 'speak of the struggle of the mind for mastery over matter; of the contests waged by the white-vested disciples of Esculapius in their warfare against the inroads of the advance guard of disease.' A published history of the hospital from its inception to 1913, written by Superintendent C.K. Clarke, was available. This book also had a role for the future, for, a reviewer suggested, it 'may inspire some student to perform the work

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which will entitle the hospital to become famous in the scientific medical world.'83 The product of the years of fund-raising, design, and construction that dominated the corner of College Street and University Avenue was both impressive and practical. The replacement Toronto General was 'new, modern, absolutely,' announced W.A. Young's new journal, the Hospital World. Its capacity of 670 patients surpassed all other hospitals in Canada and the United States, as well as many in Europe. Being the most recently built hospital in North America, it incorporated all innovations possible and was ahead of those older, more established hospitals such as Berlin's Virchow Hospital, Paris's Hotel Dieu, and London's Guy's. The Toronto General Hospital was again second to none anywhere. Eleven multi-storey structures housed a pathological laboratory, emergency hospital, outpatients clinic, central administrative building with medical and surgical wings attached, private patients' pavilion, nurses' residence, obstetrics building, servants' quarters, and powerhouse; the complex immediately became a Toronto landmark. As a sizeable portion of the hospital's nine-acre site contained landscaped gardens, this downtown area had become as attractive as it was functional. Every attempt had been made to blend science and art to create a healthful locale. To think that this section was one of the overcrowded districts of the "Ward" at one time,' observed the Hospital World, 'and to look at the stately buildings and spacious gardens now is to realize what a wonderful transformation has been accomplished in the space of a couple of hard-worked years.' Equally as impressive as the hospital's imposing massive exterior was its interior. Inside, everything was as 'perfect from a medical point of view as modern science can devise.' All surfaces were smooth, no cracks or corners would harbour disease-causing germs: 'Microbes will find but a scant picking in the entire block of 9 acres.' Marble floors in lavatories, tile in the operating suites, and light green, impervious paint on walls increased the sanitary nature of the hospital. The hospital's water purification and ventilation systems, mattress-sterilizing and -fumigating plants, and garbage incinerator added to the sense of well-being, while patients diagnosed with infectious diseases were isolated in rooms in the basement of the medical wing. Of the 670 beds available, 520 were for public ward patients. A complement of 176 nurses, 200 staff members, and 26 resident doctors worked towards the care and comfort of patients. Quiet, rubber-wheeled beds, linoleum that was soft and warm to the feet, roof gardens, personal bedside tables and lamps, a silent

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nurse-call signal system, and hospital courtyards paved with wooden blocks to lessen noise - all contributed to patients' comfort. Presided over by 'the most efficient of chefs,' the kitchen contained a 'thousand up-to-the-moment things' and 'tea urns big enough to drown even a Baptist.' The facilities of the Shields Emergency Hospital enabled it to function as a hospital within a hospital. Furnished with public and private wards, a sterilizing room, an 'etherization' room, two large accident rooms, a teaching clinic, and an operating suite, it was ready to receive emergency cases twenty-four hours a day. The installation of specialized electrical lighting in the operating room - a Bartlett light consisting of a circle of eight powerful lamps that cast no shadows - permitted surgeons to work at any time of day or night. This operating room was available to any Toronto doctor who had 'won recognition in the doing of major surgery' who needed to perform a 'rush' operation. It was hoped that this service would relieve the pressure on the operating room staff of every other Toronto hospital.84 The Canada Lancet considered the new hospital a 'great enterprise'; the Canadian Journal of Medicine and Surgery called it 'a necessity, a blessing.' Provincial inspector Dr R.W. Bruce Smith termed it 'a splendid pile,' located as it was in the most central part of the city. As there was probably 'no better hospital in the world,' he encouraged people to take pride in the project. The Canadian Hospital Association was similarly effusive. At its 1913 annual meeting, held in the General's Clinic Hall, H.A. Boyce, the association's president and superintendent of the Kingston General Hospital, declared it 'one of the greatest hospital buildings of America.' The only dissenting voice was that of Conrad Thies, secretary of the British Hospital Association, who, after a visit, thought that it should have been built several miles further north on higher, less expensive ground. He also thought that passages and corridors were not adequately lit.85 In July, three ambulances began to transfer patients from the old to the new General. Soon, except for women patients in the Burnside obstetric unit, the Gerrard Street hospital was empty.86 The old buildings continued to house community services until they were demolished in 1922. At first, a group of east Toronto doctors was prepared to take them over to operate a separate hospital for residents in that area. Protestant fraternal societies and a Roman Catholic deputation expressed their support for the creation of a city-run municipal hospital on the

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property; physicians opposed this plan in fear that such a hospital would become a vote getter, a 'sweet morsel for ward politicians.' None of these proposals was accepted by the Toronto General's trustees.87 In 1913 and 1914 the trustees permitted the city to use some of the old Gerrard Street East pavilions as a detention hospital for mental and nervous patients and as a shelter for the 'casual poor.'88 For the next five years the federal Department of Militia and Defence rented the property, turning the old General into a military base hospital. Finally, in 1919 the city purchased the site, and thirty years later it built hundreds of lowcost rental houses to create Canada's first public housing development, Regent Park. Over time, as the development became a haven for thousands of recent immigrants in addition to others on low or subsidized incomes, it acquired a population profile analogous to that of 'the Ward' several generations earlier - ironically, people displaced by the new Toronto General Hospital.89 Extending the Hospital's Social Role and Services

Scarcely had the opening-day speeches faded when Joseph Flavelle cautioned Superintendent Clarke not to let his responsibility to the hospital 'drift' in favour of the medical school. The trustees, he reminded him, were the 'governing body in fact as well as theory.' Clarke retorted that Flavelle's training had been 'along lines quite foreign' to his own as a doctor and that the businessman's ways of getting results were 'quite unknown' to him. 'Finally,' Clarke asked, 'do you really believe that you and I can adjust our points of view in such a way that we can work in harmony - and in the very best interests of the hospital?'90 Once again, Flavelle had displayed his frustration with doctors, and they with him, owing to their mutually 'foreign' ways. Yet any tensions between the academic organization of the new hospital and its lay control were to be submerged for the time being in order to deal with its day-to-day operation. There were teething problems to address in addition to completing construction of several parts of the hospital. Marble was to replace glass shelving throughout; laundry equipment was unsatisfactory; elevators had yet to be installed and then proved so defective that there was almost a fatal accident; completion of the private patients' pavilion had to wait because the tile and marble contractor could not honour the original order. Apart from pointed correspondence among trustees, architects, and contractors over construction,

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trustees also dealt with problems caused by the new location. When a local resident complained about the sight of cadavers being removed from the new pathology laboratories, they ordered that bodies be transferred at night and that a hedge be planted to act as a screen. They also tried, unsuccessfully, to induce the privately owned - and quarrelsome Toronto Railway Company to slow its streetcars, which were notorious for excessive noise.91 In the midst of this activity the trustees had to choose a new superintendent of nurses. At the same meeting, trustees accepted the resignation of Robina Stewart, who had been superintendent for only a couple of years, and approved Clarke's nomination of Jean I. Gunn as her replacement. The alacrity of this action is suggestive, as was Stewart's final speech to graduating Toronto General nurses, in which she criticized the hospital for overworking nursing students. Officially, her resignation was ascribed to ill-health. Jean Gunn, a Canadian who had graduated from New York's Presbyterian Hospital nursing program in 1905, remained Toronto General's superintendent of nurses until her death in 1941. In this capacity she became an acknowledged leader in nursing education and administration both nationally and internationally.92 Flavelle and Clarke finally got their house in order by early 1914. In February they welcomed a special visitor: Field Marshal Prince Arthur, Duke of Connaught, governor general of Canada. In their speeches, board chair and governor general envisaged different roles for the Toronto General. Reflecting medical sentiment, Flavelle hoped that it would become 'one of the greatest centres on this continent for the scientific study of Medicine'; the governor general, in contrast, spoke abstractly about health and the 'great question of population': 'Canada is in need of men and women to populate her vast uncultivated areas. With her wide spaces and her splendid bracing climate, her birth rate should be high and her death rate low; there should be little wastage of population. It is to the teaching and to the work of such institutions as the Toronto General Hospital that we must look for the achievement of this aim.'93 Provincial Inspector R.W. Bruce Smith had seen hospitals in a similar light as a community mechanism for 'teaching people how to live, in order that they may keep healthy,' as he told the Canadian Hospital Association in 1907. On other occasions, Smith addressed issues that impinged on Ontario hospitals and health. He demanded that the rule for immigration be 'Quality not Quantity' to avoid having Ontario, especially Toronto, become a 'dumping ground' for an undesirable class of immigrant; he singled out the 'helpless epileptic or imbecile' as a spe-

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cial problem, for whom the cost of institutional care lay beyond provincial public charities.94 Both these leaders espoused contemporary views. Early in the twentieth century, schools introduced public health inspections and programs for pupils, baby clinics for expectant and new mothers sprang up, and advice literature became widely available. Canadian historians have examined these developments in depth and have explained how fears over 'race suicide' and 'social degeneration' began to surface as white middle-class families had fewer children while non-British immigrants procreated at higher rates -with seemingly higher likelihood of producing disabled or 'feeble minded' children. Canada was not exempt from social purity or eugenics movements, whose leaders agitated for the control and/or incarceration of mentally deficient mothers and children in their effort to advance race betterment.95 Provincially run asylums, which bore the brunt of the care and treatment of those labelled idiots, imbeciles, or morons, have received the most critical inquiry among scholars,96 but to them can be added the Toronto General Hospital. Although it might have admitted a demented patient on occasion, from its inception the Toronto General was neither intended nor designed to care for the insane. With changing attitudes and definitions of mental illness, the late-nineteenth-century medical specialist known as the 'alienist' evolved into the early-twentieth-century psychiatrist, who grounded his branch of medicine in biology, particularly the neurosciences.97 The work of Dr D. Campbell Myers in the early twentieth century in treating those suffering from epilepsy, hysteria, neurasthenia, and other 'nervous diseases' represented the hospital's first formal foray into psychiatry. With the arrival of psychiatrist-turned-superintendent C.K. Clarke, Myers was quickly ousted under the ploy that the hospital needed his quarters - the former superintendent's cottage - to house student nurses.98 Clarke redirected the psychiatric component of the hospital with the appointment of Clarence Hincks and of Ernest Jones, fresh from study in Emil Kraepelin's Munich Klinik (which specialized in biological psychiatry). Clarke also formed a department of social service. Originating in major hospitals in the eastern United States from about 1905, social service departments embodied the 'great awakening sense of social responsibility' and were designed to complete the care provided by the hospital and to aid in the patient's diagnosis and treatment. Functioning as a social agent in the community through its social workers, the

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hospital could help ensure that once patients returned to their homes treatment would continue; by this means, too, information obtained about patients' personal, social, and economic status could help determine which factors might contribute to their ill-health or slow their recovery. Within the purview of social service departments were tasks such as home visits, care of young unwed mothers, counselling of alcoholics, arranging for legal aid, assistance for the homeless and immigrants, and the placing of children in reformatories or temporary homes. As this list suggests, social workers dealt with hospital patients from the lower strata of society." The Toronto General's social service department - one of only three in the country - became one of its most important. Shaped by the likes of C.K. Clarke and Helen MacMurchy, it became a vehicle for eugenics in the country's largest city: in Clarke's words, it 'unearthed a gold mine' in Toronto's immigrant and poor working-class community. Within a few years, Clarke would air his 'frankly fascist views,' as Mariana Valverde has portrayed, in a public forum. In particular, he maintained that children of Jewish immigrants belong to 'a very neurotic race,' a certain proportion of whom were therefore 'mental defectives' who 'should be kept for several days under inspection, and the weaklings weeded out remorselessly.' Two years after she helped form this department, Helen MacMurchy resigned from the hospital's gynaecology department to become the province's assistant inspector of hospitals and charities under Dr R.W. Bruce Smith. As part of her duties, she was to pay particular attention to the custodial care of the feeble-minded. Up to this point, she had written several government reports about infant mortality in Ontario and the feeble-minded and had spoken repeatedly on these issues. MacMurchy's government appointment received applause at the time, but an unknown irony of her crusade to rid society of deviants was the fact that her amorous involvement with Marie Slopes, the advocate of birth control and eugenics, would probably have appeared aberrant to her male superiors.100 The link between the social service department and the psychiatric clinic under the control of Clarke and Clarence Hincks was explicit in the hospital's annual reports. In the 1916 report Hincks trumpeted: Toronto is aroused at last! The terrible menace of the feeble-minded has shocked the community.' Hincks noted that of about 1,500 cases examined at the Toronto General clinic, a 'large proportion' were feeble-minded; 285 were 'habitual thieves'; 201 were 'incorrigible' in school; 178 were prostitutes of the 'worst type,' suffering from venereal

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disease; 120 tried to commit murder; 59 'delighted in setting fire to buildings'; and finally, 53 were guilty of the 'most shocking immorality.' Further, over half of these 'defectives' were, according to Hincks, of foreign birth. Photographs were taken of all these cases, and their reports supplemented by home investigations. This activity resulted in an accumulation of data on the 'feeble-minded' that was used across the country to 'enlighten the people of Canada to the true state of affairs with regard to the menace of the mentally abnormal.' These hospital records also were to serve 'as so much ammunition that is being freely used to shatter the old time lethargy in properly dealing with the feeble-minded and insane.'101 The staff of the social service department, with 'helping hands outstretched in the propaganda for the social betterment of humanity,' proved invaluable to this process and this clinic. Reports of their activities indicate that they showed compassion whenever possible in trying to keep families together and to understand the plight of the people whom they aimed to help. Accounts of social workers paint a sad picture of the many hopeless situations that were to be found in Toronto during the early twentieth century. Prenatal work resulted in the saving and improving of the lives of many mothers and children; so too did workers' efforts to address family crises resulting from alcoholism, attempted suicide, and destitution caused by unemployment. Yet permeating these unquestionably beneficial acts was a tone of the moral superiority of the era and its class consciousness. Domestic visits provided a 'wonderful education' for nurse trainees to study racial characteristics. For example, the 'Italian with little conception of home comforts, used in Italy to out-door life, settling in our poorer districts, has to be told everything that is needed for a Canadian baby.' Or they could learn about the 'poorly kept Jewish home' or the 'English or Scotch home where the mother perhaps is struggling on alone, for very often at this time the worthless father is away.' Departmental reports had no compunction about relentlessly classifying unmarried mothers as insane, feebleminded, and morally incorrigible or other patients as idiots, imbeciles, morons, moral deviants, epileptics, and backward. Its workers made applications for 'disposal' of children to numerous residential homes, workhouses, asylums, and other institutions; similarly, arrangements to deport the unfit or the undesirable were readily made. In 1916 Jane Grant, head of the department, noted that with the elimination of the feeble-minded and insane from Toronto, 'social work would be a joy.'102 In the context of the times, these staff members and physicians were

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seen to be doing as much good as their colleagues in other departments; the eugenic-social service-psychiatric web, however, shifted the emphasis to the good of the larger community, often at the expense of the individual. With the departure of Hincks and other key supporters late in the First World War, the influence of the psychiatric clinic and the social service department waned. Nevertheless, Jessie D. Dunlap could still report in 1918 that during the previous seven years the department had 'progressed and developed beyond our fondest dreams.' Care and counsel continued to be given to unmarried mothers who ranged in age from twelve years and under (six cases) to over thirty. Of the 1,660 cases seen in the psychiatric department, about one-third had been sent from Juvenile Court, with the single most common reason given for treatment being theft. Of the total admitted, over half were born in Canada, England, or Scotland; the problem of social deviancy apparently was no longer due to foreigners - if indeed it ever was.103 Concern over the feeble-minded and the 'vicious circle' believed to connect immorality, crime, and social degeneracy also led to creation of the Special Treatment Clinic in 1915. Clarke established the clinic, and its function - to diagnose and treat syphilis - was as much social as it was medical. Dr G.K. Haywood, the Toronto General's assistant medical superintendent, emphasized the hospital's responsibility to tackle venereal disease. While preachers could only 'rant' about the problem and committees of 'pure-minded men and women commune together and wring their hands at the hopeless outlook before them,' hospital workers had a 'power in [their] hands second to none' to stop this 'great social evil.' Research in the hospital's psychiatric clinic concluded that prostitution, illegitimacy, feeble-mindedness, and venereal diseases such as gonorrhoea and syphilis were clearly related and that it was necessary to segregate prostitutes, who were often themselves 'defectives.' Clarke submitted such findings to federal officials to help them formulate national public health policy. As concern over venereal disease heightened during and after the war, the government allocated significant funds towards its treatment and control. Because of its early involvement in treating this disease through its special clinic, the Toronto General was a beneficiary of such funding.104 The Special Treatment Clinic tested suspected syphilitic cases using the Wassermann blood test and, depending on results, started treatments such as the administration of the drug Salvarsan, or 606. In 1918 it had requested over 3,200 Wassermann tests and administered 2,500

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intravenous treatments. Each month there were about 600 clinic visits and 50 home visits. At this time doctors claimed a 90 per cent cure rate for syphilis if it was detected in its primary stage. The clinic's association with the social service department, which kept in touch with patients, accounted in part for the success of this program. An outpatient clinic was added in 1917, dedicated to women and girls with gonorrhoea.105 The war era placed great strains on the newly opened hospital. Costs of all supplies increased, resulting in financial concerns. To increase revenue, the hospital placed newspaper and magazine advertisements to inform potential patients about the advantages of private rooms; it also approached the city for more funds, while trustees agreed to extend the hospital's bank overdraft to $100,000. The hospital's dependence on coal for all its heating and electrical power was crippling. At their peak, furnaces in the powerhouse devoured almost seven tons a day; by 1917, the hospital was paying an extra $50,000 a year for coal. At one point, both as a cost-saving measure and to ensure ready availability, the hospital stockpiled up to eight hundred tons of this precious commodity on its tennis courts.106 As physicians, nurses, and others received leaves of absence to serve in military hospitals in Britain and France, pressure increased on remaining members of hospital staff. Many people associated with the hospital died in the war. Most served in the army at its No. 4 Canadian General Hospital (University of Toronto) based in England and Greece; others such as John McCrae, author of 'In Flanders Fields' and a medical resident at the Toronto General in 1898—9, served in hospital units in France.107 A cohort of physicians-in-training also was affected. The University of Toronto's class of 1917 went through an accelerated program of study that seemed Very deficient' to one graduate, Frederick Banting. (Maybe so, but Banting would soon help discover insulin, and his classmate, Norman Bethune, would be celebrated for his work among Chinese communist revolutionaries.lo8) Joseph Flavelle himself took up quarters in Ottawa on his appointment as chair of the Imperial Munitions Board. Many of his hospital duties were assumed by Peter C. Larkin, and the two men corresponded regularly. Clarke also kept Flavelle informed about hospital activities. None the less, the impact of Flavelle's absence was palpable, for the hospital's administrative structure started to fray. In November 1916 came the resignation, but not the departure, of Dr Clarke as superintendent. Trustees accepted his resignation but agreed to his staying on nominally

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during the reorganization of the hospital's financial and administrative operations. In spring of the following year, trustees commissioned Horace L. Brittain, director of Toronto's Bureau of Municipal Research, to report on the hospital's problems and offer solutions. Brittain, a New Brunswicker, earned his doctorate in political science in 1907 from Clark University in Massachusetts. Through his work at the Bureau of Municipal Research, he was well-informed about Toronto's social problems, having written about•'the Ward,' housing, and the feeble-minded; yet he was less an ideologue and more a professional administrator. Criticism arose in medical circles about his layman's status, for the supervision of medical and nursing affairs was * pre-eminently the job for a doctor.' Ignoring such commentary, in October 1917 the board received Brittain's report and on its basis offered him the superintendency for one year. He was to reorganize the hospital on the understanding that Clarke, who was still dean of medicine, would become medical director and advise him on all clinical matters and doctors.109 At once Brittain laid off employees, accepted the resignations of others, and reorganized large departments such as dietary and housekeeping. He also effected savings through insulating parts of the hospital, switching to a cafeteria system for staff meals, and ensuring that all purchase requests went through his own office for approval. In addition, he negotiated special operating grants from both the province and the city. He revised salaries and wages of all on the staff and established pay scales for each position, so that any future changes fitted an overall plan rather than being handled piecemeal, as in the past.110 Senior nursing staff received raises in recognition of outstanding work and loyalty during these difficult years; indeed, the hospital acknowledged the entire nursing staff for tremendous effort. The nursing complement had not changed materially during the war years, despite the increase in the number of patients. By 1917, there was on average one nurse for every three patients; each nurse served on duty for at least twelve hours a day, with only forty-five minutes for break time. Students, who comprised the bulk of the nursing staff, were expected to spend their spare time studying. Because of this rigorous schedule, on any one day probably ten out of the 165 pupil-nurses were off duty because of illness. One graduate nurse wrote to Flavelle personally to complain. She told him that the Toronto General was a 'sweat shop' and that conditions in it had killed her sister, a nurse in training. Tou will say,' she anticipated, 'the conditions are due to the war, they are not. The nursing staff has never been sufficient to meet the needs of that immense hospital.' Flavelle responded respectfully but evasively.111

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Thousands of the wounded returned to Canada for treatment in both temporary military hospitals and institutions such as the Toronto General. While caring for these special patients, the hospital recognized them as 'returning heroes.' Medicine and patriotism aside, the influx of so many wounded had a practical benefit. Military authorities contracted with the Toronto General to reserve 140 beds, producing revenue that helped cover the hospital's overhead expenses: the army paid for the beds, whether or not they were occupied. The eventual cessation of this arrangement cancelled $12,000 in monthly revenue for the hospital.112 Despite these measures, a deficit of at least $90,000 was estimated for the year ending 30 September 1918. In a public circular trustees explained how food and fuel prices had gone up in leaps and bounds, as all Canadians were aware; drug prices, too, had soared, in some cases by up to 1,000 per cent. Trustees assured Torontonians that the hospital was giving them full value for money:113 It must be remembered that the guests of the Hospital are sick people, and that therefore the Hospital is not a hotel or boarding-house. Hotel costs and Hospital costs are not comparable. The Hotel does not supply nurses, drugs and medical attendance. For every sick person in a hospital there must be on the average one well person, in order that the sick may receive adequate attention. The Hospital therefore feeds and rooms [an] additional 500 well people for every 500 sick people in the hospital, besides supplying many needs peculiar to sick people. *13

Compounding these troubles, straining an already overworked staff, an influenza pandemic hit in late 1918. This disease had debilitated and killed hundreds of millions of people worldwide, leaving at least 50,000 Canadians dead. In October 1918 the board's vice-chair, Peter Larkin, reported to Flavelle that almost half of the 676 patients in the hospital were 'flu' cases. Worse, eighty nurses were ill, and three had died. 'We are taxed to the utmost,' Larkin revealed. 'We have 37 V.A.D. or S.O.S. young ladies doing what they can for us.' Flavelle appreciated the 'great pressure' on the hospital but was totally unprepared for the news of the outbreak among nurses. Horace Brittain also updated him, noting that almost the entire hospital had been turned into an isolation facility and that all surgical operations except for emergency cases had been discontinued. He told him how nurses were being taken out 'for an airing' day and night by volunteers such as Lady Eaton using her personal car; even Brittain's own 'flivver' was pressed into taxi service. T think we are doing

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everything that we can to keep up the spirits and health of those who are caring for the sick. They are certainly deserving of everything that we can do.'114 When the worst of the influenza epidemic ended and peace returned, attention turned again to the hospital's financial health. Mark Howard Irish, Flavelle's most trusted colleague on the board, stated succinctly: This year should either see the Hospital out of the hole and in good shape or we are in ill luck.' Irish identified trustees who could be counted on for their 'loyal support' but warned Flavelle that the board needed more solid trustees, not government-appointed 'ornaments,' for the hospital already had plenty of 'ornamental support.'115 Working tirelessly towards lifting the hospital out of the hole was also Horace Brittain. The implementation of his cost^savings plan was having a beneficial effect. None the less he remained troubled over the lack of systematic control in patients' accounts and other revenue-generating parts of the hospital. Brittain also cautioned trustees about the potentially high cost of medical research. A trained researcher himself, he recognized the value of extending the bounds of human knowledge, yet he indicated that such activity should be the domain of the university: Such research is not carried on so much for any particular patient or hospital as for hospitals and patients everywhere. It is manifestly impossible, even if it were right, for the Toronto General Hospital to bear the expense of such research inasmuch as the city only pays us $1.25 and the Province 30^ per day, for services which cost the Hospital $2.50 per day. There can be no reasonable doubt but that part of the present cost - and annual deficit - is due to the desire of the Board to live up to the standards of a University Hospital. The present deficits would be largely increased with the addition of further costs and it would, it seems to me, be unfair to ask the city to meet such deficits. The Provincial Government should bear the cost of research or any other costs of maintaining a University Hospital, over and above those of an ordinary public hospital.116 Attached to this cautionary note was Brittain's resignation as superintendent. Originally he had been appointed for one year on a consultative basis; after about two years of full-time hospital work he wished to return to his post in the Bureau of Municipal Research. The appointment of Chester J. Decker, Brittain's assistant at the bureau, to replace him continued the trajectory established by the hospital's first lay

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administration. Tension between professional staff and hospital administration surfaced again at this time. Flavelle, sensing that the doctors were 'getting on Decker's nerves,' counselled him to be patient with them and to remember that if any issue arising was a 'real one,' he would have the support of the board.11? A newly imposed tax for hospital supplies as well as rising costs presented other problems for Decker, although fiscal restraint and the massive injection of funds by Flavelle and his business colleagues greatly improved the hospital's financial situation by 1920. The weakening of the Canadian economy in the autumn of 1920 contributed to the hospital's financial well-being. A national unemployment rate of 12 per cent gave employers the upper hand, and hospital trustees were not slow to take advantage of it. The present situation of unemployment presents an opportunity to gradually weed out a number of employees who have not been satisfactory, but whom we have had to be content with during the past few years,' observed the board minutes for 15 December 1920. The following month, trustees reduced employees' wages by 10 per cent, except for nursing, administrative, and clerical staff.118 The financial impact of this measure was positive - so much so that Flavelle felt that the situation had stabilized enough to let him step down as chair, which he did in May 1921. It was the 'logical Ume' for a change in leadership, he maintained, for the goal of establishing the best-equipped hospital on the continent had been achieved. Fellow trustees considered the loss of Flavelle as chair to be irreparable, while recognizing that he was resolute in his decision. Flavelle's stepping down preceded his resignation the same year as chair of the Imperial Munitions Board and coincided with the prime minister's invitation to him to become chief executive officer of Canadian National Railways (which he declined). Now in his early sixties, with a public reputation somewhat tarnished from being labelled a war profiteer following a bacon-pricing scandal, Flavelle was beginning to wind down some of his many business activities. Upon Flavelle's motion, C.S. Blackwell, a former meat-packing associate, took the chair. Blackwell would successfully oversee the affairs of the Toronto General for the next decade, but he, too, occasionally became exasperated with hospital doctors. Demonstrating again the difference between medical men and businessmen, he confided to Flavelle that his self-control was often taxed to its limit by doctors' inability to 'take a broader view than their own personal interests, and to sympathetically consider the whole situation from a managerial and financial standpoint': 'If I owned the Hospital [Blackwell

