Manitoba Medicine: A Brief History 0887556604, 9780887553424

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Manitoba Medicine

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Manitoba Medicine: A Brief History

Ian Carr and Robert E. Beamish Photographs selected by Joseph Connor

THE UNIVERSITY OF MANITOBA PRESS

Ian Carr and Robert E. Beamish 1999 The University of Manitoba Press Winnipeg, Manitoba R3T 2N2 www.urnanitoba.ca/uofmpress Printed in Canada on recycled, acid-free paper °° All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, or stored in a database and retrieval system, without the prior written permission of the University of Manitoba Press, or, in the case of photocopying or other reprographic copying, a license from CANCOPY (Canadian Copyright Licensing Agency), 6 Adelaide Street East, Suite 900,Toronto, Ontario M5C 1H6. Front cover illustration: Manitoba Medical College lecture, about 1905. Cover design: Kirk Warren Text design: Karen Armstrong Maps:Weldon Hiebert The photographs are credited within their captions. Photographs with no credits are from the Archives of the Faculty of Medicine of the University of Manitoba (at the Neil John Maclean Health Sciences Library). Abbreviations for the archival repositories are: AGN (Archives of the Grey Nuns); BMHA (Brandon Mental Hospital Archives); HSCA (Health Sciences Centre Archives); NAC (National Archives of Canada) ;PAM (Provincial Archives of Manitoba) ;UMLA (University of Manitoba Libraries Archives);WCPI (Western Canada Pictorial Index).The figures in Appendix 1 are from the Department of Public Health, Winnipeg, as researched by Sean Gupton. Citations for direct quotations within the text are organized by chapter and listed by page number in the notes section at the end of the volume. Canadian Cataloguing-in-Publication Data Carr, Ian, 1932 — Manitoba Medicine: a brief history Includes bibliographical references. ISBN 0-88755-660-4 1. Medicine—Manitoba—History. I. Beamish, Robert E. II.Title. R463.M3 C37 1999 610'.97127 C99-920161-1 The University of Manitoba Press gratefully acknowledges the financial support for its publishing program provided by the Government of Canada through the Book Publishing Industry Development Program (BPIDP); the Canada Council for the Arts; the Manitoba Arts Council; and the Manitoba Department of Culture, Heritage and Citizenship. The publication of this book has been made possible with the support of the Great-West Life Assurance Company; the Department of Pathology, University of Manitoba; and the Faculty of Medicine, University of Manitoba.

Contents

Acknowledgements

ix

Introduction: Hippocrates on the Red

3

1

Healing and Pestilence in the North West: By Bay and Red 2 Foundations 3 The New Century: Cleaning Up the Mess 4 Interruption in Hell: The First World War 5 Between the Wars: Health and Medicine 6 Between the Wars: The Medical School and Specialists 7 Return to Hell: The Second World War 8 Medicine After the Second World War 9 Since the Wars: Ivory Towers 10 Since the Wars: The Specialists 11 Organized Medicine

99 123 129 153 173 207

Epilogue

219

Appendix 1: Population and Disease Statistics Appendix 2: Officials of Manitoba Medical Institutions Notes Select Bibliography Select List of Manitoba Medical Biographies

225 228 233 236 250

Index

9 23 51 75 79

252

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For Jean and Mary

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Acknowledgements

This book was cradled in the Department of Pathology, University of Manitoba, and is a product of the History of Medicine Program, University of Manitoba, which has been consistently supported by the Hannah Institute for the History of Medicine, Toronto. Along with Lord Wavell, soldier and anthologist, we would say that it is a garland of other men's flowers, and only the ribbon that binds them is our own. We have many co-authors, all gone forever down the stream. They include, in alphabetical order: Gordon Bell, Lennox Bell, Elinor Black, William Boyd, Henry Havelock Chown, Samuel Elkin, John Gemmell, Jasper Halpenny Sheppy Hershfield, Edward Montgomery, David A. Stewart, Paul Thorlakson, and in particular Ross Mitchell, physician, scholar, historian of Manitoba medicine, on whose book we have depended heavily. They would have wished to be quoted, and we have done so. If any word of theirs is not specifically acknowledged or is paraphrased imprecisely, then we ask the forgiveness of their shades. We have written this book using largely local archival material from the Manitoba medical journals and Manitoba medical biographies, as well as conversations with numerous medical colleagues. Seven annual symposia on the History of Medicine in Manitoba produced much information, subsequently published in Manitoba Medicine/Prairie Medical Journal. Unpublished material from these symposia is lodged in the archives of the Faculty of Medicine. One author (I.C.) came to Winnipeg in 1982, just before the end of the period covered by the book; the other (R.E.B.) was born and has lived most of his life in Manitoba. In the later chapters in particular, we have not attempted to name or characterize all the players, especially those still on the field. This may, we hope, encourage our older colleagues to write down their memories for the next historian. "The