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continued], I would be satisfied to stand or fall by my own opinion, but one is in a rather delicate position when he is performing a public service, and open to criticism, on which everyone is licensed to talk/ Blackwell's realization that he was as much running a business as performing a public service accurately characterized the evolving role of the twentieth-century hospital administrator.119 In the aftermath of the war there were also changes to clinical departments resulting from the hospital's connections to the university. Within days of the declaration of peace in Europe, University of Toronto president Robert Falconer informed Flavelle of a $500,000 gift from Sir John and Lady Eaton to endow a full-time professorial chair in medicine. The incumbent would oversee a consolidated and centralized department of medicine and spearhead laboratory research at the university and in the hospital: the Eaton professor would effectively become the czar of medicine in Toronto. In May 1919, after returning from military service, Duncan Graham assumed the chair; he remained for twenty-eight years. A Toronto medical graduate of 1905, Graham was widely considered too young and inexperienced for the job (he was just thirty-seven); worse still, in the eyes of an older generation of doctors, he was a 'laboratory man/ Undeterred by critics and with the support of those in power at the university and hospital, Graham's sweep through the medical faculty resulted in numerous resignations and a reassigning of academic rank for those remaining. In the decades that followed, Graham ruled over a medical empire of physicians who would become departmental heads and deans across Canada, influencing the development of medicine in the country. Radical changes similarly occurred in surgical circles, where Clarence L. Starr became chair of a consolidated department of surgery; funding for this position came from the Rockefeller Foundation. The appointments of Graham and Starr established a-power structure akin to the university medical school of late-nineteenth-century Germany and that of Johns Hopkins - ironically, the very model that those engineering the reorganization of 1906 had tried to avoid.120 It must have seemed by 1921-2 that a number of elements had finally come together: a strong university, a faculty of medicine that had recruited recognized leaders, and laboratory and hospital facilities that were second to none. All that was needed was demonstrable evidence that the effort expended, money spent, and hardship endured were

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worth it. A reviewer of C.K. Clarke's history of the Toronto General had hoped that it might inspire some student 'to perform the work which will entitle the hospital to become famous in the scientific medical world.' At the hospital's opening ceremonies, too, a trustee had remarked that all over the world people were at work in hospital laboratories seeking cures for incurable diseases; he wondered whether the Toronto General might not join them: Think for a moment of the distinction that awaits this city, this province - yes, this country - if in this hospital one of the great problems of medical science could be solved.'121 Spectacularly, the discovery of insulin in the University of Toronto and its testing at the Toronto General Hospital presented such an incontrovertible distinction. The collaboration of Frederick G. Banting, J.J.R. Macleod, J.B. Collip and Charles H. Best in the events leading to the discovery of insulin have been well described. The isolation and purification of this pancreatic secretion allowed sufferers of diabetes to regulate their carbohydrate metabolism, cheating certain and early death. Under the rebuilding of the university and its medical faculty, Toronto became home to scientists such as Macleod, an internationally recognized physiologist with an expert knowledge of diabetes; it was Macleod to whom Banting turned for assistance, laboratory space, and equipment. Banting began his research in the summer of 1921 and was soon able to produce a crude extract; by autumn of that year, Macleod thought that Banting and his assistant, Best, were indeed on to something useful. The later addition of the biochemical skills of Collip to the team was critical in the discovery of insulin early in 1922. For their contributions, the 1923 Nobel prize in physiology and medicine was awarded to both Banting and Macleod.122 Less well known are the contributions of the Toronto General Hospital to this medical breakthrough. On 2 December 1921 a weak, debilitated, fourteen-year-old boy weighing sixty-five pounds, with hair falling out and a swollen abdomen, was admitted to the medical ward of the Toronto General. Two and a half years earlier Leonard Thompson had been diagnosed as suffering from diabetes. Despite his controlled hospital diet, consisting of lean meat, vegetables, and bran cakes (the only means of treating the disease at the time), Thompson's condition worsened. In January 1922 he was thought a hopeless case, and a decision was made, with parental consent, to inject a 'thick brown muck' into his buttocks. From 11 January 1922 injections of the extract were given intermittently. The boy visibly regained his health, as laboratory tests

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confirmed; his urine sugar content was appreciably lower, and no acetone was detected. Other patients so treated with the new extract were similarly 'favourably influenced by its administration/123 The publication of these results in the Canadian Medical Association Journal, as well as a newsbreaking story by an enterprising Toronto reporter, brought the apparent cure for diabetes to both professional and public attention. Then, technical problems, medical politics, and hospital policies became inextricably entwined. Duncan Graham, chief of medicine, proceeded cautiously, staying in touch with Professor JJ.R. Macleod, the only member of the insulin discovery team with any formal accountability to the university or the hospital. In June 1Q22, hospital trustees responded to Graham's request that the Toronto General establish a diabetic clinic by forming a powerful committee consisting of chair Charles S. Blackwell, Joseph Flavelle, and two other trustees; the committee met with Graham and the hospital superintendent to work out details. Humanitarian relief aside, there were costs to consider and plans to make. The hospital made eleven rooms in the private patients' building available at a higher rate to patients, provided laboratory space and equipment, and reassigned a dietitian, several nurses, a technician, and an orderly to new duties in the clinic. Duncan Graham would direct the clinic without salary, Dr Banting was appointed to staff and granted a salary of $6,OOO per year; two other hospital staff doctors treated patients while maintaining their private practices. All professional fees collected were to go into a special account to support the clinic. By early autumn the clinic was operational and caring for eleven patients, only seven of whom were being treated with insulin because there was insufficient extract to treat all.124 Although Superintendent Decker extolled insulin as a 'wonderful discovery,' he was concerned about the costs of the clinic, which materially raised the hospital's expenses.125 Only a few years had elapsed since his former boss, Horace Brittain, had cautioned trustees that the hospital was not in a position to underwrite university research. The chair of the trustees privately raised other concerns. Blackwell related to Flavelle that the hospital had many hundred diabetic applicants waiting for the 'Banting treatment,' but limited space and an even more limited supply of insulin permitted treatment of only about thirty-five to forty patients in both public and private wards. More disturbingly, Blackwell confided his impression that physicians in the diabetic clinic 'seemed to be floundering around a good deal': 'Sometimes they hit it right - the next time it is wrong, and they don't find it out until they have given it to the patient with bad results; and my

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own judgment would be, if I had a sick friend who was not at the moment seriously ill, I would be inclined to hold back until they would get a more intelligent grasp of the treatment. I do not think there is any doubt that they are on the right track, but it will take time to develop.'126 The refinement of the pancreatic extract and its commercial production would soon lead to a ready and reliable supply of insulin. This wide distribution of the agent, in Duncan Graham's opinion, would lead to its indiscriminate use by doctors unaware of its dangers. He also emphasized to trustees the usefulness of treatment by regulation of the diets of diabetics. The hospital quickly acceded to his request to use the hospital's diabetic clinic as a training centre for physicians; trustees also authorized the hiring of a highly qualified dietitian. It was estimated that by early June 1923 insulin would be made available to physicians; thus at Banting's own request, the Toronto General closed its diabetic clinic at the end of May. Among its final contributions was a series of courses led by Banting and other hospital doctors that instructed 450 physicians in the insulin treatment of diabetes and the continued role of special diets.127 Thereafter the hospital continued to treat diabetic patients but integrated them with other medical cases throughout its wards. Care of diabetics strengthened with the hiring of Mame T. Porter, a dietitian from New York's Mount Sinai Hospital who had special training in diabetic and metabolic research. A graduate of Ohio State University, who had also studied at the University of Pennsylvania, Porter had extensive experience of dietary work in numerous major American hospitals. She immediately took over the new metabolic kitchen, which calculated and recorded the special dietary requirements of all patients and prepared meals accordingly. Funding for this special department came from John D. Rockefeller, Jr, who had donated $10,000 to the hospital, ostensibly to aid in the treatment of indigent sufferers of diabetes.128 The impact of insulin was enduring and widespread, bringing fame and glory to its discoverers. The care of diabetics soon became routine at the Toronto General, along with that of the approximately 63,000 other patients treated in its venereal disease, tuberculosis, dental, and outpatient clinics and wards in 1923.l29 The discovery of insulin nevertheless was a boost for the hospital. It provided an opportunity not to be missed to connect with the public. Following the dark times of war and the economic depression afterwards, the discovery and the glorification of Banting himself offered hope to Canadians. Heralding the boom period of the roaring twenties was the Toronto

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General Hospital's annual report for 1923. Unlike the dry compendium of statistics and financial data of previous years, this one was illustrated and less institutional in tone. Entitled For the Common Good, it delivered its message - that the hospital existed for 'Healing all manner of sickness and all manner of disease' - to a distribution list of 7,000, of whom 4,000 were 'executives.' Apart from only 840 copies sent to doctors, the remainder went out to barristers (909), manufacturers (900), clergymen (300), bank managers (300), brokers (232), and heads of Toronto's public schools.130 That approximately six of every seven copies went to the business and not the medical community reflected the orientation of hospital trustees themselves. This emphasis also constituted tacit acknowledgment of the philanthropy of businessmen, which helped build the hospital and substantially reduce its debt. Another tangible sign of relatively more prosperous times included the replacement of the unreliable pre-1914 White and Russell motor ambulances with a 1924 Cadillac model. The opening of a sixteencubicle room devoted to the care of premature babies greatly improved the hospital's service in this area and reinforced a sense of hope for the future. The tiny babies born and cared for - as small as twenty-five ounces - corroborated Ernest Hemingway's remark to fellow writers Ezra Pound, Gertrude Stein, and Alice B. Toklas that having a baby in Toronto was the 'specialite de ville.'131 And things just got better. For Superintendent Decker, 1925 was 'epochal.' Every department set new records for services provided, with the hospital itself frequently operating near full capacity. Surgery led the way by treating 41 per cent of the 12,895 inpatients; medical cases accounted for 22 per cent; obstetric cases and infants under one year also accounted for 22 per cent; and eye, ear, nose, and throat problems for 15 per cent. On average each patient's stay in hospital lasted eighteen days. As well, a total of 65,469 outpatients were seen. Over half of all people treated were Canadian-born, about one-quarter hailed from England and Scotland, and the remainder came from countries across Europe and the world. Funds for hospital operation demonstrate that private sources had completely outstripped public ones, a trend that had become evident as early as the late 18905. For every dollar of revenue, 68.4 cents came from the private patients' pavilion; indeed, a total of 78.6 per cent of all revenue came from private sources such as paying patients, fees for X-rays and laboratory tests, and endowment funds. Provincial and municipal contributions accounted for just under 22 per cent of all revenue collected, with the province providing only about

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one-third of this amount. Conversely, half of every dollar was spent on patient care, of which fourteen cents related to medical and surgical supplies. One-third of expenses went to staff wages and salaries.132 By 1927, the Toronto General was over capacity and had to turn patients away; it cancelled 'reservations' for private rooms - a measure that still did not reduce the backlog of people seeking admission.133 Postponing patients' treatment may have extended their period of illhealth, an unfortunate consequence of overcrowding. It also was bad for business. Since the hospital's inception, patients had been expected to contribute a minimum payment towards their care; the incorporation of private rooms in the Gerrard Street East hospital in the 18508 and in the College Street hospital's private pavilion - equipped with the 'conveniences of an hotel' - had formalized this initial aim. The trend of catering to private patients had become so entrenched, in Toronto and elsewhere, that it prompted commentaries about 'profiteering' and concern over the rise of the 'Hospital de Luxe.' In the eyes of some medical critics, private wards had become a necessary evil that allowed hospitals to become financially solvent and offset the costs of care in their public wards. Turning away private patients because there was no space for them was not to be encouraged; rather, it was a problem for which expansion was a solution. The plan to build a larger, freestanding private patients' hospital was reviewed by Dr S.S. Goldwater, hospital consultant and former superintendent of Mount Sinai Hospital in New York. He considered the plan good but not ideal. He did concede that the finished project, which also anticipated relocating the pathology laboratories to larger facilities on nearby university property (which became the Banting Institute), would make the Toronto General Hospital 'one of the beauty spots in the hospital world."34 Ideal plan or not, the need to expand became critical, as the hospital was accommodating about 850 patients at any time and had a waiting list for admissions of between three and five weeks.l35 Expansion was again contingent on the expropriation of property. As in the past, ethnicity played a role in the hospital's actions, for Jews owned the required land: 'practically every owner is a member of the Chosen People,' board chair Howard Irish told Flavelle, 'and, therefore, a bit "fussy" in his dealings.' Construction began on the property adjacent to the pathology building in the summer of 1928. In early October 1929 trustees decided to borrow up to $1.5 million to help defray the $3.8-million cost.13() The disastrous effects of the stock market crash only a few weeks later did not have any immediate impact, although trustees

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did admit that they did not expect to see much profit at first from the new building. Certainly, the threat of economic ruin did not dampen the spirits of the thousands of doctors, nurses, and members of the general public who, in April 1930, toured the hospital's newest addition.137 The private patients' pavilion seemed efficient, modern, up-to-date and that was how contemporaries viewed it. It was this and more, however. Not just another pile of hospital brick and mortar, the facility was a monument to the times that seemed almost too good to be true and to the hospital's bid to exploit them. Construction, the Canadian architectural and engineering journal, was enraptured by this nine-storey, T-shaped structure: passing through the cut-stone entrance with a Doric facade to the reception room, 'one instantly receives the impression of being within a private hotel of select character, and this, indeed, it is, for guest rooms are provided in this wonder building, together with inviting dining rooms for out-of-town visitors to patients and non-staff physicians and surgeons.' The sybaritic comforts did not stop there: Every unpleasant feature usually associated with hospitals has been most carefully eliminated from this building and a home-like atmosphere has been created ... A point well worthy of especial notice is the fact that in this building old-fashioned ideas as to the use of color in hospitals have been totally disregarded. The rotunda of dark panelled treatment, the operating and anaesthesia rooms of mother-of-pearl finish, the gleaming nickelled monel metal fixtures, the wood finished metal beds and furniture, the chintz-covered chairs, the colorful curtains, the Persian rugs and the artistic lighting fixtures are all components in a well thought out and skilfully executed color scheme.

Comfort and peace of mind dominated the operating rooms through the concealment of all equipment 'calculated to exercise a disturbing effect.' Other amenities in the pavilion were the florist's shop, smoking rooms, and personal radios. In addition to the private rooms containing 321 beds there was a nursery, where 'every precaution against infection and every provision for health and complete recovery known to modern science' had been made. The ninth floor housed nine separate operating suites, several sterilizing and instrument rooms, six delivery and labour rooms, and quarters for surgeons, obstetricians, and nurses. The physical connection between obstetric facilities and surgical suites highlighted the increasing medicalization of childbirth for

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the relatively well-off and its constant move to becoming a hospital procedure. Communication between nurses' control desks, operating rooms, all other parts of the hospital, and the main switchboard flowed through the 'telautograph'; this mechanical facsimile machine recorded and transmitted messages, permitting tracking of the movements and locations of patients and doctors throughout the hospital.138 Obviously more sophisticated, this equipment served the same function as the series of bells, whistles, and speaking tubes used in the Gerrard hospital during the 18905. In a similar vein, Canadian Hospital drew attention to the decorating and technological wonders of the new pavilion - the hospital's 'piece de resistance' and the 'largest and most glittering jewel ... added to this royal crown of buildings.' It also bestowed credit on the 'bold' actions of the hospital's administrators, for the 'man or organization which never attempts something new, inevitably falls behind in the race for progress.' Presumably trustees took strength from the wealth of adulatory statements coming their way as they settled into their new board room in the pavilion. At the very least, the room's sumptuous ambience - created by beige mohair drapes, blue Spanish leather chairs, walnut panelling, and soft rose and blue carpeting - must have comforted them during the dark days of the Depression to follow.139

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Between the * dirty thirties' and the postmodern 19905, the Toronto General Hospital became a middle-class institution where treatment was free for all. Along with other public hospitals, it developed dependence on insurance plans and government funding to finance its operations. Yet it found its constant source of income countered by spiralling costs in medical technology, on which doctors relied more and more. As early as 1932, the Canada Lancet and Practitioner discussed the 'mechanistic trend' in medicine, with its '"chain-store" method of treatment.' Cautioning that this tendency should not displace the 'personal touch' of the family physician, the editorial suggested that the 'weakness of the present hospital system' was already 'the multiplicity of agencies and individuals' providing medical care.1 In the post-Second World War era, this movement escalated. The 'landscape' of medicine then 'filled with machines,' as one historian has said, 'enveloped by an atmosphere of mechanical bleeps and clicks.' The rise of high-technology medicine and its location in the hospital raised concerns that patients might become alienated from those responsible for their care.2 This chapter looks at the expansion of the hospital 'workshop' at the Toronto General in the last seventy years and at the complex processes involved in sustaining that high-tech endeavour. First, however, it considers an early 'war' against disease that encapsulates many of the hopes and the problems of such a sustained campaign. The Cancer Campaign and the Creation of Princess Margaret Hospital

The Toronto General Hospital's role in the fight against cancer, which was grounded in the provincial government's decision to underwrite the

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costs of technology necessary in its treatment, illustrates this trajectory. Arguably the disease of the twentieth century, cancer has a very long history: the word itself derives from the Latin for crab - an evocative allusion to the shape, creeping motion, gripping tenacity, and flesh-eating ways of this creature.3 Cancer did not explode in epidemic form as did cholera, typhus, or influenza, yet in the early decades of the twentieth century it became regarded as a major public health concern. Two trends explain this development. First, in industrialized societies many more children survived into adulthood and lived longer as adults: gains made in public health during the nineteenth and early twentieth centuries through better housing, hygiene, nutrition, and immunization programs left an older population susceptible to other diseases. In Ontario, such improvements led to a significant reduction in deaths from diseases such as tuberculosis, diphtheria, measles, whooping cough, typhoid, and scarlet fever - a decline recognizable not just to the likes of Dr N.E. McKinnon, a University of Toronto epidemiologist and biometrician who compiled the province's mortality statistics, but also to the 'man on the street.'4 Consequently, deaths from cancer increased, while public awareness of the threat of cancer grew.5 A second trend involved the development of treatment techniques other than surgical removal. Notable among them was radiation therapy, first through X-rays in the 18908 and then through a radioactive substance, radium. The clinical application of X-rays and radium drew professional and public attention to the fact that some cancers could be controlled in relatively painless ways. As more people were encouraged to seek medical aid, they helped to swell the ranks of those diagnosed with cancer. In the late 19205, as the war on cancer geared up internationally, the campaign took place in Toronto on two fronts. The first aimed to control a deadly disease on the rise. The second centred on professional and institutional power: ought Toronto and its general hospital to be allowed to become even stronger by making them the centre of cancer care in Ontario? The issues, players, and tactics, and the hospital's place in the campaign, afford us an excellent window on the evolution of provincial health care, for they involved a future lieutenant-governor, premiers, hospital board chairs, Sir Joseph Flavelle, the University of Toronto and its president, prominent physicians and scientists, and a host of others. Ultimately, the campaign in Toronto directly affected the shape of cancer care programs across the province of Ontario. Initially, treatment by X-rays or radium did not necessarily take place

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in hospitals. In Toronto, Dr William Aikins operated a private clinic (called the Radium Institute of Toronto) from 1909 until his death in 1924.6 Following the appointment of Gordon Richards as radiologist for the Toronto General in 1917, the hospital mounted its first concerted program of radiation therapy treatment. In early 1921 Richards warned trustees that he was sending far too many patients to the United States for treatment and that the hospital had to get its own radium if it was to retain its foremost position in North America. By September the Toronto General received its first supply of 150 milligrams, distributed as 'needles' and as 'plaques' for treatment of tumours internally and externally, respectively.7 A significant obstacle to such purchases was the cost of radium. Because it came only in minute amounts from large quantities of pitchblende (an ore) then found in the Belgian Congo in Africa, radium was extremely expensive. Writing to Sir Joseph Flavelle in 1921, hospital board chair Charles Blackwell estimated that an existing special trust fund of about $20,000 might pay for about 200 milligrams. However, the 'life of radium is almost everlasting,' and he understood that a significant portion of fees charged to patients for treatment could help recoup the initial start-up costs.8 Fees from radiation therapy were generating upwards of $1,000 monthly, but the majority of those treated were non-paying public patients. Whatever the humanitarian and clinical gains achieved through this new therapy, it was never the paying proposition envisaged by some.9 The hospital always needed additional quantities, and by 1926 it had augmented its cache by another 125 milligrams costing thousands of dollars.10 By the late 1920s, the Toronto General Hospital had the largest provincial concentration of radium, the greatest clinical experience in its use in treating cancer, the best professional expertise in Gordon Richards, and the technical support of additional apparatus for X-ray radiation therapy in the radiological department. Yet facilities were makeshift as the technology and its clinical application became more sophisticated and demanding. A sense of unease that more ought to be done is apparent in the efforts of Dr Herbert A. Bruce and his colleagues. In 1928 Bruce attended a major conference on cancer in Britain. He returned to trumpet the virtues of radium while sounding the alarm that treatment in Canada lagged. Noting in the Canadian Medical Association Journal that radium treatment should be the 'handmaid' of the surgeon, he advocated a 'Cancer Hospital' for Toronto to study and treat the disease. The Ontario government announced that it would not

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purchase supplies of radium to expand cancer treatment.11 News that the government of Saskatchewan, an agrarian western province, had formed a cancer commission to investigate ways in which it might assist treatment - such as through the purchase of larger quantities of radium - added insult to injury for Toronto doctors. Duncan Graham, Eaton Professor of Medicine and Toronto General's physician-in-chief, asked trustees to take the initiative by establishing a 'Radium Institute' under the full direction of the hospital. Not only did he persuade trustees to do so, but, spurred on by Richards, they decided to buy one gram of radium costing $55,000 as well as establishing an emanation plant to produce radon (radium gas also used in radiation therapy) at an additional expense of $12,000.l2 During the summer of 1930, plans were drawn to renovate the Pathology Building to house the new Radium Institute. Though built on hospital grounds, this structure was owned by the University of Toronto, but with the imminent opening of laboratories and offices in the nearby Banting Institute, the university agreed to transfer ownership to the Toronto General.l3 All appeared to be going well. The proposed radiation facilities would place the Toronto General at the forefront of cancer care by ensuring a wider range of treatments for more patients. The official opening of the Banting Institute by Lord Moynihan, a noted English surgeon, went according to plan. As in the past, the celebration, on 16 September 1930, coincided with the conferring of honorary doctorates - on Moynihan, hospital board chair Charles S. Blackwell, and Johns Hopkins gynaecologist Thomas S. Cullen.14 Moynihan's other activities drew even tighter links between hospital and university, between past accomplishments and future hopes, for on 17 September he addressed the Canadian Club of Toronto on the topic of 'Cancer.'15 Moynihan conveyed two important messages: that control of cancer - the '"King of Terrors,"' a 'great killer,' and a 'dirty fighter' - was possible through surgery and radium treatment; and that a concentrated research program could lead to understanding of the roots of cancer and elimination of the disease. Fully aware that his illustrious audience included Howard Ferguson, premier of Ontario, and Frederick Banting, Moynihan made his pitch on behalf of medical research: 'If there is one place in the whole world where the word research should be acclaimed by the multitude, it is surely this city of Toronto. One thing which I have learned which has pleased me more than I can say is that here in Toronto your research work has enlisted not only the spiritual but the material support of the government, and, Mr. Prime Minister,... I should like to say in the name

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of humanity, we offer you our most grateful appreciation.' He extended his appeal to research beyond this implicit reference to insulin by expressing the hope that the cure for cancer might also be found in this city: Wouldn't it be wonderful if the research which will give us command of cancer were carried on at the Banting Institute in Toronto? ... It is always by the devotion of one mind to the problem, that great discoveries at last are made. As I have said already in speaking of Dr Banting, this is how dreams come true, and somebody must have a dream about the cause of cancer and then incite the research which at last will lead to the discovery of the cause of cancer. If I could have one more prayer answered it should be that the cause of cancer and its cure might be discovered in this city of Toronto. Whether because of this speech alone, or because of the speech in conjunction with other information, within one week Premier Ferguson reversed the province's position and declared that it would become involved in the campaign against cancer.16 He departed immediately for England without making his intentions clear. Toronto General trustees referred cautiously to his * alleged announcement' of a provincial cancer service, and confusion forced them to put all plans for the hospitalbased radium institute on hold.17 Ferguson then resigned to assume the post of high commissioner in London. In spring of the following year the hospital remained stymied. Urgently needed renovations to transform the Pathology Building into useful clinical space awaited announcement of the government's stance on the cancer clinic. In May 1931 letters flew between Sir Joseph Flavelle, surgeon-in-chief F.N.G. Starr, Charles Blackwell, and Mark Irish about the matter.18 Radium, Starr told Flavelle, was such a 'tricky thing' that it required handling in the 'most expert manner possible.' He doubted that the government would get involved in cancer treatment, since it had taken responsibility only for 'mental cases' previously, and he did not support such a role for government except for it to provide money to buy radium. Flavelle forwarded Starr's letter to Blackwell. In a covering note, always polite and ever perceptive, he called into question the motives of 'our friend, who was responsible for putting Wellesley Hospital on the map, [and] would like to sell out the property' - by whom he meant Dr Herbert Bruce. Having founded and run Toronto's Wellesley Hospital more or less as a private institution, Bruce, when it fell on hard

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times, had already lobbied Premier Ferguson to set it up as ^provincial centre for cancer treatment. Blackwell confirmed the presence of intrigue in the situation: there was, he replied, 'quite a history, (not on the surface)/ about the radium institute in limbo. Suggesting that some hospital doctors were 'more ambitious' than trustees to enter such a venture, he believed that it would be a 'relief if the government were to become more active in cancer care. He presented his perspective on the role of Wellesley Hospital in the controversy: 'Our mutual friend who has to do with Wellesley I think has a scheme in his mind for passing that institution over to the Government, and he apparently got the then Prime Minister sympathetic to his way of thinking, and it is more jealousy on the part of our staff that they should continue to take first place in any supposedly advanced step that might be brought about, and I think it is that same thought that prompts F.N.G. [Starr] to interest himself in talking it with you, as his relation with the Principal of Wellesley, as you know, has not been any too friendly/ Mark Irish shared Blackwell's view that powerful Toronto General doctors in particular, such as Starr, Richards, and Graham, were sitting on our tails trying to prod us on to the unknown, and, with the usual illogical attitude of the Medical Profession, failing to give any reasons for going ahead, but urging that we do go ahead somewhere, and perhaps this urging is not unnatural, even if it is unreasonable. We all recognize that in the Profession and out, we are being subjected to a criticism of inactivity, but I am frank to say that I do not know how we could behave ourselves otherwise. We seem to have to carry the odium of lethargy which has its origin, as a matter of fact, in the Legislative Buildings, and not in our Board Room at all.19

Demonstrating that he was more in touch with events between 1930 and 1931 than others, Irish offered a chronology to explain the origins of this controversy. Some time early in 1930, he recounted, trustees had achieved a 'triumph' over doctors. Rather than having physicians, surgeons, and radiologists compete over cancer cases, they had agreed to pool their knowledge to place the interests of patients first and provide the best method of treatment in each case. Following this accord, hospital representatives had met with Premier Ferguson to inform him that the Toronto General Hospital would launch a major cancer initiative. Ferguson

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had wholeheartedly supported their plan, which involved revamping the Pathology Building and purchasing a large quantity of radium and equipment for an emanation plant. But shortly afterwards, Irish told Flavelle, the premier had a 'spasm on the Dock in Quebec,' announcing, without warning, that the government would assume responsibility for cancer treatment. Toronto General trustees were left with 'arms in the air wondering where we were at.' On Blackwell's instructions, and in consultation with the provincial attorney general, Irish had then cabled Ferguson in mid-Atlantic to seek clarification. 'Our cable was a long one,' Irish explained, 'but in a couple of days we got one twice as long back' with 'the greatest collection of nouns, adjectives and verbs' that he had ever seen: Ferguson's cable was 'disgusting' and 'conveyed absolutely no meaning whatever.' When the premier returned to Canada, he had rebuffed all further communication with the hospital before resigning his position. Irish learned that Ontario's new premier, George Henry, and Dr John M. Robb, minister of health, had both been left 'quite in the dark' by Ferguson. After the hospital board chair had 'spent a full hour trying to elucidate the situation and get it into their heads,' the politicians 'then and there' decided to appoint a royal commission to investigate the treatment of cancer by radium. The creation of the commission would allow interested parties to voice arguments, convey an air of impartiality with respect to any recommendations, and permit the government to save face. Doctors wasted little time in criticizing the lay backgrounds of most of the commissioners. Only pathologist W.T. Connell of Queen's University in Kingston was a medical man; the other commissioners were a physicist, a newspaper publisher, and the chair, Canon H.J. Cody, rector of Toronto's St Paul's Anglican Church, chairman of the University of Toronto's board of governors, and up to the time of this appointment also a trustee of the Toronto General Hospital.20 (Cody had also served under Joseph Flavelle on the 1906 commission to reform the University of Toronto.) The non-technical bias of the commission made it vulnerable to the influence of Gordon Richards. Although commissioners examined radiation centres for cancer treatment across the United States and Europe and interviewed North American and European experts, their report echoed his approach: to centralize cancer care. Among its eight recommendations were items wholly in keeping with plans first promulgated at the Toronto General Hospital. These included buying a sizeable quantity of radium, building a radon emanation plant, creating cancer

Appointment to the house staff of the Toronto General Hospital was a privilege enjoyed by only a few recent medical graduates. Indicative of the calibre of these young doctors was the group, from 1890-1, which included classmates Llewellys F. Barker (standing centre) and Thomas S. Cullen (standing right). Dr Charles O'Reilly, medical superintendent from 1876 to 1905, is seated to the right.

Members of house staff had their own quarters in the hospital. As this 1898 glimpse of 'off-duty' behaviour illustrates, the manly pursuit of boxing, the consumption of beer, and the enjoyment of a good cigar contributed to 'male bonding.'

Even while 'on duty,' residents might indulge themselves to show the tender side of their masculine nature. Here members of house staff in 1904-5 pose with babies born in the Burnside Lying-in wing.

Although medicine remained an exquisitely male domain, in the twentieth century women started to breach its ranks. Dr Pearl Jane Sproule (seated left) was among the first to be appointed to the hospital's house staff; from 1924 to 1940, she was chief of the ear, nose, and throat department of Toronto's Women's College Hospital. Dr J.N.E. Brown, then medical superintendent, is seated centre.

Because of changing social and professional values, spurred on by a shortage of medical manpower during the Second World War, more women joined the Toronto General's house staff, constituting one-quarter by 1943. Dr Marjorie Davis was only the second woman to complete the University of Toronto's rigorous postgraduate program in surgery and became resident surgeon in 1943; she, too, would later be appointed to Women's College Hospital.

From its inception, nursing was considered women's work. By nature and by training, women were believed to be more nurturing and better providers of patient care. Here the Toronto General's graduating class of nurses in 1907 is addressed by Lady Superintendent Agnes Snively in the hospital's temporarily redecorated operating theatre.

During the First World War, many members of hospital staff volunteered for military service. Toronto General nurses formed their own complement to serve in hospitals in Britain, Greece, and elsewhere overseas. The temporary absence of so many men and women, along with the impact of the influenza epidemic of 1918, placed additional stress on the hospital.

The discovery of insulin, which revolutionalized the treatment of diabetes and won the Nobel Prize, increased the scientific profile of the Toronto General Hospital and its staff. The monitoring of patients' food consumption remained importantspeciahzed nurses recorded and regulated patients' dietary intake in the hospital's diabetic kitchen.

The Toronto General's nursing school quickly became the largest in the country, producing generations of nurses during the nineteenth and twentieth centuries. Training at the bedside remained a constant element from the program's inception.

Toronto General nurses march to convocation, with their alma mater in the background. Although nursing had allowed many professionally minded women to pursue rewarding careers, by the 19705 there was unrest in the ranks. A subsequent generation would discard the traditional white cap and uniform and become more activist.

The increasing sophistication of medical technology paralleled the development of the hospital. Christopher Widmer's (17801858) lancet for bloodletting (bottom), William Beaumont's (1803-1875) instrument for deep suturing (centre), and James Bovell's (1817-1880) wood and ivory monaural stethoscope (top) typified equipment used during the first half of the nineteenth century.

Third-year students in the Toronto School of Medicine pose in 1884-5 in the hospital's operating theatre with the latest technology of the era - a 'Lister' steam antiseptic carbolic acid sprayer (centre foreground). Designed to kill germs floating in the atmosphere, the equipment was in fact ineffective.

By the early twentieth century, surgical teams at the Toronto General, as elsewhere, observed aseptic precautions to limit postoperative wound infections. Surgical gowns, caps, rubber gloves, sterilized water, and easily cleanable surfaces proved more effective than earlier antiseptic technology.

At the close of the twentieth century, the operating room had become inundated by technology. Transplant and other sophisticated surgical procedures required a profusion of devices to monitor the patient's condition.

Technology affected the hospital in areas other than surgery. Ambulance service, which began in the i88os, required telephonic communication between the hospital and city police. In the 18905, the Toronto General opened this branch emergency hospital downtown to receive accident victims and ensure speedy treatment.

The replacement of the horse-drawn ambulance by motorized units began around the First World War. Later models, such as this Cadillac ambulance of the 1920s, afforded more comfortable transportation for patients. The vehicle is parked in the hospital's courtyard, which is paved with wooden blocks - originally installed to reduce noise caused by the clatter of hooves of horse-drawn ambulances.

The war on cancer, begun in 1930, was waged with radium-based radiation equipment. Later, cobalt-based therapies would supersede radium, but the principle of irradiating cancer cells remained constant.

The employment of technology for the routine treatment of kidney failure became feasible during the 19605. The Baxter-Kolff twin-coil unit shown here was the forerunner of commercially available dialysis units.

Dialysis equipment became more sophisticated and more common as demand grew. David Suzuki, science media guru and host of the television program The Nature of Things, explored the application of technology to medicine using the setting of the Toronto General Hospital.

Despite the proliferation and sophistication of medical technology, medicine remains a field permeated with uncertainty. Each patient presents unique problems requiring physicians, surgeons, and other health care workers to evaluate numerous factors in order to achieve a successful clinical outcome.

Throughout the life of the Toronto General Hospital, certain men have become so associated with the institution that they became identified with it. During the first half of the nineteenth century, it was Christopher Widmer's hospital; he was the only physician to chair the board of trustees.

During the first decades of the twentieth century, power was centralized in board chair Sir Joseph Flavelle (centre). Assisted by the likes of Sir John Craig Eaton (left), he created a fortuitous blend of capitalism and philanthropy with his dedication to hospital service and sizeable monetary contributions. Dr Charles K. Clarke (1857-1924), the only medical superintendent also to be dean of medicine at the University of Toronto, stands right.

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research laboratories, and developing a major institute for cancer treatment. Other recommendations allowed for a program of public education and the establishment of treatment centres in cities with medical schools (Kingston, London, Toronto) .21 Not surprisingly, the commission led Herbert Bruce to withdraw his offer of the Wellesley Hospital. Bruce told commissioners that 'widespread sentiment among friends of the hospital against the gift' persuaded him that the Wellesley, of which he owned a nine-tenths' share, should continue as a place for general medical care. A year later, Bruce was appointed lieutenant-governor of Ontario.22 Reaction to the Cody report was polarized. During a visit to Toronto, Johns Hopkins cancer expert Joseph Colt Bloodgood declared it 'without parallel in the world.' Ontario doctors criticized the report for favouritism to the Toronto General Hospital. The Cancer Committee of the Ontario Medical Association wished to see diagnostic and treatment centres for cancer throughout the province, not just in the three cities with medical schools. Matters reached a head in August 1932 with the announcement that the first cancer clinic would be located in the Pathology Building of the Toronto General. Immediately, a Toronto physician who used radium in private practice lashed out, condemning everything about the commission, its commissioners, and its report. His action sparked a groundswell of support for him among other doctors, which newspapers and magazines willingly promoted. A Toronto editorial surmised that medical critics were 'inspired partly by political bias, partly by professional jealousy, partly by careless reading of the commission's report, and partly by inadequate knowledge of the situation.' Given these mixed motives, the paper came out in support of the Toronto General as a sensible location for a cancer clinic.23 The Canadian Journal of Medicine and Surgery offered a balanced assessment. On the one hand, the Cody report 'gave a pretty good summary of what is generally known by intelligent and forward-looking doctors,' and its circulation might bring a better understanding of the cancer question. On the other hand, the Toronto General had 'always been a favored child of the provincial government ever since the hospital became the main centre of clinical medical teaching in the Toronto University, a provincial institution.'24 Just how much a 'favored child' is evident in a confidential letter from Cody to Flavelle. Writing at the end of October 1932, now as president of the University of Toronto and recently reappointed hospital trustee, he assured Flavelle that, despite the public criticism, things should be business as usual. 'My own feeling

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strongly is that it would be a fatal mistake for the Hospital authorities to draw back at this stage, and the Government is not cowed by the clamour from a limited number and is quite prepared to go ahead/25 Cody's advice was sound. Two weeks later Mark Irish, now chair of the Toronto General board, told Flavelle that the hospital and the government had signed an agreement. Irish was jubilant, for hospital trustees had not 'lost control of any part of your Hospital'; furthermore, although it contained a lot of 'window dressing,' the agreement had been achieved in good spirit. Minister of Health John Robb had congratulated the hospital for its cooperation, and, Irish reported almost boyishly, together they 'went out, arm in arm1: 'My attitude was not altogether hypocritical, because I was thankful in the extreme that the contentious matter had been amicably concluded without, so far as I could see, damage to your Hospital.'26 The hospital agreed to provide a properly equipped and staffed fiftybed unit for cancer patients, where they would receive the latest in radium and X-ray radiation treatment. The new Ontario Institute of Radiotherapy was to be directed by an eight-person executive committee of representatives from the government, hospital trustees, and the University of Toronto. Beds in the Institute were to be available for both public and paying patients, who would be subject to the same conditions as patients in the rest of the hospital. In return, the government was to grant $45,000 annually to the hospital and would pay for all radium and radon as well as the costs of building and operating an emanation plant. To fulfil its end of the bargain, the hospital agreed to renovate the Pathology Building (later renamed the Dunlap Building in honour of David Dunlap, who had bequeathed $250,000 to the hospital). The renovation of the Pathology Building went ahead as planned, and, under the financial agreement with the government, the hospital appeared better-off. The creation of the institute also promised greater harmony, in Irish's view, as key medical personnel agreed to work cooperatively on cancer and its treatment.27 The only tangible concession to external pressure was the government's decision to shy away from centralization by distributing radon 'seeds' to doctors across the province and to establish centres for cancer treatment in Hamilton and Ottawa; these two additional centres did not, however, receive annual government funds.28 The Dunlap Building was ready for patients by September 1933 but admitted none officially until April 1934. The hospital had refused to open the cancer unit formally until the government had honoured its

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commitment to provide the radium for Gordon Richards's 'radium bomb.'29 Irish's temper grew progressively shorter over government inefficiency. When he received word from the provincial minister of health at the end of December 1933 that the radium had just been ordered, with delivery expected some time in the next year, the board chair exploded: The space allocated to the Institute of Radio-Therapy contains all the equipment, except Radium, necessary to carry on the work, but remains closed, through your failure to provide this Radium, and will, apparently, so continue for some months to come. During these months we shall go on encountering the same torture of blasted hopes in the sufferers from Cancer that we have met since last Autumn. On the one hand, your Department has advocated, by speech and written word, the treatment of Cancer in its early stages, and yet, your Department has been responsible for the delay in doing the very thing which you urge. At the moment, the Toronto General Hospital is taking the blame for the conditions as they are: how long I shall feel that my duty as Chairman permits me to remain silent will be determined as time goes on.

After Flavelle expressed disapproval over this intemperate letter, Irish described for his 'dear Chief his personal concerns for the 'torture of blasted hopes' of cancer victims. 'I just had to do as I have done,' Irish pleaded, 'If you sat daily & heard what I hear: if you went to Ward "B" & saw a boy, a boy mind you, of sixteen slowly going out with Cancer: if you entered room 515 to a young man barely thirty in agony: if you went to places that I cared take you & if, after what you saw, you were told by [Duncan] Graham & [Gordon] Richards that these lives might be saved, or surely cured or eased if we had the "Bomb" - well I feel God will forgive me for what I wrote the man who is to blame.' Irish assured Flavelle that his actions would not hurt the hospital. Providence would assist, he wrote: 'You know, somehow, if one is sincere, one is guided in such things.'30 When Premier Henry, Dr Robb, and Lieutenant-Governor Dr Herbert Bruce gathered with others in April 1934 to inspect approvingly Ontario's largest fully equipped centre for diagnosis and treatment of cancer, Irish must have felt vindicated.31 Mark Irish's handling of the matter of the cancer clinic, and his later outbursts to Flavelle, reveal an increasingly frustrated board chair: 'That the Doctors would like something new to play with, where they have no responsibility and can leave it flat on its back any time they get tired of the game, is no new experience to me after two and a half years in my

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present job/ he confided in October 1934. 'I will not take second place in my respect for ... Doctors, but consultation with them ... gives me the jitters.'32 Just over a year later Irish retired. On nomination by Sir Joseph Flavelle, E.G. Fox - yet another of Flavelle's former meat-packing associates - succeeded him. Irish's farewell report shows that he had lost none of his fire. Although the Depression was taking its toll on the hospital, producing the 'largest, uncontrollable deficit' in a decade, the calibre and loyalty of administrative and nursing staff had ensured that the institution was sound. Not wishing to engage in 'captious criticism' of the medical staff, Irish none the less opined that occasionally doctors' lights 'burned dimly.' He urged those with appointments not to turn the Toronto General into a 'Closed Hospital,' reminding them that income generated by non-university doctors from private paying patients helped to support the teaching function in the public wards. Finally, he regretted the insufficient support given to the cancer clinic - an 'infant left on [his] doorstep' that he would have 'gladly refused to adopt.' Even though the cost of cancer treatment was the largest per-patient expense in the hospital, and despite satisfactory results, the province and city refused to increase funding for the institute.33 Irish's criticism of the government was not just a new variation on an old lament, for its much-publicized 'War Against Cancer' surpassed anything that it had done about diseases in the past. In his view, the province was exacerbating the problem while not assuming financial responsibility for its solution. Department of Health pamphlets - such as What Everyone Should Know about Cancer, Cancer of the Mouth, The Doctor and the Cancer Patient, and The Prevention of Cancer - circulated in the hundreds of thousands, urging Ontarians to overcome the stigma surrounding the disease, to see their family doctor, and to seek treatment from qualified cancer specialists. As well, the province produced two motion pictures about the origin of cancer and its treatment with radium and X-rays and engaged a travelling lecturer for service clubs and women's organizations.34 Another publication, Ontario's Programme for Cancer Control, identified cancer clinics in Hamilton, Kingston, London, and Ottawa, while showcasing the facilities of the Toronto General. Photograph after photograph in it illustrated the advanced scientific equipment used in modern radiation treatment and the facilities in the Dunlap Building in particular - the deep therapy unit, the radium bomb, and the four and a half tons of lead used to shield treatment rooms. This pamphlet also

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explained that the radiotherapy institutes were obligated to admit all bona fide residents of Ontario; while each hospital had only limited accommodation for cancer patients, and 'inoperable or far advanced' cases were not to be 'indiscriminately referred to them/ it implied that Ontarians had a right to be treated.35 Far from creating 'cancerophobia,' as some had feared, the government's program of public education induced many more people to seek earlier diagnosis and treatment. The net effect was to increase the pressure on services in the already-underfunded institute. Some relief came by way of reduced costs of radium. Eldorado Gold Mines, in Great Bear Lake near the Arctic Circle, mined and shipped enough pitchblende to Port Hope, Ontario, for refining that the price of a milligram of radium fell from $54 in 1932 to $30 in 1936. Not only did this development remove the need for expensive Belgian product, but the use of domestically produced radium initiated a new Canadian industry. In 1935, the provincial Department of Health purchased 3.5 grams for $150,000 for installation in the Toronto General's radium bomb to replace the Belgian radium, rented for $12,000 per year.36 Public education, radiation treatment, and cheaper radium still could not control cancer. Between 1926 and 1935, deaths in Ontario caused by cancer rose from just under 9 per cent to almost 12 per cent of all deaths occurring in the province. Of the 4,214 deaths attributed to cancer in 1935, the largest category (43 per cent) involved malignant tumours of the stomach and digestive tract; about one-quarter, breast, uterine, and related cancers among women; and the remaining onethird, lung, skin, mouth, throat, brain, and bone and joint cancers. As with other diseases, so in cancer, the Toronto General treated the largest number of cases in the province. In 1936, for example, there were 3,638 new cases of malignant and non-malignant disease treated in Ontario's cancer clinics, of which 44 per cent received care at the Toronto General Hospital. A similar pattern existed for hospitalized patients. Of the 716 public cancer patients hospitalized across Ontario in this year, 586 were admitted to the cancer unit of the Toronto General for a total of 16,183 days' stay. The average stay in Toronto of 27.6 days was one day less than the provincial average of 28.8 days.37 As director of the Ontario Institute of Radiotherapy at the Toronto General, Gordon Richards led the hospital's efforts at cancer control. His reports convey additional quantitative perspectives. Of the 942 people admitted during the institution's first year of operation, cancers of the skin made up the single largest category (24 per cent), followed by

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breast cancer and oral cancer (lip, tongue, mouth, and tonsils), at 20 per cent each. Next came cancers of the female organs (15 per cent). This relative distribution remained constant up to 1939, as did the annual intake of about one thousand patients. In the decades following the war, the number of patients admitted annually for treatment doubled, with skin, breast, cervical, and related cancers continuing to predominate. A gradual decline in oral cancers was offset by an increase in cancers of the lung and stomach.38 Treatment offered in hospital for these various forms of cancers involved deep X-ray therapy, radium, surgery, or a combination of all three.39 The choice of treatment varied with the type and severity of the tumour; or it might apparently depend on the class of the patient. In his report for 1939, Richards distinguished between private paying and public indigent patients, identifying the method of treatment for each group: there were 975 new cases of malignant disease, split evenly between private and public patients (488 and 487, respectively). Although data are for one year only and many clinical factors are unknown, paying patients seem to have received more expensive and more efficacious radium treatment. Patients treated with radium greatly outnumbered public patients (227 and 134 respectively), but almost twice as many public patients received X-rays as private patients (130 and 73). The number of private and public patients treated with a combination of surgery and X-ray was roughly the same (107 and 103, respectively). The remaining patients either received no treatment or some combination of all modes. That only 25 private paying patients died out of the 488 of that group admitted, compared with 35 deaths for an equal number of public patients, tends to support the impression that health was related to wealth.40 Richards's reports also show that cancer treatment was inexact, complicated, and unpredictable. 'Very few branches of the practise of medicine are as filled with the disappointments of failure or the thrills which come from witnessing the apparently impossible succeed,' he wrote in 1934. Seven years later he cautioned trustees to look at the radiotherapy institute as an 'experiment organised as a testing-ground or demonstration,' which had developed a better understanding of how to evaluate dosages of radium. Useful as this information was, he admitted that there had been no real research on cancer and that a lack of centralization and coordination had hindered efforts to control the disease.41 Recognizing that the 'war against cancer' was hampered by the sorts

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of problems that Richards identified, the government of Ontario announced in 1943 that it would fund a hospital and clinical research institute devoted to the investigation and treatment of cancer. That year, to facilitate this project, it set up the Ontario Cancer Treatment and Research Foundation (OCTRF), but it would take a decade and a half before the research institute/hospital materialized. In the meantime Gordon Richards, along with a new generation of colleagues such as Drs Vera Peters and Clifford Ash, continued the assault on cancer in the Toronto General's Dunlap Building.42 The first real step to building the new facility came in 1952 with the formation of the Ontario Cancer Institute (OCI). Funded by the province and operated by representatives of the OCTRF, the University of Toronto, and Toronto's teaching hospitals, the OCI was in effect an offshoot of the Toronto General's radiotherapy institute. Although Richards had died three years earlier, it was his original vision of a centralized organization that guided the OCI; it was also his junior colleagues whom he had trained that would steer it. Another link to past debates over cancer care in Ontario would be the institute's location, adjacent to the rebuilt Wellesley Hospital in midtown Toronto. The Wellesley had amalgamated with the Toronto General in 1948 because of its significant debts and operated until 1959 as its Wellesley Division.43 With the opening in 1958 of the OCI and its hospital quarters named the Princess Margaret Hospital - an independent institution dedicated to research, treatment, and care of cancer patients finally went into action. Director Clifford Ash oversaw the transfer of key Toronto General staff members and over 50,000 patient charts from the former Ontario Institute of Radiotherapy in the Dunlap Building to the new site across town. The twenty remaining patients were also relocated to the new hospital. Leaving the Dunlap Building, built in 1913 and home to radiotherapy since the 19308, elicited mixed emotions. Recently arrived from Scotland as an Ash recruit, head of radiation oncology Walter 'Bill' Rider thought the old place 'a dump of the first order.' The sentiments of those with greater loyalty to the Toronto General site were captured in a poem dedicated to the people who had 'fought under the command' of the Dunlap from 1933 to 1957: THE FINAL HOUR The old Dunlap Building is at the end of the Race It has served its Purpose with Dignity and Grace

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But Time moves on and she can't keep the Pace. For Doctors and Nurses need extra space. Its Darkroom, its Treatment rooms, consulting rooms, halls, All are enclosed in these plaster cracked walls. And try as we would we couldn't repair; Like some of its patients, it's too old to care.

It's taught Doctors, Nurses, Technicians and All But the Time has now come when the Walls must Fall; When the moment comes we will feel depressed Recalling the moments we all loved Best.

When the Final Day comes in this Fateful Year There will be speeches and shouting and a little good cheer; A Toast will be given and the staff will all Sip And feel just like rats deserting the SHIP.