x

Acknowledgements iniquity of oblivion blindly scattereth her poppy, and deals with the memory of men without distinction to merit perpetuity," said Sir Thomas Browne, physician and sage. We thank many colleagues for their help in many different ways, notably Drummond Bowden, Stuart Houston, Audrey Kerr, and David B. Stewart. We have had the consistent support of Nicholas Anthonisen, dean of the Faculty of Medicine. Graphs of infectious disease are the work of Sean Gupton. Financial assistance was provided by the Thorlakson Foundation and the Faculty of Medicine, University of Manitoba. Archival searches were done by Elizabeth Beazley. We thank David Carr and Carol Dahlstrom, University of Manitoba Press, for kindly encouragement and criticism, and Allison Campbell, for promoting the book. Help with individual topics was provided by many colleagues. Assistance with figures was provided by Angus and Hamish Carr. The following are among important sources used: the archives of the University of Manitoba, especially the Faculty of Medicine archives (particularly the executive minutes); the archives of the Winnipeg General Hospital (as contained in Provincial Archives of Manitoba) and of St. Boniface General Hospital; interviews conducted by Elizabeth Beazley with Mrs.Willard Waldon and Dr. Brian Best and by Ian Carr with many senior members of the Faculty of Medicine and with David and Ruth Stewart; Ross Mitchell, Medicine in Manitoba:The Story of its Beginnings;The Centennial Programme, Faculty of Medicine; University of Manitoba medical journals (Manitoba North West and B.C. Lancet 1887-1899, Annual Journal of the Winnipeg Medico- Chirurgical Society 1904-1909, Western Canada Medical Journal 1907-1915); Winnipeg Department of Health Annual Reports from 1909; Manitoba Provincial Board of Health/Department of Health Annual Reports from 1896; Bulletin of Manitoba Medical Association; Manitoba Medical Review 1922-1971; University of Manitoba Medical Journal, Manitoba Medicine., Prairie Medical Journal 1929-1997. Issues 62/4 (1992) and 63/4 (1993) largely devoted to local history of medicine. We thank the archivists and librarians of the Provincial Archives of Manitoba, the University of Manitoba, the Western Canada Pictorial Index, Brandon General Hospital, the Grey Nuns Manitoba, the Medical Research Council, and the National Archives of Canada. We thank Judith Hudson Beattie, Keeper of the Hudson's Bay Company Archives, for her assistance. We owe a special debt to the staff of the Neil John Maclean Health Sciences Library, Winnipeg, and University of Manitoba Communications Systems, Bannatyne Campus Audiovisual.

Acknowledgements

The bibliography is selective. An extensive file of biographical information is held in the Faculty of Medicine archives; obituary material is found in the relevant pages of Canadian Medical Journal and the Manitoba Medical journals. The list of people named is selective, particularly in recent years, and individual portraits are included only of the dead. Only where omission would grossly distort the historical record has this rule been breached. The book would otherwise have been unreadable. We have attempted to illustrate our predecessors not in their best blue suits but in their canoes; that is the flavour of Manitoba.

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Manitoba Medicine

Southern Manitoba

Introduction: Hippocrates on the Red

The Story Hippocrates, the great physician, would have smiled on the efforts of his descendants who have practised medicine in the Red River Valley, been amazed at their achievements, and reflected wryly only occasionally on their shortcomings. This book tells the story of Western medicine in Manitoba, a Canadian prairie province. Manitoba and modern medicine have grown together. Scottish settlers struggled to the forks of the Red and Assiniboine Rivers in 1812, four years before the invention of the stethoscope.The Grey Nuns were being paddled from Quebec to the Forks in 1844, around the time of the introduction of surgical anaesthesia. The Province of Manitoba was founded in 1870, three years after the first use of antisepsis in surgery. The story is woven from the writings of those who have gone before us. We have drawn on their memories (spoken, written, and pictorial) found in the provincial medical journals, in various local archives, and in the rich heritage of provincial medical biographies. It is a tale of success. Since 1870, Western medicine has been successful beyond the dreams of earlier physicians. Lives have become longer and healthier, partly because of better medical treatment. It is self-evident to us, whose lives have been saved several times by modern medicine, that it is better to be quick than dead.Those who challenge this view should throw away the penicillin next time they have severe infections and read another book. Our book starts with a brief background on the nature and development of Manitoba, describes briefly the healing practices of aboriginal peoples and early colonial medicine, and goes on to recount how, in the