The pathology/Dunlap building was demolished to make way for a new hospital wing named after board chair Norman C. Urquhart.44 With its eighty-seven beds for cancer patients, its research laboratories, its full complement of research scientists and clinicians, and its affiliation with the University of Toronto, the Princess Margaret Hospital, near Wellesley and Sherbourne Streets, was, from its opening in 1958, the province's showpiece for cancer care. The tradition of radiotherapy continued through super high-voltage X-ray machines and the maintenance of radium treatment. But the hospital also housed a new generation of technology. The onset of the nuclear age, and the development of radioactive isotopes for medical use, introduced more powerful radiation techniques using cesium and cobalt-6o units. The contributions of great scientific minds such as physicist Harold Johns, co-inventor of the 'cobalt bomb' whom Ash had also recruited to Toronto, quickly propelled the Princess Margaret to world leadership in cancer therapy.45 For the next forty years the Ontario Cancer Institute, incorporating the Princess Margaret, operated as an autonomous institution. Despite this leadership role, the hospital's twenty-fifth anniversary celebration in 1983 showed how the war on cancer still had not been won. Doctors saw

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about seven thousand new cases of malignant disease in that year. Breast cancer still remained the most frequently diagnosed type. The number of radiation treatments continued to grow - 86,000 at this one site alone in 1983. The overall cancer picture was gloomy, yet the situation for some specific cancers was improving. The work of Vera Peters on Hodgkin's disease markedly improved the survival rates of patients suffering from this cancer of the lymphatic system. Peters joined the medical staff of the Toronto General in 1937 and later moved to the Princess Margaret Hospital, where she remained until 1976.46 The Princess Margaret Hospital would become the largest radiation facility in North America, but, as we see below, changing economic imperatives returned it to the administrative orbit of Toronto's general hospital with their amalgamation in the 19905. Hospital Workshop: Forging New Technologies and New Staff Relations

More powerful or efficient equipment replaced the old as doctors in the 19308 increasingly relied on technology. Gordon Richards asked the hospital board year after year for more powerful X-ray equipment, and chair E.G. Fox acknowledged that provision for obsolescence of medical technology had become as 'necessary a charge' as wages, food, or heat.47 The adoption of new technology increased hospital costs. Beginning in the 19305, oxygen tents were used in severe cases of pneumonia, and the artificial respirator - the 'iron lung' - made its appearance for treatment of infantile paralysis, or poliomyelitis (polio). The 'iron lung' - a pressurized body-length metal cabinet - helped the patient to breathe after polio had paralysed the nerves governing lung function. In 1937, during a widespread outbreak of polio, the Toronto General had eight adults in 'iron lungs' in a special polio unit in the Shields Emergency building. On occasion, it used the artificial lungs for acute lifethreatening situations - as when a drug addict was revived following an overdose of morphine.48 The impact of technology on the Toronto General was greater than either its clinical utility or its cost. Fox knew that the hospital was for 'sick folk,' yet he also saw it as a 'manufacturing plant the raw product of which is of defective specification. The ideal objective is to turn out a perfectly manufactured article.' The diffusion of technology in the hospital in this way invited comparison with other mechanized workplaces: as with an industrial plant, progress in the hospital could be achieved by applying technology to research. Thanks to cooperation with the uni-

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versity, Fox could cite innovations in brain surgery, cancer treatment, and pharmaceuticals to illustrate the fact that a great hospital came not from more beds but from 'intelligent' research and development.49 Superintendent Chester J. Decker similarly noted the trend of developing 'apparatus in our own workshops.'50 From the 19305 to the 19605, the Toronto General's doctors and university scientists pursued research relating to circulatory diseases and cardiovascular surgery. A technique to isolate and purify the blood anti-coagulant known as heparin was developed in the 19308 by insulin co-discoverer Charles Best and his team at the University of Toronto, leading to a stream of surgical innovations.51 Gordon Murray, a surgeon, used it in a pioneering effort to reduce the incidence of dangerous blood clots in patients who had undergone surgery. Between 1935 and 1941 he successfully treated about 700 patients. In 1946 Murray was also one of the first in North America to use an artificial kidney machine, using his own construction of the equipment.52 For patients with kidney failure, this device removed their blood, purified it, and returned it to the body (a process known as dialysis). The first use of dialysis in the Toronto General was on a twenty-sixyear-old woman in a coma whose kidneys had failed because of a severe infection brought about after an abortion. Murray and other senior physicians agreed that, as the woman's death was imminent, the artificial kidney might be used as a last-ditch effort to save her. For the next few days the woman passed in and out of consciousness as the impurities in her blood were gradually removed. Within a month she had fully recovered and was discharged from hospital. As we see from the recollection of a senior medical student of Murray's, Raymond Heimbecker, the equipment was both experimental and makeshift: 'The blood pump had to be kept going at all costs! Spare fuses, spare extension cords, all had to be ready at a moment's notice! Blood-clotting times had to be determined every hour at the bedside to monitor levels of heparin ... Blood samples had to go to the chemistry lab every hour to check the level of kidney poisoning! While doing all of this, I still had to be constantly on guard to treat those convulsions.'53 As a cardiovascular surgeon at the hospital, Heimbecker would later make medical history by performing the first successful heart-valve transplant. In consultation with Murray, he conducted a preliminary series of operations on animals to refine the surgical technique. In November 1955, they decided to undertake the experimental heart surgery on a twenty-five-year-old man suffering from a heart condition

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caused by a leaking aortic valve. The replacement valve would come from a patient who had died. To avoid publicity, the booking for the operating room noted only a routine heart procedure. Excitement was at a high pitch among the surgical team, however, and the viewing gallery filled with spectators as word circulated about the actual nature of the operation. 'Dissection of the aorta as it left the heart was considered new and dangerous,' Heimbecker recalled. Forty minutes after clamping and dividing the aorta, transplanting a new valve, and gradually releasing the clamps, 'our excited fingers could feel the vigorous throb as the fragile [valve] leaflets closed and opened with each contraction. As I placed my hand on the heart muscle, it too had dramatically changed to a much quieter and more peaceful contraction.' The operation was a success, allowing the patient to live another 20 years before undergoing additional surgery that fully corrected his condition.54 Another pioneer clinician/researcher at the Toronto General was William G. Bigelow. The son of a prairie doctor, Bigelow graduated in medicine from the University of Toronto in 1938 before taking postgraduate training with the eminent Johns Hopkins heart surgeon Alfred Blalock. Two of Bigelow's contributions to heart surgery captured the spirit of his era: the use of hypothermia in open-heart surgery and the development of the pacemaker. It was generally understood that heart surgery could never advance until the organ could be opened up and operated on without the blood circulating through it. One approach to the problem in the 19408 was the 'heart-lung' machine, which allowed the blood to bypass the heart, but it remained a cumbersome and experimental piece of equipment. Bigelow decided instead to lower the temperature of the patient's body to such an extent that blood circulation would be interrupted, giving the surgeon time to operate.55 Total body cooling, or hypothermia, had previously been tried both in Philadelphia and in the Toronto General as a method to control cancer pain, but Bigelow's interest grew from his knowledge of frostbite.56 He began to study the effects of lowering the body temperature of animals in 1947. It was not until 1952 that he had gained a reasonable knowledge of the effects of hypothermia on the body. It had been possible to lower the temperature of a dozen monkeys below half of that for normal human body temperature (that is, to i8°C) and to open their hearts for twenty minutes without any deaths. The technique was then applied to adults undergoing heart surgery at the Toronto General. From 1953 to 1960, fifty 'deep-freeze operations' were performed on patients whose temperature was lowered to around 28°C by blankets

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equipped with cold-water cooling coils. Of those whose surgery was elective and whose condition was not immediately life-threatening (fortytwo), the mortality rate was a 'low' 2.4 per cent; of the eight patients classified as 'terminal' because of advanced heart disease, there was a 50 per cent mortality rate. Surgeons across North America and in Britain employed controlled hypothermia in surgery throughout the 19508 and 19605 until it gave way to more reliable and efficient methods of blood oxygenation outside the body (the heart-lung machine). The main drawback of surgical hypothermia was that the actual time available for the operation was unpredictable, ranging from ten minutes to one hour, depending on the condition of the patient.57 An important and lasting technological offshoot of Bigelow's research on hypothermia was the artificial cardiac pacemaker. The term 'pacemaker' had been coined by Dr A.S. Hyman of New York in 1932 to describe an electrical device that he had built to alter the heart rate of animals. Hyman never developed his apparatus or applied it systematically to humans. Bigelow and his colleagues resurrected the concept after puzzling over why the hearts of some research animals stopped in hypothermic states. They concluded that a short and repeated electrical stimulus of a particular type could simulate the natural impulse controlling heart action. With the assistance of an electrical engineer from the National Research Council laboratories in Ottawa, they built a pacemaker the size of a cabinet radio. This device enabled them to vary a dog's heartbeat from its normal rate of 120 beats per minute to a low of 60 and a high of 200. The report of the group's results to the meeting of the American College of Surgeons in October 1950 was well received. Although the pacemaker had not been tried on humans, the New York Times announced how doctors might be able to 'Start Stopped Hearts by Toronto Machine.' The concept and basic technology of the Toronto pacemaker would endure, although the optimism about its clinical application was premature. Not until the advent about 1960 of the transistor, which miniaturized electrical circuitry, could pacemakers be made small enough to be implanted in the patient's body.58 The inventiveness displayed by these doctors in their workshops laid the foundation for subsequent generations of research at the Toronto General. The pursuit of research would become a recognized function in the hospital as much as patient care and teaching. The value of research lay in information obtained that pushed the boundaries of medicine in new directions; research undertaken also became a mea-

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sure of institutional prestige and professional worth. The total value of research funding received in the hospital and the size of awards obtained by individual doctors and researchers would be among the new parameters of 'doing good' in the highly competitive world of peerreviewed research grants. 'Today's research is tomorrow's practice' would become a credo of the hospital as it strived to be the 'finest hospital-based research institute in the world.'59 Medical innovation driven by research, coupled with the traditional roles of patient care and medical education, transformed how hospitals came to be conceptualized. By the 19608 it was evident that they had become doctors' workshops par excellence. So much so that large North American hospitals often were referred to as 'health factories' - a phrase that resonated with board chair E.G. Fox's comments a generation earlier.60 In Toronto, medical researchers and physicians had become scattered in various buildings outside the Toronto General: in the Banting Institute across the road on College Street, in offices located in the Medical Arts Building on Bloor Street, and in the university's nearby medical school. Recognizing the need to centralize work in the hospital itself, trustees, doctors, nurses, and a team of planners set about preparing a blueprint for the future. After seven years of extensive consultation and debate, a planning study appeared in 1968 that outlined the desired shape of the Toronto General Hospital. In it, planners amassed an encyclopaedic profile of the hospital's activities in eight volumes. Predictable aspects of the plan included phasing out of patient care in the College wing, which was too old to be of use, and expanding the capacity of the hospital beyond its 1,243 beds.61 The philosophy behind the change tapped into prevailing notions of team work and an integrated approach to work. 'No longer can one hospital, one medical school, one doctor or one nurse work in splendid isolation and produce the standard of care required by society,' stated Dr J. Douglas Wallace, the hospital's 'executive director' (replacing 'medical superintendent'); unlike the 'cottage industry' of medical care in the past, in the new approach the Toronto General would become a major cog in an organized system of health care: 'The health service delivery systems of the future will be based on the efficient organization of teams of professional and technological personnel working in the community general hospital. Our concept of a complete Medical Centre at the Toronto General is based on that belief At the same time, the Toronto General would continue to assist other teaching hospitals in

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the 'System,' in particular by maintaining its 'eminent position in order that we may always provide others with the incentive to do something better.'62 Institutional hubris aside, the aims in the 1968 plan were sensible; their implementation would go a long way to consolidate the fragmented clinical, teaching, and medical research community in Toronto. Wallace was excited by it all. In his opinion, if all or most of the proposals could be accomplished, the Toronto General would become one of the world's greatest medical centres.63 The plan was sound, but its timing was all wrong. Its release coincided with a provincial construction freeze on all hospital projects; the Conservative government had sponsored too many building projects (hospitals, community colleges, universities) across Ontario, and now it wanted retrenchment. Only Toronto's new Mount Sinai Hospital and London's University Hospital managed to slip under the wire.64 Wallace remained optimistic, while admitting that all planning had ceased: the freeze on teaching hospitals, he told trustees, was not permanent, and the Toronto General was well up on the government's priority list.65 Mounting social pressures also undermined the assumptions of teamwork so loudly espoused by hospital authorities. In the late 19605, challenges to the 'system' arose from all quarters. The women's movement directly affected nursing, which re-examined its occupational values and roles.66 In October 1969 tensions came to a head at the Toronto General with the temporary suspension of the director and two associate directors of nursing. Wallace attempted to explain the situation to trustees by outlining the development of nursing over the past two decades; in this period, he noted, it had shaken off its role of helper or handmaiden to medicine in order to determine its own future. Nursing then created a third centre of power within the hospital. The three power centres - medicine, nursing, and administration - had collided over authority and finance: 'The lack of readily available and recognized channels of communication between the three groups ... quickly led to frustration, apprehension and, in some cases, actual hostility ... As a result a maze of unrecognized "short circuit" routes were developed ... Increasing heat and hostility developed, further widening the rifts that already existed and creating new ones. The situation became explosive.' Sadly, Wallace informed them, the Toronto General was not alone in having such an 'explosive situation': the same existed at 'good hospitals' across the city and country. So serious was the situation that senior administrators had already left for 'less pressurized fields of endeavour'; others were planning to leave.67

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The recommendations of a nursing task force settled some of the immediate concerns; another outcome was negotiated settlements for the suspended nurses. In 1968, Wallace had been sincere in seeking better hospital facilities for his staff and promising to obtain them. In June 1970 he joined the ranks of hospital administrators who left the field, resigning to become general secretary of the Canadian Medical Association.68 In early 1971 labour strife hit the hospital. Members of the Service Employees International Union (SEIU), which represented over one thousand housekeeping, dietary, and other staff, agitated for change in a publication called Speak Up. Believed to be 'strongly allied' with the Student Workers Alliance - a university-based protest organization that already had picketed the hospital - this 'splinter group' was deemed 'subversive' by the SEIU. According to hospital authorities, the Canadian Union of Public Employees (CUPE) was financing a plan to have the existing hospital union decertified. Coincidentally, at this time the hospital received its first bomb threat (none was found). The leader of the splinter group staged a work stoppage; within a week, he was dismissed from the hospital and other employees were disciplined. Within another month, CUPE did indeed become the bargaining agent for hospital service employees; a 5 per cent wage increase was approved, picketing of the hospital stopped, and negotiations towards a new collective agreement were expected to begin. Organized labour had become a fourth power centre in the hospital.69 Medical students posed another challenge to the system. For the first time in almost a century the deportment of students came before hospital trustees after complaints. Consequently, students were reminded that as members of the 'treatment team' they relinquished complete freedom in matters of personal habit and should not add to patients' fears by adopting 'bizarre dress, behaviour or grooming.'70 As trustees and administrators met to wrestle with these issues, they might look out of boardroom windows to see the new Mount Sinai Hospital taking shape across University Avenue. Casting its shadow over the Toronto General, this eighteen-storey building represented hightechnology medicine; by early 1974, it had become fully affiliated with the University of Toronto and was recruiting first-class clinicians and scientists.71 But the Toronto General would expand again, thanks to an eventual thaw in the government's freeze on capital projects, a more modest architectural vision, and financial support from the business community.72 The John David Eaton Wing, erected in time to commem-

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orate the hospital's i5Oth anniversary in 1979, along with renovated sections of the older hospital, assembled many clinical and research services. Built on the site of the 1913 private patients' pavilion, nurses' residence, and Burnside obstetric unit, the new fourteen-floor Eaton Wing housed doctors' offices, clinics, laboratories, and diagnostic and teaching facilities, as well as 400 beds for patients. For the first time, physicians held 'geographic full-time' appointments, as their practices came to be located in the hospital. The Eaton Wing kept alive the concept of the 'complete Medical Centre,' although it was not the centralized, multi-use facility envisaged a decade earlier. The revamped Toronto General was able to care for patients as never before. By the mid-1980s, it was admitting over 30,000 patients annually, and they stayed on average for ten days. Each year the hospital received over 43,000 emergency visits and 256,000 ambulatory-care visits to clinics; it performed almost 23 million laboratory tests and radiological examinations and served over-1.5 million meals. After closely observing life at the Toronto General between 1983 and 1986, Martin O'Malley published a richly textured portrait of people behind these activities. Patient and staff experiences take centre stage in his engaging perspective of 'life and death' in the Toronto General: the busde of the emergency room on a busy night, the control in the operating room during complex surgical procedures, the joys and frustrations of everyday people who passed through the hospital. Case studies of celebrated transplant patients minutely record the inside story of their anguish and stamina, their operations, the exhilarating or tragic outcomes. Jennifer, a telephone operator, languished in the Eaton Wing for thirteen months suffering from polyposis, a rare disease involving growths throughout the intestine. As her condition worsened from other complications, she became eager for a small-bowel transplant. Since it had never been performed sucessfully, such an operation would be newsworthy. After obtaining approval for the procedure, surgeons transplanted the small bowel from a ten-year-old boy who had died in a car accident. Although the operation went well, Jennifer died from unknown causes on her twenty-seventh birthday. Tom, a fifty-seven-year-old Toronto salesman, was another transplant patient who made the news. Tom had pulmonary fibrosis, a disease that hardens the lung tissue, and sought a lung transplant after hearing about these procedures at the Toronto General Hospital. Overcoming objections to his age for the operation, he met the hospital's ethics committee, which informed him about the record of failure for lung trans-

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plants. With approval granted, Tom underwent a single-lung transplant; he was later upset to learn that the donor had been a thirteen-year-old car-crash victim. (Tom, who would become the longest-surviving singlelung transplant patient, volunteered his time to help other transplant patients.) Diane, a petite twenty-eight-year-old Montrealer, needed a new heart and lungs - the result of a rare, fatal heart disease. Having spent two years in California waiting for a transplant, she jumped on a plane for Toronto after reading about the Toronto General's successful lung transplant for Tom. The donor was a thirty-four-year-old woman who was much larger than Diane, leading to problems fitting the replacement organs in her chest. After a series of procedures, some of which left her chest open for post-operative changes to settle, she prepared to return to Montreal four months later, buoyant and wearing a T-shirt sporting 'I Left My Heart and Lungs in Toronto.' What would become known as cluster transplantation surgery, where as many as four vital organs would be replaced in one patient during a fifteen-hour operation, by the turn of the twenty-first century made the capabilities of the doctors' workshop appear limitless.73 (Refinancing the Hospital: Health Insurance, Mergers, and Restructuring

The mechanistic trend in medicine had a high price. Its rise had initially coincided with the Depression years, forcing hospitals, doctors, and society to re-examine both medical costs and payment practices. There were calls for hospitals to curtail lavish spending, although critics conceded that expenses were necessitated by 'revolutionary advances' in medical science. The Toronto General's superintendent, Chester J. Decker, thought that it would be humiliating if his hospital were not suitably equipped. In his opinion, part of the financial problem lay in the demise of philanthropic support brought about by rising taxes and succession duties.74 Others agreed that the rich were no longer supporting hospitals, leading to a decline in 'post-mortem benefaction.' Financial pressure arose at the other end of the social spectrum. As labourers travelled between municipalities in search of employment, they created an 'indigent wandering class' that often needed medical attention in hospitals. Under existing legislation local governments were obliged to pay for hospital attendance only for indigents who were bona fide residents. As times got harder, the number of people claiming indigent status rose too. The distinction established in the nineteenth century

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between deserving and non-deserving patients became problematic in the 1930s. Often hospitals and municipalities would turn to the courts for rulings on a patient's financial status to determine who would pay the bill. It became a figure of speech that the doctor was the last person to be paid.75 With all levels of society feeling the pinch, people turned to the state for a solution. The Ontario government responded in 1930 by creating a separate Department of Health under the control of its own minister. Part of the mandate of the new department was the promotion of health through educational programs such as those that we saw above for cancer awareness; another was closer oversight of the administration of hospitals throughout the province.76 The passage of the Public Hospitals Act in 1931 gave the minister power over these institutions. This legislation, successor to J.W. Langmuir's act of 1874 and another act of 1912, dropped the terms * charity' and 'charitable* from the official vocabulary. Since 1874 provincial support had risen from $28,000 for 10 hospitals to just under $2 million for 162; but this seventy-fold increase in funding was not enough. Moreover, the existing mechanism of payment did not seem to work properly. The ministry recognized that the high costs of 'intensified specialization' and reductions in revenue from pay patients, municipalities, and bequests left hospitals frantically trying to retrench. The answer, suggested a ministry publication in 1934, could be health insurance that included hospital services.77 In the meantime, the state gave some relief to hospitals by assuming responsibility for transient indigents; beginning in 1936 the province would pay $2 per day towards their hospitalization costs.78 During the 19305, doctors and hospital administrators became more receptive to the possibility of greater state intervention in medical care. For some, the idea conjured up thoughts of Russia. Soviet-style socialized medicine was an experimental approach that many doctors approved in principle at the time79 - it was not just those such as Norman Bethune who were drawn to the political left. Even Fred Banting, a classmate of Bethune's, visited the Soviet Union in the 19308 and declared afterwards that he was a communist.80 But if the tenets of socialized medicine and health insurance held some sway, it was prudent to move cautiously. 'We cannot adopt the Russian system by Bolshevist methods: that is not the way modern Britishers carry out measures meant for the public good,' warned the Canadian Journal of Medicine and Surgery in 1936. In Toronto, Dr L. Kazdan drew attention to the book Red Medicine, by prominent British physician and senior public

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health administrator Sir Arthur Newsholme; following Newsholme's definition of a socialized health service, he described for colleagues how the state would make preventive and curative medicine available to all individuals. Neither 'visionary nor Utopian,' this goal was 'reasonable and possible as a further step in the evolution of society.'81 The possibility of socialized medicine, perhaps through the creation of health insurance plans, would directly affect hospitals and patients; doctors imagined what benefits would accrue under a new relationship. By the mid-i930s the issue was not 'if but 'how': The problem of the moment is not whether our sick citizens should have proper up-to-date medical treatment, but which of two systems are to be adopted - State Medicine or contributory insurance? Or, until we anchor in the former, toward which we are evidently drifting, what form or measure of health insurance should obtain and be held compulsory for the people ... ?'82 Insurance plans had been implemented in Europe, Britain, and western Canada with apparent success; even some U.S. hospitals had started insurance schemes. Why not Ontario? The likelihood that hospitals could be freed of their financial burden through group insurance plans appeared to be fundamentally sound.83 The Ontario Medical Association's endorsement of the principle of health insurance pushed things along.84 Another strong voice in favour belonged to G. Harvey Agnew. In 1928 Agnew gave up private medical practice to head the Canadian Medical Association's newly created department of hospital service. Through this post and others in the Canadian Hospital Association, the Canadian Hospital Council, and the University of Toronto, Agnew became the most respected Canadian authority on hospital administration.85 During the 19305 he made it clear to hospital administrators that they lived in an 'insurance age' and that their institutions would gain from a well-thought-out group hospitalization plan. Any such scheme would not be a panacea, however, because insurers would focus on 'Mr. Average Man,' the 'patient of moderate means,' to allow him and his family to be freed of the costs of hospitalization during sickness. Agnew none the less could see the day when a more generalized state-sponsored plan would arrive.86 Capitalizing on the need for change, the Toronto General's Chester Decker assumed a leadership role to help design and implement Ontario's first province-wide hospital insurance plan. In January 1939, as president of the Ontario Hospital Association (OHA), Decker pushed for a group hospitalization plan to be sponsored by the hospitals of Ontario through the OHA. By October of the following year the OHA

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had approved an insurance plan formulated by Decker, Agnew, and others; in the spring of 1941 what became known as the Ontario Blue Cross Plan for Hospital Care enrolled its first members. Plan members would be entitled to hospital room and board; nursing, operating, and intern services; necessary drugs, dressings, and medications; specified laboratory tests; physical therapy; and anaesthetic materials. These services would be available for up to twenty-one days in hospital during any year on payment of a monthly premium of about two dollars.87 At the close of the plan's first year of operation it had enrolled 48,000 participants and paid out $46,000 to hospitals across Ontario. By 1950 over 1.5 million Ontarians were members, and $12 million had been paid out in hospitalization costs. During this decade services expanded to include coverage for antibiotics and an extension of the total allowable stay in hospital.88 The OHA's Ontario Blue Cross plan quickly became the single largest hospital insurer in the province. Along with several other non-profit employee plans, commercial insurers, and governmental plans such as the Workmen's Compensation Board, it provided hospital coverage for 3.3 million Ontarians by 1954 - or two-thirds of the population.89 The Toronto General Hospital benefited through the assured revenue provided by these plans; it could also take pride in the fact that, through staff members such as Decker, it had again changed organized health care in Ontario. From the 19505 to the late 19605 the structure of health care once again altered dramatically. The creation of the Ontario Hospital Services Commission and passage of the federal Hospital Insurance and Diagnostic Services Act in 1957 increased government participation in the operation of hospitals. Under the new legislation the federal government would pay 50 per cent of all authorized in-patient hospital costs, provided that a province would license, inspect, and supervise its hospitals. In 1959 the province introduced its own insurance scheme with the Ontario Hospital Services Plan; a decade later the federal Medical Care Act of 1966 led the way to a national program of hospital and medical insurance for all Canadians. The road to medicare in Canada has been well-described by others; its effects on hospitals are of specific interest here.90 First, the state became directly involved in the running of hospitals and the provision of medical care generally. In the past, the provincial government in Ontario had assisted with the financing of the Toronto General; now it was the hospital's primary source of revenue. Ultimately government bureau-

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crats would dictate how much hospitals would receive to fund their operations. Whatever the benefits of the new relationship, it began to erode the autonomy of the institutions. Second, the introduction of a government-sponsored universal payment plan swept away the classification scheme for patients used since the nineteenth century. Terms such as 'charity case/ 'pauper,' 'indigent,' 'pay patient,' and 'deserving,' beginning to be questioned in the 1930s, became meaningless by the 19705. With the state paying for each patient's hospital bill through taxes, everybody assumed equal status. Any lingering stigma in the public's mind of the hospital as a charitable institution for the sick poor evaporated; the Toronto General, like other public hospitals, became primarily a middle-class and egalitarian institution. Third, patients' equality translated to 'clinical material' in a teaching hospital. For the previous hundred years or so, indigent, public patients had had to submit to the requirements of medical education; private, pay patients were exempt. Under the new rules, everyone was available to students and their teachers for training purposes. Finally, the structure and function of government payment plans tacitly endorsed curative medicine as superior to preventive medicine and reinforced the belief that hospitals were the place for caring and curing. This emphasis sustained doctors' workshops in what can be regarded as a golden era for hospitals. The solutions of the 1950s and 19605 to problems that arose in the 19305 sowed the seeds for the crises that the Toronto General would face during the final decades of the century. The involvement of the federal and provincial governments in the affairs of hospitals and medical services generally turned health care into a political issue. The reliance of hospitals on public funding linked their fate to public policy and the changing economic imperatives of both levels of government. The downside of this relationship became manifest when in the late 19708 and the 19808 governments' fears of health care costs' spiralling out of control resulted in programs of reduced funding, ceilings on budgets, closing of beds, and use of other economic 'blunt instruments.'91 Belt tightening among hospitals also led to sharing of resources and occasionally joint programs to avoid duplication of services. The Toronto General and Mount Sinai agreed to purchase high-technology equipment together as a cost-saving measure; the construction of underground tunnels connecting these hospitals on opposite sides of University Avenue not only allowed the transfer of patients and staff, permitting the shared use of equipment, but also signified the need for hospitals to work together.92

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The climate of cost containment spawned more ambitious plans as the logic and methods of business were applied ever more boldly to hospitals. Why not reduce the competition for scarce funds by merging institutions and consolidating their budgets, staffs, services, and programs? Such was the plan of W. Vickery Stoughton, president of the Toronto General Hospital from 1981 to 1991. An American in his thirties, Stoughton had experience at Boston's Hospital for Women and Peter Bent Brigham Hospital, along with experience of mergers.93 A judicious blend of economic imperatives with his professional ambition and personal connections led to the merger of the Toronto General with the Toronto Western Hospital in 1986. The merger was a trailblazing move. In the 1990s, many other hospitals across Ontario would follow suit. The Toronto Western Hospital was itself well-regarded. Founded in 1896 in a converted house by twelve doctors, the facility and its dispensary served patients in western Toronto. Early government reports were complimentary about the work done for the poor patients treated, particularly women. By 1899 the Western was treating over six hundred patients annually. The hospital was financially sound, with revenue from the provincial government, patients' fees, and community donations.94 By 1913, after having expanded to larger quarters, it acquired newly erected buildings, and medical students gained admission to its wards for training purposes. The hospital also ran a successful nursing school. In 1925, the Toronto Western amalgamated with the smaller Grace Hospital (formerly an institution oriented to homoeopathic medicine); both institutions continued to operate at different sites for another ten years. The ongoing financial support of the Fasken family from its legal and life insurance endeavours, along with a sizeable bequest from the estate of groceteria tycoon T.P. Loblaw, enabled the Toronto Western to expand again in the mid-i93Os. By this time it could accommodate over five hundred patients and had a staff of six hundred doctors, nurses, trainees, and other workers. Its new clinical laboratory and surgical facilities were second to none, as were its quarters for public and paying patients. During the next half-century, the hospital put down roots in the community that it served. Addressing the needs of successive waves of ethnic groups settling in the area -Jews, Italians, Portuguese, and Chinese - it developed strengths in family and multicultural care as well as programs in cardiovascular surgery, kidney transplantation and dialysis, and the neurosciences. (In 1968, the first heart transplant in Ontario took place at the Western.) Counterbalancing the hospital's

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good standing in the community was its ailing financial health and its older buildings. The appointment in 1984 of Carl Hunt, an American, as president helped turn its recurring operating deficit into a surplus the following year; none the less, the Western faced serious financial difficulty.95 What began as discussions by the American presidents of the Toronto General and the Toronto Western to coordinate some clinical services quickly became secret negotiations towards a merger. During the summer of 1985, Stoughton and Hunt evaluated the cost-effectiveness of a single hospital entity, as well as the impact on clinical programs and teaching; over time, they brought board chairs and vice-chairs of the two hospitals into the discussion. In October, the cat was out of the bag. A Toronto newspaper shocked everyone with the announcement that merger talks were in progress. At the Toronto General's board meeting in November, chair Alfred Powis confirmed that the idea had been 'quietly explored' for several months and apologized to trustees because they had found out only through the media. The source of the 'leak' was unknown. After poring over circulated background and position papers and listening to Stoughton's presentation, the trustees agreed to continue with merger talks.96 News of the plans precipitated a series of events. The Toronto Western's president resigned to assume another executive position in health care. Outraged doctors cried 'foul.'97 They blasted hospital administrators over the 'autocratic and threatening' process and complained that the merger would damage both institutions. From a clinical perspective, it would be a 'disaster,' and amalgamation would have serious long-term effects on the entire system of University of Toronto teaching hospitals. One doctor who had worked in both hospitals tried earnestly to convey the shared sense of frustration. The 'feelings from other institutions regarding "the flag-ship hospital" [the Toronto General] run from suspicion through disdain and right on to hatred,' he informed Stoughton. 'The roots of these impressions go back many years.' At the same time, doctors at the Toronto Western did not trust their own leaders, let alone those 'of the famous hospital to the east.' A doctor at the General invoked the flagship metaphor, with scathing effect: The Toronto General Hospital has justly been called the flagship of the University Teaching Hospitals. Using this analogy, the flagship is now planning to take in tow a battered hulk. This will inevitably slow the flagship in its delivery of high quality health care ... Navigation through the treacherous waters of the present financial restraints will become increasingly difficult.'

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This doctor did not trust his administrative leaders at the Toronto General, who had been heard to say: This hospital would be a better place to work in if there weren't any doctors/ The resentment displayed by individual doctors carried over into official plans. One medical division feared that resources would be drained from the Toronto General to strengthen the less-well-equipped Western hospital, while a surgical group complained that those in charge 'had not done their homework.'98 To overcome this hostility, Stoughton met with every key medical group in both hospitals, with concerned individual doctors, and with management staff. The University of Toronto's Faculty of Medicine simultaneously appointed its own committee to review the merger process, while the dean met with the chief executive officers of other Toronto hospitals. This concerted effort led to both boards of trustees formally agreeing to a merger, with Stoughton becoming the chief executive officer of both hospitals. But the hearts and minds of the majority of doctors and hospital staff had still to be won over." Management briefing sessions, press conferences, press releases - all were deployed to transmit the message that things were more or less as usual. 'Think of this like a partnership with a big brother,' Western staff heard.100 The chair of the Toronto Western's board, Peter Crossgrove, informed staff members that no jobs would be lost, that each hospital would continue to operate under its current name and on its existing site, and that the Toronto Western would receive government funding for needed renovations. He also gave reassurances that medical leaders in the Toronto Western had endorsed the merger and that 'sufficient safeguards' had been formulated to justify proceeding with amalgamation.101 Doctors had been indignant over the merger; others were scared by it. Fears increased in spring 1986 with active consideration under way of relocating the Toronto Western to the General's site and of having the smaller Doctors Hospital move into the vacated Western site on Bathurst Street. This situation was what members of staff had been afraid all along that their 'big brother' might do. It was the turn of patients and nurses to voice their concerns. A letter-writing campaign to administrators, the minister of health, members of Parliament, and the media made the feelings of those opposed to relocation a very public affair.102 Patients in the Toronto Western who had received dialysis treatment, or treatment for other chronic conditions, for upwards of ten years expressed their admiration for its staff and described its warm and caring environment. The hospital was 'like my home,' wrote one; patients

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and staff felt 'panic and low moral [sic],9 and why change a good thing? worried two others. A kidney-transplant patient who had visited the hospital every year since his operation in 1977 learned of the possible relocation on a radio talk show hosted by Betty Kennedy (who was a board member at the Toronto Western). He had no complaints about a merger with respect to computer terminals and accounting procedures but was 'dead against' it when it affected patients and their treatment. The laboured, semi-handprinted letter of one patient must have taken a long time to compose and write: 'This is my home - for four years/ it pleaded, 'and no body wants me. These nurses and Doctor are the caring family I have. Please Please dont take them away from me.' The hospital's nurses spoke out. They wrote to their superiors and politicians, identifying potential breaches in the merger agreement; they also indicated that Toronto Western's nurses were the most caring, responsible, and friendly in the city. In a letter to Liberal Minister of Health Murray Elston, one nurse summarized trends that had been growing in hospitals, especially the Toronto General, during the previous decades: 'If you have ever had the misfortune of being admitted to T.G.H. then you know that it is already too big and too impersonal. You're only a number! The thought of being swallowed up by the bigger fish, is not only devastating to we the existing [Toronto Western] employees, it is also demoralizing. Americanization and business management has a great role in our society ... But let's keep our health care system a pleasant and humane place to enter when the need arises.' Class consciousness and attacks on capitalism's encroachment on hospitals intensified when organized labour added its voice to the chorus of dissent. The president of the local CUPE bargaining unit sought to defend the rights and interests of the working class against the decision makers in corporate boardrooms. He told union members how the entire system of health care had developed in 'subordination to the interests of capital, - and how could it be otherwise in a society in which capital dominates every sphere of life?' Claiming that Ontario's hospital workers had a 'long history of struggle against this bourgeois dictate,' the union leader urged members to be vigilant about the activities of their capitalist bosses. He was not entirely accurate in portraying provincial health care policy, regardless of party, as always determined by the 'profit motives of the rich and not the delivery of health care to the working class and people.'103 Such an assessment failed to take into account the rise of socialized medicine and the government's wish to cover the hospitalization costs of 'Mr. Average Man' beginning in the

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Depression years of the 19305. By the same token, it reflected the popular belief in the 19805 that money, power, and politicians seemed to be driving hospital policy. The people had spoken - loudly - and decision makers had to listen. They did. On 29 May 1986, the board of the Toronto Western Hospital reaffirmed its commitment to two hospital sites and the idea of two institutional identities. In a handwritten note to himself, Toronto General president Stoughton recorded that his board chair was 'naturally disappointed' at the turn of events; more telling, he noted that emotions had intensified to the point that the merger could have fallen through if the plan to relocate was not abandoned.104 During the following period of truce, other matters were attended to, such as the shepherding of required legislation about the merger. In the autumn of 1986 an act to create a new entity, The Toronto Hospital, consisting of the General division and the Western division, became law.105 In the meantime, the two boards had joined forces to create a fifty-member super board; through attrition, and under the terms of the new act, this number would be reduced by half. Similarly, by 1990 there was a single medical advisory board, and numerous administrative departments, such as finance and human resources, had united. As chiefs of services and leaders of clinical divisions stepped down at both hospitals, a single office holder replaced them.106 The creation of 'The Toronto Hospital' was not one event but an ongoing process. Reactions to the merger said much about the status and reputation that the Toronto General had earned. It also threw into relief how institutions with the same overall goal of doing good could develop unique internal cultures because of their different social and historical development. Only about a mile separated these hospitals within the city, yet it would require more than the shuttle bus for staff and patients to bridge the distance between them. Dr Albinjousse, a pioneer in the treatment of spinal-cord injury, and a physician who had been associated with the Toronto General since his student days in the 19305, also hinted about the existence of this cultural gulf. He quietly counselled Vickery Stoughton that administrative expertise was not an adequate substitute for the bonds of loyalty that good hospitals built up in their staff.107 Within only a few years, the Toronto Hospital was set to expand through amalgamation with neighbouring Women's College Hospital. This institution began in the iSgos when faculty members of the Ontario Medical College for Women established a dispensary for needy women. The wife of Toronto General benefactor Sir John Craig Eaton

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approached the board of the Toronto General with the idea of installing an all-women's hospital on the property, but it rejected her proposal. In 1915 she and other prominent Toronto women raised funds to erect a formal hospital. The efforts of Lady Eaton and others during the 19308 led to a new Women's College Hospital on property facing the College wing of the Toronto General; for the next half-century, this facility was a magnet for women physicians and their female patients. Despite its recognized strengths, in 1989 the board of Women's College decided to merge with the Toronto Hospital for fiscal reasons. This decision split Women's College Hospital, with the result that a powerful splinter group was able to raise both funds and a legal challenge to the proposed merger. In this instance, the anti-merger faction was successful; directors in favour of joining the Toronto Hospital resigned. The publicity and allegations surrounding these events led to an independent review by the Ministry of Health into the proposed merger process. Adding to the fractiousness of the times, a Toronto Hospital trustee and city councillor who opposed the merger was accused by the chief executive officer of Women's College Hospital of pursuing 'scare tactics and political pressure based on misleading and inaccurate information.' Although the majority of the board of the Toronto Hospital supported the merger, the independent review committee rejected inferences made by some that the hospital had acted in a 'predatory manner' towards Women's College Hospital.108 Merger tensions still simmered into the last decade of the century. In 1991 the widely publicized death of a patient was blamed on a delay in her transfer between Toronto General and Toronto Western sites. Before consensus arose that having two hospital divisions was not to blame for this tragic outcome, this stressful situation involved top-rank doctors, the media, board members, and the minister of health.109 Worsening economic times added only more stress. Ontario's hospitals were in a state of financial crisis. By the end of 1991, the Toronto Hospital's new president, former surgeon-in-chief Dr Alan Hudson, was facing a $io-million deficit and troubled labour relations. Decisions to cut costs by eliminating about 150 beds and laying off over 200 employees, coupled with a newspaper story that hospital bosses in Toronto, including Hudson, received annual salaries of up to $400,000, heightened tensions.110 Unions fought back with allegations of financial mismanagement at both hospital divisions in the five years since their merger. They pointed to extraordinary expenditures: for computer equipment abandoned

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uncrated on a loading dock, and for installation of an ill-fitting revolving door (claimed to have come free from a bankrupt casino in Nevada). They also expressed frustration over the administration's lack of communication with the workforce, noting that a sister union, the Ontario Nurses Association, was boycotting the hospital. A special, exhaustive audit of the General division of the Toronto Hospital, undertaken by the office of the provincial auditor, concluded that charges against the hospital were 'generally without substance or were overstated/ Senior administrators had considered taking legal action, because they felt maligned, but concluded that the results of the audit had fully exonerated them.111 The 'flagship' of Toronto hospitals sailed on, though badly listing from government cutbacks on the outside and strife on the inside. Its greatest liability - its large size - was also the source of its strength: the combined hospital complex was too big to sink. Moreover, the concept of hospital mergers and the reduction of duplicated services, as well as other ways to 'harmonize* and/or 'streamline' programs, became de rigueur'm the 19905. The Toronto Hospital was itself an ongoing experiment in hospital reform and worthy of continuing support. Reform soon gave way to restructuring as successive provincial governments juggled health revenue and expenditures. In 1993-4 over one-third of the province's $50billion budget went to health care, and about half of that to supporting hospitals.112 In February 1994 the Ministry of Health mandated the Metropolitan Toronto District Health Council (MTDHC) - the regional planning health authority - to undertake a study of hospital services in the city.113 A century earlier the provincial hospital inspector had asked whether too many hospitals were being built in Toronto and wondered how they could all be supported. The District Health Council raised similar questions. By the 19905 the city had forty-four publicly funded hospitals, employing about 54,000 people and costing $3 billion per year to operate. In 1993-4, approximately 1.5 million people received hospital care in Toronto as in-patients or through emergency rooms; 75 per cent of all those treated were residents of Metropolitan Toronto. The primary objective of this survey was to recommend ways to develop a rationalized system for the city that would consolidate hospital activities and services - in other words, to determine which hospitals were redundant and should be closed. Any restructuring would affect the Toronto Hospital, but the coun-

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cil's recommendation that the Western division be closed and its clinical services relocated to the General division's site had a direct impact.114 Owing to its commitment to its Western division, the Toronto Hospital challenged the council's recommendation while endorsing the overall report. Arguments that council planners had greatly underestimated the cost of closing the Western by up to $40 million proved convincing. The Globe and Mail reported that the Western was not 'headed for the junk heap' as 'red-faced researchers' admitted their miscalculations.115 The MTDHC's review was conceived and started when the leftist New Democratic Party was in power; by the time it concluded the political scene had moved to the right with the election of a Progressive Conservative government and its self-styled 'Common Sense Revolution' under Premier Mike Harris.116 This change in government delayed action on the council's report: the document would later provide the basis for Harris's plan to restructure hospitals in Toronto. In the meantime, the exercise had shown hospitals the need to increase their efforts to reduce expenditures through voluntary cost-sharing and consolidation of services. Neighbouring hospitals at the north end of University Avenue, such as Mount Sinai, the Hospital for Sick Children, and the Toronto Hospital, discussed merging food services, medical laboratories, and groundstaff. Toronto Hospital president Alan Hudson believed that 'tens of millions' of dollars could be saved in this way; the hospital's public affairs spokesperson, David Allen, explained that as $1 billion was spent each year on hospitals in this downtown block, there would easily be cost savings. Their statements were well-received, although their board asked for greater openness in discussions. Newspaper references to 'secret talks' among institutions did not look good.117 A participant in the secret, or 'informal' talks (the preferred term among hospital administrators) with the Toronto Hospital was the Ontario Cancer Institute/Princess Margaret Hospital, which had relocated to University Avenue in the mid-1990s. By the late 19805 it had outgrown its quarters, and its research could be better served if the hospital were closer to other downtown hospitals and the university. After being located for about forty years in the eastern end of the city, the province's main facility for radiation treatment returned to its roots. The new Princess Margaret Hospital occupied renovated and expanded buildings formerly headquarters of the Ontario Hydro-Electric Commission, directly opposite the spot where the Dunlap building and Ontario Institute of Radiotherapy had once stood. In its new location on an 'alley of hospitals,' the facility aspired to blend curing with healing.

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Built as a high-tech doctors' workshop, it sought to 'put a tender edge between emotional attitude and physical treatment1 - recognizing society's continuing fear of cancer. A revival of private philanthropy in the 19905 made possible a garden for patients and staff. This 'healthful oasis' located on a fifteenth-floor roof was a healing and spiritual space in which horticulture was therapeutic.118 The proximity of the new Princess Margaret to the General division, their historical association, and the prevailing economic climate occasioned more informal discussion between the chairs of their boards over projects of mutual interest. These meetings expanded to include executive administrators and the dean of the Faculty of Medicine and led to agreement to collaborate in the formation of a world-class cancer centre. In June 1994 the Princess Margaret Hospital and the Toronto Hospital struck a partnership that left the two boards intact, while Alan Hudson became president and chief executive officer of both institutions. This joint venture, predicated on the familiar argument of saving money through sharing, also sought to rationalize clinical services. When the Princess Margaret Hospital was created in the 19508, it became the centre for radiation and other non-surgical cancer treatment, while the Toronto General remained the primary surgical facility, with research being conducted at both sites. As cancer clinicians and scientists in the early 1990s generally supported the move to consolidate their various treatment and research programs, the sort of intense opposition and protracted debate that happened at the Toronto Western did not arise. Consultation with the premier, the minister and deputy minister of health, and the president of the Ontario Hospital Association further facilitated agreement.119 With all research and medical, surgical, and radiation oncology services centralized, the whole of Gordon Richards's vision of the 19305 achieved reality. Notwithstanding the maintenance of two boards and the retention of the Princess Margaret's corporate identity, the legal step from joint venture agreement to formal merger was predictable. The Ontario Health Services Restructuring Commission (HSRC) endorsed this process. Created by the Conservative provincial government in 1996, the HSRC operated as an independent body at arm's length from the government. Its four-year mandate was to review every hospital in the province and recommend to the minister of health which ones should be closed, merged, or have their services restructured to make them more effective and efficient, with the aim of improving the overall quality of care in Ontario's hospitals. Often a regional report submitted by the commission left communities frustrated and angry as they learned that their

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local hospital was slated for closure; many mounted legal challenges in an effort to have recommendations reversed - and occasionally they were successful. In July 1997 the HSRC released its plan for Metropolitan Toronto. Using the earlier MTDHC report as a starting point, the restructuring commission concluded that, despite positive steps taken by the city's hospitals since 1995, Toronto's hospitals were 'characterized by duplication of services, surplus capacity, an over-concentration of services in the downtown core and ageing physical plants.' To 'enhance' delivery of health care in Toronto, it recommended that the city's thirty-nine hospitals, located on forty-six sites, be restructured to twenty-four hospitals on thirty-five sites.120 The plan did not significantly affect the Toronto Hospital, which had restructured itself through its merger with the Toronto Western and its joint venture with the Princess Margaret. However, in addition to endorsing the anticipated merger between the Toronto Hospital and the Princess Margaret (an action finalized in December 1997),121 the HSRC recommended the closing of Doctors Hospital and the folding of its programs into the Western division of the Toronto Hospital. Doctors Hospital was a smaller, community-oriented institution a short walk from the site of the Western division. It had no tradition of research or academic medicine; its focus was the people of the neighbourhoods that it served. With even stronger links than those of the Western to its ethnically diverse community, Doctors prided itself on its ambulatory care facilities, its 'Women's Own Detox' centre, its child health program, and its numerous social outreach services. Consciously multilingual and visibly multicultural, it also differed from the Toronto Hospital in having on its board a woman as chair and several more women and people from visible minorities as members. Whatever the logic on paper for closing the hospital, members of this vibrant, politically engaged community institution reacted strongly. Doctors Hospital mounted several legal challenges against the government over its mandated takeover, all unsuccessful. Only after appointment of a facilitator, implementation of a complex multilingual plan of public relations and communications, and noisy negotiations between the two hospitals and the Ministry of Health was the takeover achieved in 1999. In the process, only ten workers were laid off, out of a workforce of approximately five hundred.122 The hospital building was then razed. The mergers, amalgamations, joint ventures, and takeovers involving the Toronto General in the 19805 and 19905 were expedited by the promise of financial savings as well as the threat of government action.

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Another important facilitating factor was the shared social and professional backgrounds of senior members of the boards of these hospitals. During these years Fraser Fell was chair of the Toronto Western Hospital and then of the Toronto Hospital (his brother, Anthony, had been chair of the Princess Margaret Hospital and would chair the board of the amalgamated hospitals in 2000). Peter Crossgrove had been chair of the Toronto Western Hospital, the Toronto Hospital, and the Princess Margaret Hospital. Also in these years, Alfred Powis served as chair of the Toronto General Hospital, with Frederik Eaton as his vice-chair; Eaton became chair of the Toronto Hospital in 1994 and would see the hospital into the twenty-first century. In some cases these influential men were old friends, relatives, or connected through marriage. They shared a common outlook because of their corporate backgrounds and were used to mergers. The consolidation of hospitals led to a complex made up of four institutions on four million square feet of space spread across several downtown blocks and employing approximately 10,000 people. A single hospital board of representatives from each institution, from the University of Toronto, and from other constituencies established a unified centre for governance. Coordination of management at the various hospital sites was more problematic. Continual changes left staff members bewildered over who their bosses were; patients became confused over which hospital or site they were to visit for treatment. Merger mania had hit so many Toronto institutions that a new form of hospital humour circulated: if Women's College Hospital and the Hospital for Sick Children were to merge, went one joke, the new logo would be a lifeboat with the motto * Women and Children First' Another jibe hit closer to home. The merger of the Toronto Hospital and the Princess Margaret, coupled with their sharing of clinical programs with Mount Sinai, led some to quip that a fitting name for all might be the Toronto Jewish Princess Hospital.' This confusion called for clarity. In 1999, the University Health Network (UHN) was formed as a holding company to operate the constituent hospitals - the Toronto General, the Toronto Western, and the Princess Margaret - along with their hospitals' fund-raising foundations. The concept of a hospital holding company had been investigated in the United States by senior medical administrators six years earlier.123 At an abstract level, the umbrella name conveyed a sense of institutional cooperation and embraced the organization's longstanding commitments to teaching, research, and patient care. It also denotes the grow-

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ing field of medical informatics, which emphasizes sharing data, linking institutions electronically, and generating paperless patient records.124 Another element in this institutional makeover was the development of a new corporate logo of three stylized human faces to replace earlier symbols of impersonal technologized medicine. At a practical level, the reversion to their former names by the Toronto General and the Toronto Western hospitals, and the retention of the name for the Princess Margaret, upheld the cultures and identities of each institution. Staff reacted favourably in particular to these changes in names. The 'branding' of the organization, with the new logo emblazoned throughout its many hospital sites, on T-shirts, and on publications, might seem to cynics an expensive exercise in public relations. But after a decade and a half of tumultuous change and, at times, the deliberate fostering of an 'acutely uncomfortable' work atmosphere, it was vital that administrative leaders take stock of what the Toronto General and its hospital partners had become. The hospital already had a reputation for being too big and impersonal; now it had become amorphous, with octopus-like tentacles stretching in various directions. Worse, the stress and strain of restructuring and reinvention had taken its toll on staff. A comprehensive survey of employees' attitudes revealed a high level of dissatisfaction with their place of work. At the same time, a survey commissioned by the Ontario Hospital Association of the majority of hospitals in the province presented a report card based on patient satisfaction, among other measures. Newspaper headlines said it all: 'Fed Up: That's How Hospital Patients Feel' and 'Patients Can't Get Satisfaction in Toronto.' The UHN's score of between 'below average' and 'average' attested to the difficult times. These reactions were echoed in the survey report of the Canadian Council on Health Services Accreditation. In 2000, the council granted the UHN the maximum three-year hospital accreditation but encouraged it to develop its 'customer service philosophy.'125 The collective portrait of patients expressing their dissatisfaction was an important reminder that the primary business of hospitals was not business, but care of patients. Yet achieving the much-desired balance between financial responsibility and patient satisfaction remained a daunting task for the UHN, with admission of over forty thousand people annually for an average hospital stay of 7.4 days along with almost another million people a year treated in emergency rooms and ambulatory and surgical day care. Under these pressed conditions, UHN presi-

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dent Alan Hudson admitted, patients' satisfaction was Very tough to pull off without the hospital's spending a good deal of money: 'We have top notch clinical outcomes. Four years ago, we were the city's 15th most efficient hospital. Now we're the most efficient... but we have not done well for customer satisfaction.' To help overcome the 'stress, burn-out... and low morale' caused by restructuring, the hospital allotted $2 million to address patient and staff concerns.126 A similarly enormous challenge is the continual drive to improve and expand the hospital's facilities to cope with present and anticipated needs, especially in an era of fiscal restraint. To finance redevelopment (Project 2003), including demolition of the private patients' pavilion of 1930 along with other buildings, Alan Hudson spearheaded a plan to issue public bonds or debentures. The sum of $280 million was considerably more than that required when the hospital issued debentures in the 18508, but board chair Frederik Eaton exuded confidence. 'Canada would have to be destroyed in a catastrophic war or a catastrophic event where Toronto was leveled for this plan not to work,' he told fellow trustees. Fortunately for all, no catastrophe intervened, and the bonds sold within a day and a half of their release.127 An unexpected $14 million from the Ministry of Health on the eve of the new millennium was more good news, for it averted a shortfall in the organization's $680million budget for 2OOO-1.128 The appointment of Tom Closson, who succeeded Alan Hudson in September 2000, suggested the direction that Canada's largest hospital would take in the twenty-first century. The board chose an experienced hospital executive with a background in industrial engineering and business administration for the presidential position. Expectations for the chief executive officer, according to a Globe and Mail report, included abilities to 'lure' private business from the United States and to 'compete in the wired world of electronic private health care.' The hospital hoped to generate revenue while preserving access to treatment for Canadians.129

Conclusion: Holding It Together

Lewis Thomas, the informed and witty commentator on biomedical life, wrote that hospitals function through the 'constant interplay' of powerful and opposing forces, often leaving the patient astonished that the 'whole institution doesn't fly to pieces.'1 One of a small number of organizations to have historically functioned every hour of the day, every day of the week, it is expected to operate efficiently, even though it has little control over revenue or demands placed on its unique services. We expect it to have the latest in high-technology equipment while displaying a high level of personal contact and consideration for those in its care. The staff embraces a broad array of sophisticated technical skills, knowledge, and attributes, yet the occupational group most readily associated with it doctors - is not its employ. The hospital is a very public place while simultaneously being the site of intensely intimate and personal events that span the life cycle.2 The hospital can instill both fear and hope at once; it can isolate people from society or integrate them back again. A large urban research and teaching hospital is even more complex and paradoxical. Its connection to the medical school and university dramatically increases the number of factors affecting administration, policies and procedures, and educational requirements. Through onsite researchers, more agencies external to the hospital become indirectly involved in its activities (when, for example, they fund clinical trials). Patients become subjects for study by a wide range of health care practitioners in training. So much so, that in Toronto's new University Health Network, the Patient Relations Office disseminates a 'Patient Bill of Rights and Responsibilities' in pamphlets and posted notices - partly to seek patients' understanding and cooperation with health care professionals in fulfilling the hospital's role in teaching and research.

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At many stages in the two-hundred-year life of Toronto's general hospital, competing forces in its disparate constituencies and spheres of involvement might well have pulled it apart. But over this long timeframe, the hospital held together through its formations as private charitable insitution, public charity, business organization, and temple of high-technology medicine. As this concluding chapter emphasizes, its many voices - trustees, patients, public, doctors, health care students, government, business - acted in a kind of constructive tension to ensure its continuity. Similarly, its goal of doing good adapted along with changes in external social, religious, fiscal, medical, technological, and governmental hopes and values. Representing the colonial establishment, trustees of the York General Hospital were well-connected and powerful men who reflected the elite of Upper Canadian society. From its opening in the 18305 especially, they represented the commingling of personal, professional, and political spheres that were key components of the colonial Family Compact. Later boards included members representing broader interests of the community, but trustees have consistently come from the top levels of the commercial and political worlds. During the twentieth century, the * family compact' appears to have evolved into a corporate compact. Members had connections through business, family, or marriage. Whether in Upper Canada or in Ontario, such alliances led to a shared vision of hospital development that permitted continuity while embracing change. By the 19905, greater diversity had emerged through appointments of women and representatives spanning the political spectrum, such as a top-level Conservative strategist and a former New Democratic premier. For the first time, board meetings were also open to the public. Certain trustees have been so attached to the hospital that it became identified with them. During the first half of the nineteenth century, it was Christopher Widmer's hospital. The only doctor to chair the board, Widmer bridged medicine and administration at a time when the hospital was small enough to accommodate both in a chair. Widmer oversaw the transition from the original small establishment to the massive new quarters in eastern Toronto. For much of the first half of the twentieth century, Sir Joseph Flavelle influenced the hospital's development, serving on its board for almost forty years, many as chair; he maintained a connection to the hospital through the two chairs immediately after him, who were his close business associates. Not only did Flavelle relocate and rebuild the hospital from eastern Toronto to the university

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area, he all but reinvented it. His plan of reorganization was an arrangement that most could agree to, and it was one that forged unbreakable links to the University of Toronto. Throughout the hospital's history, trustees have acted on a voluntary basis. Not only discharging their responsibilities in governing the institution, on many occasions in the nineteenth and early twentieth centuries they involved themselves in direct management of its day-to-day affairs (making decisions on admissions, inspecting the wards, interviewing patients). During fund-raising campaigns for rebuilding or enlarging the hospital, trustees themselves often gave generously. In the early twentieth century, in addition to lending the benefit of their positions in Canadian society to the hospital, Flavelle and members of the Eaton family personally donated hundreds of thousands of dollars as well as their time and other resources. In the latter part of the century, board member Peter Munk supported the development of a cardiac centre through his donation of millions of dollars. From its beginning, the hospital sought to treat the sick poor. Because curing them was often not possible because of the limits of medical knowledge and practice, the York General Hospital provided a useful social service in providing for their extended care. The eighteenthcentury worldview, from which the institution emerged, saw medicine as a convenient cultural place to promote 'the local and the general good/3 Enlightened beneficence on the part of society's elite had its limits: it meant that only one segment of society was likely to seek hospital care. As Christopher Lawrence explained, medicine also held the 'potential to deliver' a message to the poorer and lesser members of society to show respect, gratitude, and deference to social betters. Conditions in the general hospital therefore differed substantially from those in the lives of the institution's founders, supporters, and doctors. The 'sick poor' comprised a heterogeneous group of homeless immigrants, men and women who had sustained financial reverses, and workers of meagre means. For some, the hospital became a temporary home or refuge until they got better, died, or were removed to the homes of friends or relatives. It always cared for the destitute, but during the second half of the nineteenth century it also admitted artisans and skilled workers. By the end of the century, and into the twentieth, middle-class people began to seek treatment at the Toronto General until they became the dominant patient population. All patients were expected to pay for their care - an impossibility for

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most. The trickle of those admitted who could, and did, cover their care increased late in the nineteenth century. Each time the hospital rebuilt, it added private rooms to cater to paying patients of the new middle class; this plan was both successful and necessary. By about 1897, revenue generated from such patients equalled that received from government; over time, the cost of care for people in non-paying public wards came to be subsidized by those in private hospital wings. The opening in 1930 of the freestanding private patients' pavilion, which resembled a deluxe hotel, was a historical event. That its first patient was the son of the lieutenant-governor - admitted, almost to the month, a century after the York General received its first indigent patient in June 1829 symbolized the hospital's social transformation. Development of insurance plans beginning in the 19408 levelled the differences between public and paying patients, as the hospital, like other Canadian institutions, came to serve the needs of Mr Average Man (and his family). The frugality of its day-to-day operations and references to vermininfested bedding suggest that life in the York General Hospital was miserable. The facility helped thousands of people, but we know very little about them. No detailed case records exist of the men, women, and children who were admitted, were treated, or died there. We do not know how long they stayed, or how unpleasant their stays might have been. Like the larger population of transient emigrants, the destitute, and the sick poor, those whom the hospital aided in the 18305 and 18405 remain faceless. For patients later in the century we know more. Clinical case accounts published by physicians or medical students record names, occupations, and social circumstances. As well, these and other accounts, such as those of trustees, begin to capture the voices of patients themselves usually in criticisms of hospital care or service. At mid-century patients might complain about insufficient medical attendance or harsh treatment by hospital staff; by the end of the century, some resorted to legal measures. Frustrated or dissatisfied patients appear to be a perennial part of hospital life, as late-twentieth-century surveys also demonstrated. Over the decades, trustees, administrators, and other members of hospital staff have dealt with these problems in various ways, whether by replacing grossly discoloured bedding, by selecting more courteous, bettertrained staff, or by establishing a formal office and assigning personnel to respond to patients' concerns.

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Most patients do not complain, often because they are grateful for their treatment, or sometimes because they are too ill to do so. A great many of those admitted to the hospital during most of the nineteenth century would probably fall into the second category. As cholera, smallpox, typhoid, typhus, and other epidemic fevers constituted the single largest group of conditions treated, most patients would be physically unable to worry about their surroundings. But throughout the nineteenth century and into the next, the Toronto General treated numerous other conditions - indeed, as government reports indicated, examples of almost every medical ailment imaginable could be found in the hospital's wards at one time or another. The breadth of conditions encountered reflected the Toronto General's ability to draw patients not just from Ontario's largest city, but from much of the rest of the province. While the mortality rate for individual fevers could be horrendously high (up to 50 per cent), the limited data available indicate that the annual death rate for the Toronto General remained relatively constant, at 10 per cent - not atypical for a nineteenth-century hospital. During the twentieth century a broad range of conditions continued to be treated, consistent with the institution's role as a general hospital. Added to them were epidemics of influenza, poliomyelitis, and HIV/ AIDS (for which the Toronto General houses Canada's largest clinic), along with the rising scourge of cancer in its various forms. For most of the nineteenth century, only occasionally did the general hospital admit pregnant women to give birth. During the last quarter of the century, this situation changed with the amalgamation with the Burnside Lying-in Hospital. But because these women were mostly unmarried or deemed to be of ill-repute, the hospital sequestered them from other patients. It grounded this policy as much in the medical belief that birthing women might spread disease as on moral grounds either way, it saw this type of patient as impure. About the mid-nineteenth century a stay of several months in the hospital was not unusual; by the close of the century, an average stay lasted about one month. During the twentieth century, the length of time constantly decreased: by the late 1990s, most patients might be in the hospital for no more than a week. (Those undergoing transplants or similarly complex procedures would sometimes remain for extended periods.) The fact that many people in the mid-nineteenth century ended up in hospital because of work-related injuries in construction, industry, and trades reflects both the development of the province and the beginning

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of a shift in the hospital's evolution from a mixed-care institution to a place for acute care. Hospital-based medicine formed one of the 'most critical developments' in medical history beginning in the eighteenth century, Guenter Risse has written, because it 'gradually but decisively changed the character, content, and direction of medicine.'4 His study of the Royal Infirmary of Edinburgh demonstrates the growing connection between the hospital, caring, and medical education. The eighteenth-century hospital did not completely anticipate the present-day teaching hospital, however. While some doctors saw advantages in becoming associated with it, most could still conduct their practices without depending on, or ever referring to, the hospital. In its earliest days Toronto's general hospital certainly was marginal to physicians with respect to their livelihoods, but it could heighten their profile in the community. As connection with it came to bestow some professional prestige, exclusion from its medical staff increasingly became grounds for dispute. Appointments to the hospital afforded new opportunities for doctors to increase their professional scope and activities. Through interactions in the hospital ward, doctors came to care for the sick poor, a segment of society with which they had previously had little contact (and vice versa); and, by providing their services free to hospitals, doctors could be seen to be virtuous. Beginning in the 18405, affiliation with both the hospital and a medical school conferred such power and status on doctors that those alienated from the hospital by the 18505 transformed their disaffection into open hostility and ridicule. Just as temperatures in its many clinical cases rose until fevers broke, so the hospital endured a grand professional fever until its crisis in 1855. The fever always seemed to rage around one central irritant: Dr John Rolph, a man driven to save his medical school while settling old political scores. Rivalries not only reflected poorly on the doctors of Toronto, retarding their attempts to become professionally organized, but also harmed the hospital. Sectarian dissension disrupted hospital activities and jeopardized the care of patients. As passions subsided, and doctors came to work more cooperatively, they were able to develop areas of expertise that enhanced the hospital's reputation. The Toronto General provided doctors with facilities that allowed them to develop specialties such as general surgery, gynaecology, laboratory medicine, ophthalmic surgery, radiology, and radiotherapy.

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The process of medical specialization intensified in the early twentieth century as doctors, the university, and the hospital became more tightly bound and their services integrated. A common thread influencing the protracted process of reorganization consisted of the views of William Osier, although his model of the Johns Hopkins Hospital and Medical School did not prevail. Once the university's Faculty of Medicine and the Toronto General Hospital were reorganized by 1920, professional rivalries re-emerged, as many doctors with teaching and hospital appointments considered themselves superior to those without them. For the rest of the century, it was crucial for doctors intent on advancing their careers to be affiliated with both institutions; as the pursuit of research became more significant, the gap between 'have' and 'have not' physicians widened in their professional community. The differences that doctors saw between those who held Toronto General appointments and those affiliated with other hospitals became evident during merger discussions in the igSos. The competitive (if not disputatious) spirit of doctors played itself out more directly within the hospital. Public inquiries in the 18505 and i86os showed that doctors believed that lay trustees knew little of medical matters, while trustees wanted physicians excluded from administration. The correspondence of non-medical trustees and administrators during the twentieth century reveals their frustration in trying to deal with doctors. Sir Joseph Flavelle, Chester Decker, and Mark Irish all stated that doctors needed to appreciate the well-being of the whole hospital, not just their own interests on any particular issue. Fifty years later, the medical head of a Toronto General department hinted that similar tensions still simmered when he reminded colleagues that doctors practised in the hospital at the 'expressed permission' of the board. If trustees decided that something was in the best interest of the hospital, then 'medical staff is obliged to go along with it and make bloody sure that the expectations of the board are met. That's one point of view and one which we [doctors] tend to forget.'5 Long before the province's first formal medical school was established in Toronto, the city's general hospital had been a site for medical education. The rise and fall of so many medical schools but the existence of only one hospital increased competition for patients (dead or alive). None the less, as clinical reports by students and their instructors attest, the hospital was constant in providing a place for medical education; indeed, the training of doctors was a factor often advanced by physicians, trustees, and government officials in support of the hospital's operation.

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As members of the lower classes, patients provided ideal 'clinical material' for medical students: the 'deserving sick poor' were to repay their debt to society by allowing themselves to become subjects for instruction. Successive generations of doctors-in-training came to regard their experience in the Toronto General as a major educational milestone, with the many hours spent in the wards, in the operating-cwrw-lecture theatre, or in the post-mortem room. For its part, the hospital gained revenue from the sale of lecture-admission tickets to students; senior medical students and residents also were a source of free labour. The demands of clinical instructors who wished to keep up with developments in medical education required the hospital to adapt to change. Often this meant scheduling operations, ward visits, and other hospital events to suit the timetable of students; it might also result in physical changes to the building not only to accommodate more students but, late in the nineteenth century, also to accommodate (grudgingly) women. During this latter era the Toronto General established its own training program for nurses, which developed into the largest in the country and helped further the goal of creating a new type of nurse. This school blazed a career path that many women eagerly and successfully pursued. The introduction and expansion of modern nursing, which advanced the professional bedside activities of nurse probationers and graduate nurses, benefited physician and patient alike. Nurse trainees also provided the hospital with a ready supply of inexpensive labour during the later nineteenth century and for most of the twentieth. Although the Toronto General Hospital did not become a Canadian Johns Hopkins, William Osier's insights were a catalyst for change in the early twentieth century. The university's consolidated Faculty of Medicine and its proximity to the Toronto General enabled medical education to flourish: the earlier process of specialization became formalized after the Second World War through jointly administered residency and postgraduate programs, and the hospital actively participates in other joint ventures with the university, including the study of medical education and the practice of bioethics. Teaching hospitals such as those that make up Toronto's new University Health Network are unlikely to disappear, because they are too central to education in the health sciences. Nevertheless, changes in the training of doctors and other health care workers, such as the use of virtual teaching modalities, will probably force alterations in the relationship between the hospital and the university.

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Hospitals underwent their most dramatic transformation in the nineteenth century, emerging by its end recognizably modern.6 Scholars agree that about 1900 the hospital in North America, once an institution marginal to society and to medicine, became central to both. As so cogently argued by Charles Rosenberg, in the United States between 1800 and 1920 medicine became hospitalized' (based in the hospital) and the hospital became 'medicalized' (greatly under the influence of doctors).7 As David Gagan has shown, hospitals in Ontario, both urban and rural, also followed this trend.8 Clearly, the Toronto General Hospital fits this pattern, although its transformation seems to have led the pack in Ontario. Never isolated or insulated from the rest of society, barometer-like, Toronto's general hospital responded to, or was influenced by, external pressures - war, demography, religion, technology, economy, local and international politics. The hospital held a marginal place in the colonial capital of York/Toronto from the 17905 to 1840. Even in a time of medical crisis such as the cholera epidemic of 1832, town residents displayed considerable ambivalence towards it; for the majority, home was the place for care and treatment of the ill. Perhaps those who had the most to gain from the existence of the York General Hospital were the gentlemen charged with the maintenance of regularity and order in the colony. Whatever other medical and surgical duties the hospital discharged, it served as clearing station for a potentially troublesome element; from this perspective, it was doing good in this era by fulfilling its dual role as both a social safety valve and a safety net. Unlike its urban counterpart in the older, more heavily populated colony of Lower Canada, Toronto's hospital, its town, and its province all experienced their growing pains together. Founded in the same decade, the Montreal General Hospital (1821) shared the ideals of the era, but in the context of a different cultural heritage derived from a mix of the French and the Scottish: it was not subject to the sort of political rivalries found in the tiny Anglican bastion of York. The first years of the Montreal General were therefore not nearly as uncertain as those of its contemporary.9 Similarly, hospitals begun earlier in well-established American cities, such as Philadelphia, showed more stable development. Both the Philadelphia General Hospital (1732) and the Pennsylvania Hospital (1751) addressed the needs of the sick poor but do not appear to have been so constantly rocked by external actions.10 Hospital life in the Toronto General in the 18408 and early 18508, as reconstructed here, shows that it was a decidedly domestic affair - quite

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unlike the modern hospital, where lines of operation separate board members from staff and patients. The onerous responsibilities of maintaining this charitable institution and daily care for dozens of the sick poor meant that trustees, staff, patients, and physicians all interacted regularly. Their recorded encounters reveal a distinct chain of command, although working relationships frequently overlapped. This feature, combined with restrictive admission policies dating back to 1830, shows that the hospital was still a long way from being medicalized. Whatever power doctors may have possessed inside and outside its walls, it was lay trustees (notwithstanding the chairmanship of Christopher Widmer) who * called the shots/ The charitable tenets of deservedness dictated admission policy ahead of most medical considerations. Many times in the hospital's history it has been subject to criticism by the public. Issues sparking controversy included the trivial (a revolving door) and the serious (its filthy condition). The Toronto General came in for its most vociferous attack in the 18508 for its blatant partisanship, shocking treatment of some patients, irregular policies, and, at times, seeming disregard for society outside. Yet it is wrong to forget that, through it all, the hospital retained an extensive medical and surgical commitment to the sick poor and indigent. Similarly, the litany of criticisms in this period did not attack the ideal of the hospital as a charitable institution. In contrast to the early generation of Upper Canadians for whom the hospital was only of limited worth, an institution only for the lowest of society, the 18408 and 18505 represented a turning point in public perception. Society accepted the notion that a hospital served a useful purpose for a segment of the population that included working people of modest economic means. The hospital's increasing significance for different sectors of society also thrust a submerged and under-appreciated issue to the surface: its ownership. The earlier Georgian worldview assumed that the hospital, as a Christian charitable institution, was a natural extension of the statechurch alliance. With the advent and rise of responsible government in Canada, along with the interests and plans of politicians themselves, church and state began to separate. As the gap between the two widened, it became unclear who or what owned the hospital. Concurrent with this dawning realization was the related confusion over the hospital's governance and its management, to say nothing about where and how doctors, medical schools, and universities fitted in. At the heart of the public's criticism in the 18505 and its repeated calls for non-partisanship was the notion of 'secularization' - a process that had already happened with the university in Toronto. The incorpora-

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tion of the hospital in 1847 was a foundational step in its secularization. As editorials were fond of pointing out, the institution of the hospital, its trustees, its doctors, and its charges more and more belonged to a public domain. In short, in the 18408 and 18508 there began the recasting of the hospital from a charitable institution allied to the church and motivated by Christian duty into a public charity increasingly sustained by state and voluntary support. Despite the secularization of the hospital and its official non-denominational status, religion continued to play a role in its affairs. Most of the public saw the hospital as a Protestant organization, and during its first half-century specifically an Anglican one. Religious denominational exchanges implicating the hospital flared up over medical schools in the 18505. Ongoing public debates involved the Roman Catholic community of Toronto and centred on Archibishop Joseph Lynch's repeated attempts to control the hospital. These plans were consistently quashed by Protestant trustees on the grounds that the public would not tolerate what would probably be a denominational (that is, Catholic) hospital. Religious sentiment was so strong that Toronto General trustees decided to see the hospital close briefly in 1867-8 rather than having it become Catholic. Religion continued to influence the hospital with the ascent to its board in the years after 1900 of Methodist tenets, embodied in Joseph Flavelle and his business associates. These men used their Christian compass to navigate the hospital, as had Anglicans before them, but unlike their predecessors they were extremely wealthy. Their generous dispensing of money to the hospital greatly aided in its development. The Protestant orientation of the Toronto General, as well as of the city at large, had its darker side. Bigotry emerged in the anti-Jewish sentiments expressed by superintendent Dr C.K. Clarke, and even by board chairs, and in the hospital's discriminating against Jewish doctors in staff appointments. The eventual disappearance of openly religious orientation saw the hospital emerge as truly non-denominational in the late twentieth century. In this respect, it reflected the post-iQGos' values of diversity and equality and the reality of multicultural Toronto. The concept of public duty had increased the roles of philanthropy and government by the last quarter of the nineteenth century, allowing trustees, with help from other community leaders, to overcome the hospital's periods of financial distress. The provincial Charity Aid Act of 1874 laid a firm and lasting foundation on which the province could build a welfare state and the Toronto General prosper. Passage of this act, along with actions that led to it, initiated the hospitalization of Ontario society. The admission of fewer chronic and incurable cases to

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the hospital after 1874, a result of government pressure for financial reasons, helped destigmatize the Toronto General as one of many institutions for the care of the homeless, the hopeless, and the destitute. Almost every numerical index illustrates the hospital's expansion and growing complexity starting in the last quarter of the nineteenth century: the hospital cared for more patients, employed more people, and trained more medical and nursing students than ever before. It also gained more professional respect and deeper public confidence. There was no defining moment in this process. None the less, one year can serve as a symbol of the transformation. In 1897 revenue from paying patients matched that of the provincial grant, showing that both private and public funds had become essential for hospital operation and maintenance and that more members of the middle classes were prepared to be treated in hospital. Throughout this process, technological innovations shaped the hospital. In the late nineteenth century, the telephone, electricity, and electrical apparatuses were quickly installed in the hospital, not only aiding its daily work but also helping establish its reputation for being progressive. Its doctors had been criticized in mid-century for lagging behind the scientific times in such matters as use of the microscope, but by 1900 things had changed here too. The introduction of general anaesthesia, antiseptic and aseptic methods, X-ray technology, and laboratory medicine benefited patients while bolstering the scientific image of the hospital and its doctors. The continual acquisition of ever-more specialized equipment, combined with the constant expansion of knowledge and refinement of technique, signifies the marriage of medicine with technology. In addition, the routine use of many medical innovations, for which paying patients were charged, became a vital new source of revenue for the hospital. With all these changes, even if the hospital was still an institution controlled by laymen at the close of the nineteenth century, it was becoming increasingly medicalized. Similarly, owing to the greater magnitude and complexity of its operations, the Toronto General Hospital became the dominant medical institution in the city and in the province, if not in the country. Surgical superstars of the late twentieth century who perform day-long multiorgan transplants at the Toronto General might consider the methods of their predecessors primitive - as indeed might any observer. That medicine has made advances over time is unequivocally clear, yet the delicate eye and plastic surgery performed by William Beaumont in the 18405 and 18505, the life-saving amputation of limbs undertaken by other Toronto

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General surgeons, and the successful treatment of countless accident victims attest to the skills of these earlier doctors, regardless of later standards of care and surgical technique. When the new private patients' pavilion opened in 1930, it symbolized in so many ways how society had become hospitalized since 1830 and how the hospital had become medicalized. These two ongoing processes were nudged further along by the provincial government's support for the war on cancer and by other decisions that it took, all about 1930. Its simultaneous creation of a Department of Health with its own minister to whom hospitals reported, its promulgation of the Public Hospitals Act, and its funding of a chain of hospital-based institutes of radiotherapy (of which the Toronto General's was the leader) constituted the strongest signal since Langmuir's legislation of 1874 that hospitals ought to be the locus of most medical treatment. During the rest of the twentieth century, as Rosemary Stevens has shown, the relationship between 'medicine, money, and power' turned the hospital in North America into a 'massive corporate complex.' Although altruism and community spirit - even the 'ideal of charity' have continued, when all is said and done, twentieth-century hospitals operated as businesses.11 Soon after 1900, administrators of the Toronto General began introducing hospital management ideas and techniques circulating in the United States. They joined the American Hospital Association and promoted its goals of efficiency and economy; thereafter, they often sought American advice on hospital design, expansion, and organization. Resonances of an American hospital-as-business ideology appear in the hospital to the end of the twentieth century, but commitment to altruism and community spirit continues to predominate. That such is the case probably results from the more-or-less constant involvement of the government with the Toronto General, with both originating and growing together, and even, at one time, occupying the same building. The long-standing implicit consensus among ordinary people that the hospital ought to function as a public non-profit institution is another likely reason. Even as early as 1908 people from the United States attending the Toronto meeting of the American Hospital Association commented on the different and, for them, better manner in which hospitals such as the Toronto General were able to function on a mix of public and other funds and to treat all those in need. Under the social aegis of unbridled optimism in technological

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progress, coupled with apparently unlimited third-party and public funding, Toronto General doctors achieved significant clinical and research milestones in the second half of the twentieth century. However, the elevated importance of research work, the pressures of medical teaching, and the constant demands of patient care raised the pressing issue of institutional priorities. For all the benefits that accrued from these medical paths, did the privileging of one over another redefine the hospital's goal of doing good? Few would deny that a Canadian teaching hospital such as the Toronto General was striving to 'do good,' but had it not become too big, too impersonal, too factory-like, too American? Had the focus shifted too much, as David Rosner described the American situation, from 'doing good' to 'doing well' from a business and administrative perspective?12 Meanwhile, government bureaucrats would no longer indulge hospitals that operated with a deficit. From the 19705 the medical profession's prestige went into decline - doctors entered into disputes over remuneration with governments; the glitter of technological Utopia began to fade; the public became concerned with scandals over such matters as the tragically flawed Canadian blood supply; and the rise of consumerism made Canadians generally more critical of venerable and trusted institutions such as hospitals. Doing good, whatever else it meant, now embraced the aim of institutional survival by whatever measures. At one level, these pressures increased cooperation between hospitals neighbouring the Toronto General through shared costs of equipment and services. At another, they led to suspicion, fear, and strife as the Toronto General engaged in mergers, amalgamations, and takeovers of other city hospitals. The first obvious outcome was the creation of the corporate entity known as the University Health Network, consisting of the Toronto General, Toronto Western, and Princess Margaret hospitals. A second involved the ongoing reorganization and ' prioritization' of these hospitals' clinical activities. Growing from the Ontario Institute of Radiotherapy, originally based in the Toronto General, the Princess Margaret Hospital continues to focus on cancer care and radiotherapy; it now also performs the surgery in cancer treatment that was once the domain of the Toronto General. The Toronto Western Hospital positioned itself to pursue the neurosciences specialty, which moved to its site after decades of success at the Toronto General; the Western now has Canada's largest neuroscience centre. And while the Toronto General continues to pursue a broad range of specialties, it will emphasize transplantation and cardiac sciences. To facilitate its new priorities, it

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has also transferred its trauma and obstetrical programs to St Michael's and Mount Sinai hospitals, respectively. The transfer of clinical programs from one hospital to another was very much a reaction to prevailing conditions in the 19905, though often articulated in the rhetoric of 'proaction,' as decision makers such as Alan Hudson tried to anticipate the place of the hospital in the global community of the new millennium. Broadly speaking, it reveals a plan to replace the general hospital qua medical department store, as it had evolved in the late nineteenth and early twentieth centuries, with a more focused and specialized roster of services and products to serve clients in the twenty-first century. Such thinking also reflects the culmination of business ideology within the hospital that first became evident at the beginning of the twentieth century. The corporate-wide identity project of promoting 'brand recognition' in the late 19905 through the creation of a new name, new logo, and other signage is indicative of business methods in action. The name 'University Health Network' does not mention 'hospital,' which connotes a monolithic structure at one particular site - a concept that no longer accurately reflects Toronto's general hospital at present or in the future. Similarly, it reflects a trend in the United States in which mergers and the redistribution of clinical services among hospitals may lead to the decline in dominance of the general hospital. Increasingly, it is recognized that over-reliance on hospitals by both the public and the medical profession has taken place at the expense of less costly domestic, primary care. Progress in hospital care in the twenty-first century might be gauged by the degree to which hospital services are de-emphasized13 or balanced with those available through home care. The name 'University Health Network' recognizes the tight interweaving of the hospital and the university-based medical school that has created a new entity - what has been called in Toronto the 'hospiversity.' Though an ungainly term (perhaps 'mediplex' or 'healthplex' would be less jarring?), the notion accurately captures what Toronto's general hospital has become and points the way of its future development within the University Health Network. Despite the problems dogging the health care system in Canada, including overloaded emergency rooms, patients being sent (again) to American cities for cancer treatment, nurses leaving the profession, and government vacillation on funding,14 Toronto's general hospital (however labelled) seemed set in its continuing course of doing good for a third century.

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Notes

Abbreviations AMH AO BAJ BAJMPS BAMPJ BHM CBMH CH CJMSc CJMSu CL CL&P CMAJ CMJ CMR CP CPR DCB DM] DMM HMNW HW JHAUC JHMAS

Annals of Medical History Archives of Ontario, Toronto British American Journal British American Journal of Medical and Physical Science British American Medical and Physical Journal Bulletin of the History of Medicine Canadian Bulletin of Medical History Canadian Hospital Canadian Journal of Medical Science Canadian Journal of Medicine and Surgery Canada Lancet Canada Lancet and Practitioner Canadian Medical Association Journal Canada Medical Journal and Monthly Record of Medical and Surgical Science Canadian Medical Review Canadian Practitioner Canadian Practitioner and Review Dictionary of Canadian Biography Dominion Medical Journal Dominion Medical Monthly and Ontario Medical Journal Hospital, Medical and Nursing World Hospital World Journal of the House of Assembly of Upper Canada Journal of the History of Medicine and Allied Sciences

2?2

Notes to pages 4-5

JLAPC MC MH NAG OH QUA-FP

Journal of the Legislative Assembly of the Province of Canada Medical Chronicle Medical History National Archives of Canada, Ottawa Ontario History Queen's University Archives, Kingston, Ontario, Joseph W. Flavelle Papers TAHA Transactions of the American Hospital Association TGH Toronto General Hospital TRL Toronto Reference Library TWH Toronto Western Hospital UCJ Upper Canada Journal of Medical, Surgical and Physical Science UHN-OP University Health Network, Toronto, Office of the President UHNA-OCI/PMH University Health Network Archives, Toronto, Ontario Cancer Institute/Princess Margaret Hospital fonds UHNA-TGH University Health Network Archives, Toronto, Toronto General Hospital fonds Introduction: A Social and Political Barometer 1 Expressions of these various facets of the hospital, either implicitly or explicitly, appear in its very architecture. In fact, the relationship between architectural design and function affords another excellent window on changes in the hospital. See W. Gill Wylie, Hospitals: Their History, Organization, and Construction (New York: D. Appleton, 1877); Edward F. Stevens, The American Hospital of the Twentieth Century (New York: Architectural Record Company, 1921); John D. Thompson and Grace Goldin, The Hospital: A Social and Architectural History (New Haven, Conn.: Yale University Press, 1975); and David Charles Sloane, 'Scientific Paragon to Hospital Mall: The Evolving Design of the Hospital,' Journal of Architectural Education 48 (Nov. 1994): 82-98. 2 Michael Shortland, Medicine and Film: A Checklist, Survey and Research Resource (Oxford: Wellcome Unit for the History of Medicine, 1988); see also Moving Pictures, special issue of Literature and Medicine 17 (spring 1998). 3 Guenter B. Risse, Mending Bodies, Saving Souls: A History of Hospitals (New York: Oxford University Press, 1999) 4 See Lindsay Granshaw and Roy Porter, eds., The Hospital in History (London: Routledge, 1989); Grace Goldin, Work of Mercy (Toronto: Stoddart, 1994); Daniel Hickey, Local Hospitals inAncien Regime France: Rationalization, Resistance, Renewal, 1530-1789 (Montreal: McGill-Queen's University Press, 1997);

Notes to pages 5-7

273

Christopher Lawrence, Medicine in the Making of Modern Britain (London: Routledge, 1994), 2O; Roy Porter, The Gift Relation: Philanthropy and Provincial Hospitals in Eighteenth-Century England/ in Granshaw and Porter, eds., Hospital in History, 165. See also Jonathan Barry and Colin Jones, eds., Medicine and Charity Before the Welfare State (London: Routledge, 1991). 5 Robert Pinker, English Hospital Statistics, 1861-1938 (London: Heinemann, 1966), 57; [A.A. Allan], The Hospitals of Ontario: A Short History (Toronto: H.H. Ball, 1934); and Morris Vogel, The Invention of the Modern Hospital: Boston 1870-1930 (Chicago: University of Chicago Press, 1980), 'Introduction* 6 Charles E. Rosenberg, The Care of Strangers: The Rise of America's Hospital System (New York: Basic Books, 1987) 7 Nancy Cybulski et al., Reinventing Hospitals: On Target for the 21st Century (Toronto: McLeod Publishing, 1997) 8 S.E.D. Shortt, The Canadian Hospital in the Nineteenth Century: An Historiographic Lament,' Journal of Canadian Studies 18 (winter 1983-4): 3-14 9 Colin Howell, A Century of Care: A History of the Victoria General Hospital in Halifax, 1887-1987 (Halifax: Victoria General Hospital, 1988); and David Gagan, A Necessity among Us: The Owen Sound General and Marine Hospital, 1891-1985 (Toronto: University of Toronto Press, 1990) Since an essay review appeared in 1990, J.T.H. Connor, 'Hospital History in Canada and the United States,' CBMH^j (1990): 93-104, other published histories include Neville Terry, The Royal Vic: The Story of Montreal's Royal Victoria Hospital, 1894-1994 (Montreal: McGill-Queen's University Press, 1994); and Lesley Marrus Barsky, From Generation to Generation: A History of Toronto's Mount Sinai Hospital (Toronto: McClelland and Stewart, 1998). 10 For example, Denis Goulet, Francois Hudon, and Othmar Keel, Histoire de I'Hopital Notre-Dame de Montreal, 1880-1980 (Montreal: VLB Editeur, 1993) 11 For Quebec, see Francois Rousseau, La Croix et le scalpel: Histoire des Augustines et de rHotel-Dieu de Quebec, 1:1639-1892 (Sillery, Que.: Editions du Septentrion, 1989); Albert Desbiens and Yvan Lamonde, eds., L'Hotel-Dieu de Montreal (1642-1973) (Montreal: Editions Hurtubise HMH, 1973); Normand Perron, Un Siecle de vie hospitaliere au Quebec: Les Augustines et rHotel-Dieu de Chicoutimi, 1884-1984 (Sillery, Que.: Presses de 1'Universite du Quebec, 1984); and 'L'Hotel-Dieu de Quebec: 350 ans de soins hospitaliers,' Revue d'histoiredu Quebec Cap-aux-Diamants, hors serie 1989. Studies of Roman Catholic hospitals in the Anglo-Canadian context include JJ. Dinan, St. Mary's Hospital: The Early Years (Montreal: Optimum Publishing International, 1987); R. Alexander Stephen and L. Mackie Smith, The History of St. Joseph's Hospital: Faith and Caring, London, Canada (London, Ont.: St Joseph's Health Centre of London, 1988); Irene McDonald, For the

274

Notes to pages 7-lQ

Least of My Brethren: A Centenary History of St. Michael's Hospital (Toronto: Dundurn Press, 1992); Jessie V. Deslauriers, Hotel Dieu Hospital, Kingston 18451995- The House of Tender Mercy Continuing to Serve (Kingston: Hotel Dieu Hospital, 1995); and Christopher J. Rutty, A Circle of Care: 75 Years of Caring, St. Mary's General Hospital (Kitchener, Ont: St Mary's General Hospital, 1999). 12 C.K. Clarke, A History of the Toronto General Hospital (Toronto: William Briggs, 1913); W.G. Cosbie, The Toronto General Hospital, 1819-1965: A Chronicle (Toronto: Macmillan, 1975); and Martin O'Malley, Hospital: Life and Death in a Major Medical Centre (Toronto: Macmillan, 1986) 13 Guenter B. Risse, 'Hospital History: New Sources and Methods,' in Roy Porter and Andrew Wear, eds., Problems and Methods in the History of Medicine (London: Croom Helm, 1987), 175-203. For an introduction to types of hospital records and a comparative list of those extant in fifty-seven institutions, see Barbara L. Craig, 'A Guide to Historical Records in Hospitals in London, England and Ontario, Canada c. i8oo-c. 1950. Part I: An Overview of the Continuities and Changes in the Content and the Forms of Records,' CBMH 8 (1991): 263-87; and Tart II: A Consolidated List of Records,' CBMHy (1992): 71-141. The destruction or lack of retention of hospital records remains a problem for historians; see Carolyn Heald, 'Challenges Posed by Health Care Restructuring in Ontario,' CBMH 16 (1999): 147-54 and Donna Kynaston, 'Establishing Standards for Health Care Archives: A Case Study of the Calgary Regional Health Authority,' CBMHi6 (1999): 155-61. /: A Hospital for Muddy York - Eventually, 1797-1840 1 TRL, Baldwin Room, Peter Russell Papers, Letterbook 1796-1808, Peter Russell to John Graves Simcoe, 9 Dec. 1797; and NAC, Minutes of Executive Council, 20 Dec. 1797, Upper Canada State Book B, 93, quoted in Edith G. Firth, The Town of York, 1793-1815: A Collection of Documents of Early Toronto (Toronto: University of Toronto Press, 1962), 47 2 John Douglas, Medical Topography of Upper Canada (London: Burgess and Hill, 1819), 5, 9> 10, 14 3 TRL, Baldwin Room, Elizabeth Russell Papers, Diary of Elizabeth Russell 1806-1808 4 'Select Committee on Regulating the Practise of Medicine [24 September 1792],' in Richard Sage and Aileen Weir, eds., Select Committees of the Assemblies of the Provinces of Upper Canada, Canada and Ontario 17g 2-1991: A Checklist of Reports (Toronto: Ontario Legislative Library, 1992), 1 5 Joseph F. Kett, The Formation of the American Medical Profession: The Role of Institutions, 1780-1860 (New Haven, Conn.: Yale University Press, 1968);

Notes to pages IQ-22

6 7 8 9 10

11 12

275

M.Jeanne Peterson, The Medical Profession in Mid-Victorian London (Berkeley: University of California Press, 1978); and Kett, 'American and Canadian Medical Institutions, 1800-1870,' JHMAS 22 (1967): 343-56 An Ex-settler, Canada in the Years 1832, 1833, and 1834 (Dublin: Philip Dixon Hardy, 1835), 23 William R. Riddell, The First Medical Case in the Province,' Canadian Law Times 35 (1915): 580-3 William Colgate, 'Dr. Robert Kerr: An Early Practitioner of Upper Canada,' CMA/64( 1951): 542-6 Mary Harrington Farmer, 'The Ledger of an Early Doctor of Barton and Ancaster, 1798-1801,' WentworthBygones8 (1969): 34-8 In The Medical Profession in Upper Canada, 1783-1850 (Toronto: William Briggs, 1894), William Canniff attributed this quotation to Robert Gourlay, but in all likelihood it came from Barnabas Bidwell; see S.R. Mealing's introduction to Robert Gourlay, Statistical Account of Upper Canada (1822; reprint, Toronto: McClelland and Stewart, 1974), 18 n 88. Gourlay, Statistical Account, 203, 226 Thomas Gibson, 'News Notes Illustrative of the Practice of Medicine in Upper Canada, in the Early Years of the Nineteenth Century,' CMAJ22

(1930): 699-700 13 William Buchan, Domestic Medicine; or a Treatise on the Prevention and Cure of Diseases (1769). This book went through over 140 'editions' until publication of it ceased in Britain in 1846 (although the work continued to be published in the United States until 1913). See CJ. Lawrence, 'William Buchan: Medicine Laid Open,' M//19 (1975): 20-35; and Charles E. Rosenberg, 'Medical Text and Social Context: Explaining William Buchan's Domestic Medicine,' BHMtf (1983): 22-42. 14 AO, Diary of Ely Playter, quoted in Firth, York, 1793-1815, 249 15 TRL, Diary of Elizabeth Russell 16 Douglas, Medical Topography, 106-7, 81 17 NAC, Neilson Papers, John Bennett to John Neilson, 18 Sept. 1801, quoted in Firth, York, 1793-1815, 242 18 Douglas, Medical Topography, 71 19 Charles G. Roland, '"Sunk Under the Taxation of Nature": Malaria in Upper Canada,' in Roland, ed., Health, Disease and Medicine: Essays in Canadian History (Toronto: Hannah Institute for the History of Medicine, 1984), 154-70. On folk medical beliefs, see Wayland D. Hand, Magical Medicine: TheFolkloric Component of Medicine in the Folk Belief, Custom, and Ritual of the Peoples of Europe and America (Berkeley: University of California Press, 1980); and Hand, American Folk Medicine: A Symposium (Berkeley: University of California Press, 1976).

276

Notes to pages 22-6

20 Colgate, 'Robert Kerr,' 542-6 21 TRL, Diary of Elizabeth Russell 22 J.T.H. Connor, '"Larger Fish to Catch Here than Midwives": Midwifery and the Medical Profession in Nineteenth-Century Ontario,' in Dianne Dodd and Deborah Gorham, eds., Caring and Curing: Historical Perspectives on Women and Healing in Canada (Ottawa: University of Ottawa Press, 1994), 103-34 23 Robert L. Fraser, 'Baldwin, William Warren,' DCB, VII, 35-44. On the medical world of Edinburgh, see R.G.W. Anderson and A.D.C. Simpson, eds., The Early Years of the Edinburgh Medical School (Edinburgh: Royal Scottish Museum, 1976); Guenter B. Risse, Hospital Life in Enlightenment Scotland: Care and Teaching at the Royal Infirmary of Edinburgh (Cambridge: Cambridge University Press, 1986); and Lisa Rosner, Medical Education in the Age of Improvement: Edinburgh Students and Apprentices, 1760-1826 (Edinburgh: Edinburgh University Press, 1991). 24 TRL, St George Papers II, William Warren Baldwin to Quetton St George, 22 Sept. 1810, quoted in Firth, York: 1^3-1815, 276 25 Jane Errington, The Lion, the Eagle, and Upper Canada: A Developing Colonial Ideology (Montreal: McGill-Queen's University Press, 1987), 55 26 AO, Diary of Ely Playter, quoted in Firth, York: 1793-1815, 281; AO, John Strachan to Dr Owen, 1 Jan. 1814, quoted in Firth, 324-5. See also Charles G. Roland, 'War Amputations in Upper Canada,' Archivaria 10 (summer 1980): 73-8427 Douglas, Medical Topography, 85 28 Errington, The Lion, the Eagle, and Upper Canada, 86 29 Peter Oliver, 'Terror to Evil-Doers': Prisons and Punishments in Nineteenth-Century Ontario (Toronto: University of Toronto Press, 1998), 89-90 30 TRL, Baldwin Room, Society of Friends to the Stranger in Distress (report for 1824-5); and Audrey Saunders Miller, ed., The Journals of Mary O'Brien, 18281838 (Toronto: Macmillan, 1968), 32. On other charitable societies at the time, see 'York Emigrant Committee,' (York) Canadian Freeman, 19 April 1832, 2, for the York Emigrant Society; and 'York Widow and Orphan Society,' (York) Christian Guardian, 30Jan. 1833, 1, for the Society for the Relief of the Orphan, Widow, and Fatherless. The latter society in particular linked the dispensing of Christian charity with the instilling of moral values, noting that it was 'actuated by virtuous and religious principles and motives' to avert future crime posed by poverty among children. 31 Oliver, 'Terror to Evil-Doers,'100-1 32 John Strachan, A Sermon Preached at York, Upper Canada, Third of July, 1825, on

Notes to pages 26-34

277

the Death of the Lord Bishop of Quebec (Kingston: James Macfarlane, 1826), quoted in William Westfall, Two Worlds: The Protestant Culture of NineteenthCentury Ontario (Kingston: McGill-Queen's University Press, 1989), 23 33 Westfall, Two Worlds, 23 34 TRL, Baldwin Room, Early Toronto Papers, Board of Health Papers 6-34, W.D. Powell, 'Some Account of the General Hospital at York' (manuscript); and C.K. Clarke, A History of the Toronto General Hospital (Toronto: William Briggs, 1913), 20-33 35 TRL, Baldwin Room, Early Toronto Papers, Board of Health Papers 6-34 36 TRL, Baldwin Room, Broadside Collection, (Report of) Meeting of the Governesses for the Relief of Women during Their Confinement, Held at the Government House on the I2th November 182'/; and Report of the Proceedings of the Female Society for the Relief of Poor Women in Child-Birth (York: J. Carey, 1825) 37 UHN-OP, Board of Trustees, Minutes of Meetings, 15 June 1822 and 6 Jan. 1825. Minutes of the trustees of Toronto's general hospital have recently been bound in volumes, some covering decades for the early period in York; for conciseness I cite them as Minutes of Trustees by date of meeting. 38 TRL, Powell, 'Some Account of the General Hospital at York' 39 S.R. Mealing, 'Powell, William Dummer,' DCB, VI, 605-13; and Patrick Brode, 'Powell, Anne,' DCB, VI, 603-5 40 'Select Committee on the Subject of a Building for the Legislature [26 Dec. 1825],' in Sage and Weir, eds., Select Committees, 21-2 41 Rainer Baehre, 'Pauper Emigration to Upper Canada in the 18305,' Histoire Sociale/Social History 14 (Nov. 1981): 355-6 42 JHAUC, Session 1828, 116, quoted in Firth, York: 1815-1834, 230-1 43 See (York) Loyalist, 24 June 1829, quoted in Firth, York: 1815-1834, 22. 44 NAG, Macaulay Papers, George H. Markland to John Macaulay, 29 Dec. 1829, quoted in Firth, York: 1815-1834, 22-3 45 Rules and Regulations Proposed for the Government of the General Hospital (York: Robert Stan ton, 1830). These rules were first proposed by John Strachan and accepted by the hospital's board 12 Dec. 1829, Minutes of Trustees 46 UHN-OP, Minutes of Trustees, 30 Sept. 1830 and 7 May 1831 47 No full-length biography exists for Widmer, but see Margaret Charlton, 'Christopher Widmer,' AMH4 (1922): 346-50; R.I. Harris, 'Christopher Widmer (1780-1858) and The Toronto General Hospital' (typescript), 1963; and Paul Romney, 'Widmer, Christopher,' DCB, VIII, 931-6. 48 JHAUC, Session 1830, 'Report of the York Hospital and Dispensary,' 38 49 JHAUC, Session 1831, Appendix, 'Annual Report of the York Hospital and Dispensary,' 169 50 Margaret Pelling, Cholera, Fever and English Medicine, 1825-1865 (Oxford:

278

Notes to pages 34-41

Oxford University Press, 1978); Michael Durey, The Return of the Plague: British Society and the Cholera, 1831-2 (Dublin: Gill and Macmillan, 1979); and Charles E. Rosenberg, The Cholera Years: The United States in 1832, 1849, and i860 (Chicago: University of Chicago Press, 1987) 51 Geoffrey Bilson, A Darkened House: Cholera in Nineteenth-Century Canada (Toronto: University of Toronto Press, 1980); C.M. Godfrey, The Cholera Epidemics in Upper Canada 1832-1866 (Toronto: Seccombe House, 1968); and Marian A. Patterson, The Cholera Epidemic of 1832 in York, Upper Canada,' Bulletin of the Medical Library Association 46 (1958): 165-84 52 Dundas Museum, Diary of James Lesslie, quoted in Firth, York: 1815—1834, 240-5; AO, MU 7453, James C. Goodwin Collection, 1813-1953, HenryJ. Boulton to Samuel Street, 31 July 1832 53 NAG, John Strachan to Richard Whatley, 24 Sept. 1832, quoted in Firth, York: 1815-1834, 253-4 54 TRL, Baldwin Room, Early Toronto Papers, 8131 Board of Health Minutes, 1832, Board of Health Minutes, 25 June 1832 55 See (York) Courier of Upper Canada, 15 Aug. 1832, quoted in Firth, York: 18151834, 251-2. 56 Bilson, A Darkened House, 58-9; see also TRL, Baldwin Room, Early Toronto Papers, Board of Health Papers 6-34, John Rolph to George Ridout, 3 Aug. 1832. 57 TRL, Baldwin Room, Early Toronto Papers, Board of Health Papers B-34, James Cathcart to George Ridout, [3 Aug. 1832] 58 JHAUC, Session 1831-32, Appendix, 'Annual Report of the York Hospital and Dispensary,' 17; and JHAUC, Session 1832-33, Appendix, 'Annual Report of the General Hospital and Dispensary,' 81 59 See (York) Courier of Upper Canada, 13 Oct. 1832, quoted in Firth, York: 18151834, 25460 (Brockville) Recorder, 9 Nov. 1830, i; 2 June 1831, 3. See also Edwin Seaborn, The March of Medicine in Western Ontario (Toronto: Ryerson Press, 1944); and E.N. Lewis, Early Medical Men of Elgin County (St Thomas, Ont.: Sutherland Press, 1931). 61 Canniff, Medical Profession, 61-2, 71 62 NAG, Upper Canada Sundries, Vol. 137, quoted in Firth, York: 1815-1834,176-7 63 Meeting of the Medical Board of Upper Canada, Oct. 1836, quoted in Canniff, Medical Profession, 85 64 Anna Jameson, Winter Studies and Summer Rambles in Canada (1838; reprint, Toronto: McClelland and Stewart, 1965), 74 65 UHN-OP, Minutes of Trustees, 'General Statement of Receipts and Payments Made on Account of The Toronto General Hospital to 31st December

Notes to pages 4 7-5

279

1841'; JHAUC, Session 1836, Appendix 69, 'Annual Return of the General Hospital i February 1835-1 February 1836,' j-S;JHAUC, Session 1836-37, Appendix 36, 'Report of the General Hospital, Toronto';/HA UC, Session 1837-38, Appendix, 'Report of the General Hospital, Toronto, Commencing 1st January and Ending 31st December 1837,' 4O%;JHAUC, Session 1839-40, Appendix, 'Report of the General Hospital, Toronto [i Jan. 1839 to 8 Dec. 18391/308-10 66 JHAUC, Session 1835, Appendix 21, 'Seventh Report of Committee of Grievances,' 79. See Paul Romney, 'A Struggle for Authority: Toronto Society and Politics in 1834,' in Victor L. Russell, ed., Forging a Consensus: Historical Essays on Toronto (Toronto: University of Toronto Press, 1984), 9-40. 67 Canniff, Medical Profession, 86-9 68 JHAUC, Session 1836, Appendix 69, 'Documents Sent Down by His Excellency the Lieut.-Governor, Relating to the Provincial Hospital and Its Revenues and Endowments,' 2-14 69 UHN-OP, Minutes of Trustees, 28 Feb. 1839 70 Rainer Baehre,' The Medical Profession in Upper Canada Reconsidered: Politics, Medical Reform, and Law in a Colonial Society,' CBMH12 (1995): 101-24 71 Robert J. Burns, 'Markland, George Herchmer,' DCB, IX, 534-6 2: Medical Politics, Political Doctors, and a Beleaguered Hospital, 1841-1856 1 R.D. Gidney and W.P.J. Millar, Inventing Secondary Education: The Rise of the High School in Nineteenth-Century Ontario (Montreal: McGill-Queen's University Press, 1990); A.B. McKillop, Matters of Mind: The University in Ontario, I79i-igt)i (Toronto: University of Toronto Press, 1994) 2 J.M.S. Careless, The Union of the Canadas: The Growth of Canadian Institutions, 1841-1857 (Toronto: McClelland and Stewart, 1967) 3 Gregory S. Kealey, 'Orangeism and the Corporation: The Politics of Class during the Union of the Canadas,' in Victor L. Russell, ed., Forging a Consensus: Historical Essays on Toronto (Toronto: University of Toronto Press, 1984), 76 4 See W.H. Kesterton, A History of Journalism in Canada (Toronto: McClelland and Stewart, 1967); Elizabeth Hulse, A Dictionary of Toronto Printers, Publishers, Booksellers and the Allied Trades, ipgS-igoo (Toronto: Anson-Cartwright Editions, 1982); and Edith G. Firth, ed., Early Toronto Newspapers, 1703-1867 (Toronto: Baxter, 1961). 5 On the Anglo-American Magazine and its editor, Robert Macgeorge, seeJ.J. Talman, 'Macgeorge, Robert Jackson,' DCB, XI, 557-8; and Frederick H. Armstrong and Neil C. Hultin, 'The Anglo-American Magazine Looks at Urban

280

Notes to pages 45-8

Canada on the Eve of the Railway Era,' in Edith G. Firth, ed., Profiles of a Province: Studies in the History of Ontario (Toronto: Ontario Historical Society, 1967), 43-58. 6 Letter by 'A Medical Student/ (Toronto) British Colonist, 24 March 1855 7 See Jennifer J. Connor, 'To Advocate, To Diffuse, and To Elevate: The Culture and Context of Medical Publishing in Canada, 1630 to 1920,' PhD thesis, University of Western Ontario, London, Ont., 1992, chap. 5; and Charles G. Roland, 'Ontario Medical Periodicals as Mirrors of Change,' OH 72 (1980): 5-15. 8 Gerald M. Craig, Upper Canada: The Formative Years, 1784-1841 (Toronto: McClelland and Stewart, 1963), chap. 13 9 Charles R. Sanderson, ed., The Arthur Papers, Being the Canadian Papers ...of Sir George Arthur, KC.H.,^vols. (Toronto: University of Toronto Press, 1957), 2:304 10 George Metcalf, 'Draper, William Henry,' DCS, X, 253-9 11 JHAUC, Session 1839-40, 'Message of His Excellency the Governor General, and Report of Commissioners on the State of the Provincial Hospital at Toronto [6Jan. 1840],' 313-19 12 UHN-OP, Minutes of Trustees, 20 Aug. 1842, 11 Aug. 1843 13 'Toronto Hospital,' British Colonist, 12 May 1841 14 UHN-OP, Minutes of Trustees, i Oct. 1841, 20 Jan., 12 Feb., 5 March 1842 15 On Armstrong and on Ross, see Edith G. Firth, The Town of York, 1815-1834 (Toronto: University of Toronto Press, 1966), 127 and 85, respectively. Marion Bell MacRae, 'Ewart (Euart), John,' DCB, VIII, 280-2; Douglas McCalla, 'Ridout, George Percival,' DCB, X, 619-20; and H.E. Turner, 'Grasett, Henry James,' DCB, XI, 367-9 16 Barrie Dyster, 'Harris, Thomas Dennie,' DCB, X, 335-6 17 Quoted in William Canniff, The Medical Profession in Upper Canada, 1783-1850 (Toronto: William Briggs, 1894), 215 18 JLAPC, Session 1847, Appendix II, 'Toronto Hospital Bill' 19 'An Act to Incorporate the Trustees of the Toronto Hospital,' 10 and 11 Vic., cap. 57, [1847], 1583-6 20 UHN-OP, Minutes of Trustees, 3 Sept. 1847 21 Hereward Senior, 'Boulton, William Henry,' DCB, X, 79-81 22 UHN-OP, Minutes of Trustees, 21, 22 Jan. 1848. Within a few years, Widmer would confide not only that all trustees should be laymen but that 'Doctors should have no seat in the Board!': University of Toronto, Thomas Fisher Rare Book Library, Academy of Medicine Collection, William Thomas Aikins Papers, Box 2, File 89, Christopher Widmer to John Rolph, 23 March 1853-

Notes to pages 49-54

281

23 UHN-OP, Minutes of Trustees, 19 Aug. 1845, 3 Sept., 12, 19, 26 Nov. 1847, 14, 24 Jan., 15 Feb., 15 April 1848 24 Ibid., 20June 1845, 24jan. 1846 25 Ibid., 5 March, 1, 13 July 1842, 19, 23, 26 Nov. 1847 26 Ganniff, Medical Profession, 177, 387, 422 27 UHN-OP, Minutes of Trustees, 13 May, 5 Sept. 1840, 1 Oct. 1841 28 Ibid., 15 Sept. 1847 29 Ibid., ljuly 1842 30 R.D. Gidney and W.P.J. Millar, Professional Gentlemen: The Professions in Nineteenth-Century Ontario (Toronto: University of Toronto Press, 1994), 403-5 31 UHN-OP, Minutes of Trustees, 24 Nov. 1842, 19 Nov. 1847, 15 Feb. 1848 32 Ibid., 14 June 1845, 25 March, 15 April 1848 33 Ibid., 16 May, 11 Aug. 1843, *5 MaY ^45; AO, Ms. 385, Toronto City Council Papers, G. Ryerson to Charles Daly, 25 Jan. 1847, and C. Widmer to Mayor of Toronto, 28 Oct. 1848 34 UHN-OP, Minutes of Trustees, 28 June, 8 Dec. 1842, 22 Nov. 1843, 14, 20 June 1845 35 UHNA-TGH, Ace. TG-OO3O, TG 1.8.1, Board of Trustees Visitors Register, 'Toronto General Hospital Register' 36 UHN-OP, Minutes of Trustees, 19 Aug. 1845 37 Ibid., 12 March 1842 38 AO, Ms. 385, Toronto City Council Papers, Petition of the Committee of Management of the Toronto Lying-in Hospital, 4 Oct. 1848; TRL, Baldwin Room, Report of the Toronto Lying-in Hospital, for the Year 1857 39 UHN-OP, Minutes of Trustees, 20 Jan. 1842, 11 Sept. 1847 40 Thomas E. Brown, The Origin of the Asylum in Upper Canada, 1830-1839,' CBMHi (1984): 27-58; and Brown '"Architecture as Therapy,"' Archivaria 10 (summer 1980): 99-124 41 UHNA-TGH, Toronto General Hospital Register,' 30 May 1856 42 UHN-OP, Minutes of Trustees, 19 Feb. 1846 43 Ibid., 21 Jan. 1848 44 John King, 'Cases of Psoriasis Invetera,' UCJi (1851-2): 45-53 45 'A Clinical Lecture upon a case of abscess in the perineum of a patient, treated in the Toronto General Hospital: By Dr. Aikins, one of the surgeons of that Institution. Reported by Mr. Gamble, a student of the Toronto School of Medicine,' UCJ$ (1853-4): 158-67 46 James Bovell, 'Cases of Angeioleucitis or Barbados Leg, with remarks on the probable Pathology of that Disease,' UCJi (1851-2): 235-9, 273-7, 453-8, 505-8

282

Notes to pages 54-61

47 Julian A. Smith, William R. Beaumont: Mechanical Genius (Toronto: Fitzhenry & Whiteside, 1995) 48 William Beaumont, 'Cheiloplasty, and operation for Atresia oris,' UCJi (1851-2): 54-9 49 William Beaumont, 'Cases of Operations for Cataract, chiefly at the Toronto General Hospital,' UCJi (1851-2): 329~32,36i-5» 407-11, 51O-5; 2 (1852-3): 177-9 50 JLAPC, Session 1856, Appendix No. 4, 'Return [of the Toronto General Hospital]'; 'Hospital Economics,' BAJi (1860): 230-1 51 Despite the numerous preventive and treatment measures put in place, the hospital and its doctors remained a target for criticism and ridicule. This popular response stemmed as much from fear of disease as from disdain for action taken by physicians in the hospital. See 'Emigration, Disease, and Death,' Toronto Mirror, 20 Aug. 1847; 'Two in One Coffin,' Toronto Mirror, 10 Sept. 1847; and 'Health of the City,' Toronto Mirror, 10 Sept. 1847. 52 The Late Dr. Grasett,' BAJMPS$ (1847): no. Grasett's obituary, written probably by his brother, captures much of the poignancy and concern of the moment: 'In the humble abodes of the suffering poor of this large town, in the reception room of the [Toronto General] Dispensary where his benevolent smile was wont to greet them, his virtues are the theme of daily praise, and his death the subject of deep and lasting sorrow... His death has furnished another evidence of the fatal efficacy of the exciting cause of the fever at present raging among the emigrants, the true character of which has been concealed under an unmeaning name.' See also 'Obituary [Joseph Hamilton],' BAJMPS 3 (1847): 222. 53 UHN-OP, Minutes of Trustees, 18, 22, 29 April 1848 54 See W.F. Bynum, 'Nosology,' in W.F. Bynum and Roy Porter, eds., Companion Encyclopedia of the History of Medicine, 2 vols. (London: Routledge, 1993), 1: 335-56. 55 W.F. Bynum, 'Hospital, Disease and Community: The London Fever Hospital, 1801-1850,' in Charles E. Rosenberg, ed., Healing and History: Essays for George Rosen (New York: Science History Publications, 1979), 97-H5 56 JHAUC, Session 1839-40, 'Message of His Excellency the Governor General,' 319 57 'York Dispensary,' 'To the Public,' 'York Dispensary - To the Poor of York,' (Toronto) Christian Guardian, 24 April 1833 58 'Toronto Dispensary and Lying-in Hospital,' Church, 6 Feb. 1851; and TRL, Baldwin Room, Annual Report of The Toronto General Dispensary and Lying-in Hospital (Toronto, 1852); Report of The Toronto General Dispensary and Lying-in

Notes to pages 61-7

283

Hospital: With List of Subscribers (Toronto, 1853); and Report of The Toronto Lying-in Hospital, for the Year 1857 59 TRL, Baldwin Room, Annual Report of The Toronto General Dispensary (1852); and Report of the Toronto General Dispensary (1853). In 1854 Dr W.T. Aikins of the Toronto School of Medicine wrote to Drjohn Rolph, its proprietor: 'We must not forget the Lying-in Hospital belonging to the Church people [Anglicans]'; quoted in George W. Spragge, 'The Trinity Medical College,' 0//58(i96o): 72. 60 'Statistics of the Toronto General Dispensary for the Year 1846,' BAJMPS2 (1847): 309-10 61 Elizabeth Jane Errington, Wives and Mothers, School Mistresses and Scullery Maids: Working Women in Upper Canada, 1790-1840 (Montreal: McGillQueen's University Press, 1995), 199-207 62 Ibid., chaps. 5 and 6 63 'Toronto Hospital,' British Colonist, 12 May 1841 64 Canniff, Medical Profession, 50-60 65 H.E. MacDermot, One Hundred Years of Medicine in Canada, 1867-196*7 (Toronto: McClelland and Stewart, 1967), 112; and Canniff, Medical Profession 66 Quoted in Canniff, Medical Profession, 116 67 The University of Toronto and Its Colleges, 1827-1906 (Toronto: University of Toronto Library, 1906), 23, 170 68 Canniff, Medical Profession, 259-62 69 UHN-OP, Minutes of Trustees, 9 Oct. 1843, Jan. 1^44, 1 Aug. 1844 70 Ibid., i Aug., 5 Oct. 1844 71 Ibid., 21 Nov. 1844 72 Canniff, Medical Profession, 459-62 73 'The Mystery Solved!' British Colonist, 3 May 1844 74 R.D. Gidney and W.P.J. Millar, '"Beyond the Measure of the Golden Rule": The Contribution of the Poor to Medical Science in Nineteenth-Century Ontario,' OHS6 (1994): 219-35; and Royce MacGillvray, 'Body Snatching in Ontario,' CBMH§ (1988): 51-60. For the general context of dissection, grave robbing, and hospitals, see E.M. Sigsworth, 'Gateways to Death? Medicine, Hospitals and Mortality, 1700-1850,' in Peter Mathias, ed., Science and Society 1600-1900 (Cambridge: Cambridge University Press, 1972), 97-110; and Ruth Richardson, Death, Dissection and the Destitute (London: Penguin, 1988). 75 Spragge, Trinity Medical College,' 63-98; and T.A. Reed, History of the University of Trinity College (Toronto: University of Toronto Press, 1952) 76 G.M. Craig, 'Rolph, John,' DCB, IX, 683-90; M.A. Patterson, The Life and Times of the Hon. John Rolph, M.D. (1793-1870),' MH$ (1961): 15-33 77 Spragge, Trinity Medical College,' 63-98; Reed, History of Trinity College

284

Notes to pages 67-71

78 See The Late Corpse Raising,' (Toronto) Globe, 3 Feb. 1849; 'Body Snatching,' British Colonist, 5 March 1850;' Grave Robbery at St. Thomas - Horrible Outrage of the Dead,' Globe, 23 Jan. 1858; The Late Outrage at St. Thomas,' Globe, 28 Jan. 1858; and 'Grave Robbing,' Globe, 10 May 1858. See also Gidney and Millar, '"Beyond the Measure of the Golden Rule."' 79 Quoted in Spragge, Trinity Medical College,' 72. See also The Anatomy Act,' UCJ1 (1851-2): 422-7, for the full text of the act and also an editorial asking why in a city such as Toronto, with three medical schools, no appointment had yet been made. It was not until 1854, with the appointment of an 'Inspector of Anatomy' for Toronto, that a mechanism regulated the distribution of corpses for dissection and instruction; it remains moot how effective this person was in his duties. See 'Inspectorship of Anatomy,' (Toronto) Leader, 6 April 1854, 2; and 'Inspectorship of Anatomy,' 'Public Notice,' UCJ 3 (1853-4): 328. 80 R.D. Gidney and W.P.J. Millar, The Reorientation of Medical Education in Late Nineteenth-Century Ontario: The Proprietary Medical Schools and the Founding of the Faculty of Medicine at the University of Toronto, 'JHMAS 49 (1994): 52-78 81 McKillop, Matters of Mind, 3-25; W. Stewart Wallace, A History of the University of Toronto, 1827-1927 (Toronto: University of Toronto Press, 1927); and Wallace, The Graduates of King's College, Toronto,' OH42 (1950): 163 82 The minutes from May 1848 to February 1866 are missing and appear to have been so for several decades. 83 'General Hospital, Toronto,' UCJ2 (1852-3): 217-18 84 The Toronto General Hospital,' UCJ2 (1852-3): 28o-[8] 85 Toronto Hospital,' (Toronto) Semi-Weekly Leader, 22 March 1853, 2; University of Toronto, Aikins Papers, Box 2, File 89, Christopher Widmer to John Rolph, 23 March 1853 86 The Ice-Boat - Sederunt IX,' Anglo-American Magazine (March 1853): 316[19]; The Editor's Shanty- Sederunt X,' Anglo-American Magazine (April 1853): 43i-[2]; The Editor's Shanty- Sederunt XI,' Anglo-American Magazine (May 1853): 526-[30]; and Talman, 'Macgeorge,' DCB, XI, 558 87 To the Readers of the Upper Canada Medical Journal,' UCJ$ (1853-4): 18-22 88 Toronto General Hospital,' UCJ3 (1853-4): 29 89 Toronto General Hospital,' UCJ3 (1853-4): 69-77; see 76-7. 90 To the Readers of the Medical Journal,' UCJ3 (1853-4): 77-8 91 'Incorporation of the Medical Profession,' UCJ3 (1853-4): 266; 'Rough Notes of a Clinical Lecture, Delivered by Dr. Beaumont, F.R.C.S., London, and One of the Surgeons to the Toronto General Hospital, on a Case of

Notes to pages 71-5

285

False Aneurism. Reported from Memory,' 251-7; 'Remarks on Dr. Beaumont's Case of False Aneurism of the Common Carotid Artery, by the Editor,' 257-8; 'Doctor Beaumont's Case of Aneurism,' 273-4; 'Dr. Beaumont's Case of Aneurism,' 325-7; 'Toronto General Hospital,' 464-9; and 'Toronto General Hospital,' 483-9 92 'Professor Liebig's Paper,' UCJ$ (1853-4)1461-3 93 'Toronto General Hospital,' UCJ$ (1853-4): 488-9 94 Toronto General Hospital,' UCJ3 (1853-4): 562 95 Canniff, Medical Profession, 640 96 'Assault by an Hospital Officer' (Toronto) Globe, 24 Feb. 1855 97 'Toronto General Hospital,' Globe, 4 April 1855; 'Toronto General Hospital - Second Day,' Globe, 5 April 1855; 'Toronto General Hospital - Third Day Concluded,' Globe, 6 April 1855; 'The Toronto General Hospital - Investigation into the Charges of Alleged Mismanagement - First Day,' Leader, 4 April 1855; 'The Toronto General Hospital... Second Day,' Leader, 5 April 1855; and 'The Toronto General Hospital... Second Day (Continued),' Leader, 6 April 1855 98 Report of an Investigation by the Trustees of the Toronto General Hospital, into Certain Charges against the Management of That Institution (Toronto: Globe Book and Job Office, 1855). Ure was a journalist who wrote first for the North American and then for the Globe', he also wrote a temperance pamphlet and TheHand-Book of Toronto (see chap. 3, n 14, below): see W. Stewart Wallace, Macmillan Dictionary of Canadian Biography (Toronto: Macmillan, 1926), 406. 99 The Toronto General Hospital,' MC2 (1855): 494-7 100 The General Hospital,' Globe, 6 April 1855; The Toronto Hospital,' (Toronto) Examiner, 11 April 1855; 'Summary,' Christian Guardian, 18 April 1855 101 Toronto General Hospital,' Examiner, 2 May 1855. See also University of Toronto, Aikins Papers, Box 2, File 87, William Aikins to John Rolph, 8 May 1855; and Box 2, File 77, Petition ofDrs. Aikins and Wright, setting forth certain grievances, and praying that the Royal prerogative may be so exercised as will ensure their restoration to the Toronto General Hospital In their petition, printed 3 April 1856, Aikins and Wright refer to a letter signed by George Herrick, W.R. Beaumont, E.M. Hodder, and James Bovell that noted that these four Trinity doctors could no longer consult with them at the hospital because of a 'total want of cordiality.' 102 See, for example, The Adjourned Inquest,' Leader, 30 July 1855, 31 July 1855; 'The Broom Case,' Leader, 1 Nov. 1855; The Blackie Inquest,' Leader, 17 Aug. 1855, 2O Aug. 1855; 'Coroner's Inquest,' Leader, 2oAug. 1855; The Blackie Inquest,' Leader, 21 Aug. 1855; 'Medical Treatment Again

286

Notes to pages 75-82

Impeached - Another Coroner's Inquest,' Globe, 9 Aug. 1855; 'The Blackie Inquest,' Globe, 15 Aug. 1855, 16 Aug. 1855, 17 Aug. 1855, 18 Aug. 1855; and The Blackie Inquest - The Verdict Rendered,' Globe, 21 Aug. 1855. 103 See Jacalyn Duffin, 'In View of the Body of Job Broom: A Glimpse of the Medical Knowledge and Practice of John Rolph,' CBMHj (1990): 9-30. 104 'Our Medical Schools,' Globe, 5 Sept. 1855; 'War amongst the Doctors' (Montreal) Argus, reprinted in Globe, 28 Aug. 1855 105 The Affairs of the Hospital,' Globe, 2 Oct. 1855 106 The Hospital Management, and Medical Department of Victoria College,' Christian Guardian, 12 Dec. 1855 107 [Editorial], Leader, 31 Jan. 1856 108 Cecilia Morgan, Public Men and Virtuous Women: The Gendered Languages of Religion and Politics in Upper Canada, 1701-1850 (Toronto: University of Toronto Press, 1996), 189-96 109 S.J.R. Noel, Patrons, Clients, Brokers: Ontario Society and Politics, I7Q1-1896 (Toronto: University of Toronto Press, 1990), 182 n 12 110 This portrayal, and the epithets from contemporaries, are from Craig, 'Rolph, John,' DCS, IX, 683-90. The descriptions came from such diverse people as Sir Francis Bond Head, George Brown, Thomas Dalton, Dr Tiger' William Dunlop, William Lyon Mackenzie, James Hervey Price, and many other 'Old Reformers.' 3: New Quarters, New Status, 1856-1875 1 Association medicale canadienne, Origine et organisation de I'Association ... avec les minutes des assemblies tenues a Quebec, octobre 1867 (Montreal, 1868); H.E. MacDermot, History of the Canadian Medical Association (Toronto: Murray, 1935) 2 The college succeeded an earlier, short-lived Upper Canadian college as well as the Medical Board of Upper Canada, both under the presidency of Christopher Widmer: see R.D. Gidney and W.P.J. Millar, The Origins of Organized Medicine in Ontario,' in Charles G. Roland, ed., Health, Disease and Medicine: Essays in Canadian History (Toronto: Hannah Institute for the History of Medicine, 1984), 65-95; and William Canniff, The Medical Profession in Upper Canada, 1783-1850 (Toronto: William Briggs, 1894), 113-74. The Toronto Medico-Chirurgical Society was formed in 1861 'to unite the members of the profession in bonds of friendship.' BAJ"2 (1861): 137-8 3 Before the advent of the College of Physicians and Surgeons of Ontario in 1869 and its annual register of licentiates, it is difficult to determine the exact number of physicians practising; these figures are informed estimates

Notes to pages 82-7

4

5 6

7 8 9 10

11

12 13

14

287

based on publications of licences issued. See BAJMPS% (1848): 247-50; BAMPJ6 (1851): 516; 7 (1851): 361; BAJ2 (1861): 44~5, 140-2, 236-9, 285-6; and 3 (1862): 93; 'Analysis of the Ontario Medical Register,' CM/7 (1870): 17-18; Ontario Medical Register, 1882, 1892, 1903; and Robert W. Powell, The Doctor in Canada (Montreal: Gazette Printing Company, 1890). For an overview of the trials and tribulations of rural medical practice in this era, seejacalyn Duffin, Langstaff: A Nineteenth-Century Medical Life (Toronto: University of Toronto Press, 1993). 'Medical Tariff, &c.,' UCJ$ (1853-4): 127-8 R.W. Garrett, 'The Science and Art of Surgery: Its Progress during the Nineteenth Century and Its Prospects for the Twentieth,' Kingston Medical Quarterly 5 (1901): 95 G.P. de T. Glazebrook, The Story of Toronto (Toronto: University of Toronto Press, I97i)» 135-40 UHN-OP, Minutes of Trustees, 3 Sept. 1847 'Toronto General Hospital - New Building' (Toronto) Leader, 5 Aug. 1853 'Sale of the Hospital Grounds,' Leader, 13 Aug. 1853; 'Building Lots,' Leader, 13, 15, 16 Aug., 10, 12, 13 Sept. 1853; 'To Contractors,' Leader, 16 Nov. 1853; and 'Toronto General Hospital Debentures,' Leader, 19 Sept. 1854 Cumulative financial data has been derived from annual tables of receipts and expenditures contained inJLAPC, Session 1856, Appendix No. 4, 'Return [of the Toronto General Hospital].' 'Toronto General Hospital,' UCJ$ (1853-4): 69-77 Eric Arthur, Toronto, No Mean City, rev. ed. Stephen Otto (Toronto: University of Toronto Press, 1986), 250. For Hay's views on architecture and the Canadian context, see his 'Architecture for the Meridian of Canada,' AngloAmerican Magazine 2 (1853): 253-5, in Geoffrey Simmins, ed., Documents in Canadian Architecture (Peterborough, Ont.: Broadview Press, 1992), 51-8. 'Charitable and Benevolent - The General Hospital' (Toronto) Globe,

13 Dec. 1856; and A Member of the Press [George P. Ure], The Hand-Book of Toronto; Containing Its Climate, Geology, Natural History, Educational Institutions, Courts of Law, Municipal Arrangements, &c. &c. (Toronto: Lovell and Gibson, 1858), 232-4 15 See Richard Splane, Social Welfare in Ontario, 1791-1893: A Study of Public Welfare and Administration (Toronto: University of Toronto Press, 1965), chap. 3; and [Ure], Hand-Book of Toronto, 234-6. 16 Rules and Regulations of the Toronto General Hospital: Adopted by the Trustees (Toronto: Leader & Patriot Book & Job Steam-Press, 1855)

17 'Government Works in Toronto,' Globe, 11 Sept. 1855; 'Toronto General Hospital,' Leader, 20 Sept. 1855

288

Notes to pages 87-94

18 UHNA-TGH, Ace. TG-OO3O TG 1.8.1, Board of Trustees Visitors Register, Toronto General Hospital Register,' 26 Sept. 1856 19 'Charitable and Benevolent,' Globe, 13 Dec. 1856 20 UHNA-TGH, Toronto General Hospital Register,' 18 Dec. 1856 21 'Melancholy Occurrence,' Globe, 19 Dec. 1856; 'Sudden Death,' Leader, 19 Dec. 1856; 'Death by Poisoning,' Leader, 2O Dec. 1856; The Inquest on the Late Dr. Clarke,' Globe, 24 Dec. 1856 22 'Death of Dr. Widmer,' MC6 (1858): 45 23 UHNA-TGH, Toronto General Hospital Register' 24 Ibid., 16 June 1865, Grand Jury of the Quarter Session and County Courts; 15 March 1866, Grand Jury of the Quarter Session for the United Counties of York and Peel; 20 Dec. 1866 [Grand Jury of the Recorder's Court] 25 Ibid., 17, I9june 1864 26 Ibid., 26 Aug. 1861, 6 June 1870, l Sept. 1868 27 UHN-OP, Minutes of Trustees, 5, 12 March 1866 28 Bruce W. Hodgins, 'Disagreement at the Commencement: Divergent Ontarian Views of Federalism 1867-1871,' in Donald Swainson, ed., Oliver Mowat's Ontario (Toronto: Macmillan, 1972), 52-68; Bruce W. Hodgins, 'John Sandfield Macdonald,' inJ.M.S. Careless, ed., ThePre-Confederation Premiers: Ontario Government Leaders, 1841-1867 (Toronto: University of Toronto Press, 1980), 246-314. See also J.E. Hodgetts, From Arm's Length to Hands-On: The Formative Years of Ontario's Public Service, 1867-1940 (Toronto: University of Toronto Press, 1995). 29 UHN-OP, Minutes of Trustees, 19 Feb. 1868 30 Ibid., 18 March 1867 31 Ibid., 22, 23, 25, 29 April, 5 Aug. 1867 32 Ibid., 23, 29 July, 30 Sept. 1867 33 The General Hospital - Meeting in Aid of the Trust Fund - Large and Influential Attendance - Bishop Lynch's Proposal Rejected,' Leader, 6 Dec. 1865, 3. On the financial crisis of 1865, see W.G. Cosbie, The Toronto General Hospital, 1819-1965: A Chronicle (Toronto: Macmillan, 1975), 618-71. On Lynch, see Charles W. Humphries, 'Lynch, John Joseph,' DCB, XI, 535-8. 34 UHN-OP, Minutes of Trustees, 4, 14 Oct. 1867, lojan. 1868; AO, William Canniff Papers, Ms. 768, Series K, Newspaper Clippings, Toronto General Hospital [Oct. 1867]. On W. Stewart Darling, see T.A. Reed, 'History of the Church of the Holy Trinity,' typescript at Holy Trinity Church, Toronto. 35 The Toronto Hospital,' CM/4 (1868): 336; The Report of the Trustees of the Toronto General Hospital,' CMJ$ (1868): 35-43 36 AO, RG 49-80, container l, Select Committee Appointed to Inquire into the State of the Toronto General Hospital, 1868

Notes to pages 94-104

289

37 UHN-OP, Minutes of Trustees, 6, 15, 27 April, 4 May 1868 38 Ibid., 22 June, 14 July 1868; 'Re-opening of the Toronto General Hospital,' DMJl (1869): 15 39 Graham Parker, 'Wilson, Sit Adam,' DCB, XII, 1107-9 40 UHN-OP, Minutes of Trustees, 22 June 1868; see also Ontario, Sessional Papers (1868-9), Vol. l, No. 22. 41 Details of the founding and operation of Ontario's other early hospitals are available in the following: Margaret Angus, Kingston General Hospital: A Social and Institutional History (Montreal: McGill-Queen's University Press, 1973); John R. Sullivan and Norman R. Ball, Growing to Serve: A History of Victoria Hospital, London, Ontario (London, Ont.: Victoria Hospital Corporation, 1985); and [A.A. Allan], The Hospitals of Ontario: A Short History (Toronto: Herbert H. Ball, 1934). 42 Peter Oliver, 'Langmuir, John Woodburn,' DCB, XIV, 601-5; Richard B. Splane, Social Welfare in Ontario, 1791-1893 (Toronto: University of Toronto Press, 1965), 46-54. After his retirement from public service, Langmuir became involved in private psychiatric care and the treatment of addicted persons; see Cheryl Krasnick Warsh, Moments of Unreason: The Practice of Canadian Psychiatry and the Homewood Retreat, 1883-1923 (Montreal: McGillQueen's University Press, 1989). 43 Ontario, Sessional Papers (1870-1), No. 6, 70-1 44 Answer of the Trustees of the Toronto General Hospital to the Report of the Inspector of Prisons, etc., Lately Presented to the Legislative Assembly (Toronto: Printed at the Leader Office, 1871) 45 Ibid., 16-18 46 Ibid., 8-10. The figure of 22 cents a day was not entirely accurate, however. Trustees' minutes reveal that the true cost for the maintenance of a patient, including staff salaries, upkeep of the hospital, and so on, was actually about 44 cents a day; see UHN-OP, Minutes of Trustees, 6 Dec. 1870. 47 Answer of the Trustees, 11-13 48 Ontario, Sessional Papers (1871-2), No. 4, 105-9 49 Ibid., No. 42, Return [of the Toronto General Hospital] 50 'Aid to Charitable Institutions,' CL\ (1872): 342-3 51 Ontario, Sessional Papers (1872-3), No. 2, 66-9 52 Hereward Senior, 'Orangeism in Ontario Politics, 1872-1896,' in Donald Swainson, ed., Oliver Mowat's Ontario (Toronto: Macmillan, 1972), 136-53 53 UHN-OP, Minutes of Trustees, 4 March 1873;