4

Introduction

thirty years after the incorporation of Manitoba in 1870, the foundations of a modern western medical system were laid. From 1900 to 1914, a determined attempt was made to improve public health.War changed everything between 1914 and 1919; we record only a few of the medical experiences in that war. Between the wars, there was significant improvement in medical care and in the public health.War again interrupted progress in 1939; we chronicle a few more medical experiences in that war. Since the wars, the "Cold Peace," or Cold War, set a background tapestry of threatened nuclear doom, against which modern scientific medicine developed, supported by public funds. We have not attempted to write recent history and have concluded our book with the great centenary jamboree of 1983, when the graduates of the Faculty of Medicine gathered to celebrate their successes. We have avoided, as far as possible, naming recent participants."Ne'er of the living can the living judge, Too blind the affection, or too close the grudge," wrote Alexander Pope. It is difficult to select names for mention among so many worthy of memory; a complete account would resemble the catalogue of ships that fared forth to the siege of Troy. Particularly since 1945, we have included names only where omission would falsify the record. The illustrations depict the dead, with a very few exceptions. Our story is biased by its sources. We have much information on what the doctors thought, although we are dependent on the vagaries of biography and rely heavily on the accounts of those lives that have been recorded. Others equally worthy go unrecorded. Our sources give little attention to the social factors that cause disease and are limited by their origins; physicians affect the welfare of humankind less than they think. Initially, the tale is told in chronological order, more or less, until 1945, when the skeins become too tangled and an account by topic is preferred. Writing as we do in the centre of a modern medical institution, we cannot avoid our own institutional myths; like all such myths, they need a grain of salt. While the story proper stops in 1983, we finish with an overview of today's problems. We know little about what patients thought. How satisfied were they about their medical care? How well were they treated? How much was there to pay, either across the counter or in taxation? We know almost nothing about what aboriginal people thought. Until recently, medicine has been dominated by men, so women play a relatively small part in the story. Only sixty-nine women had graduated from medical school in Manitoba before 1939. Women were not admitted in larger numbers partly because of social attitudes outside the

Hippocrates on the Red

medical school and partly because of selection bias within the medical school.Their subsequent careers were heavily affected by childbearing and child care, and few of them entered the traditionally male-dominated specialties such as surgery. By conventional yardsticks, it seems likely that the small number of women involved were extraordinarily successful. The history of nursing is not part of the story; others have described it well. The subjects are, however, interwoven. Early nursing education was heavily influenced by the male-dominated medical profession, and nursing schools developed around the main hospitals, which needed nurses and perforce had to train them.

The Background Manitoba is the province in the centre of Canada; it is made up of flat prairie in the south and west, with the woods and lakes of the Shield in the east and north.The Red River rolls its brown way north to Lake Winnipeg, joined from the west by the Assiniboine at the Forks, a meeting place for centuries and now in the centre of Winnipeg. The climate is extreme: hot in summer, bitingly cold in winter.The prairie was once pasture for bison, and thus sustenance to the hunters who fed on them, and is now a grain field that nourishes their successors. More than a million people now live in the province, two-thirds within the perimeter highway of its capital, Winnipeg.

The Indigenous People People have lived in this land for ten millennia or so; until 250 years ago the population was sparse and aboriginal. Before European invasion, the area was inhabited by two major groups, often hostile to each other: in the far north, the Inuit, or Eskimo, and in the south those aboriginals whom the Europeans called Indians, Chipewyan to the north and Cree to the south. The Ojibway migrated into Cree territory in the early eighteenth century, particularly after the Cree had been decimated in the smallpox

epidemic between 1779 and 178. The Sioux, or Dakota, lived farther south

and west. Aboriginal people migrated seasonally in search of food and shelter along the river valleys and fought with other groups.

The Invaders The European dream in the sixteenth century was to find the Northwest Passage, a path to the riches of Cathay.The first European to set foot on the soil of what eventually became Manitoba was the English navigator Henry Hudson, in 1610.The first explorer to survive a winter on the frigid shores

5

6

Introduction

of Hudson Bay was Jens Munck, a Dane, in the winter of 1619-20. Over the succeeding centuries many others followed, as the English and French battled over the shores of Hudson Bay for more than a century and fought for the inland fur trade. Explorers from New France paddled up the Winnipeg River from the east, notably LaVerendrye in 1737, perhaps the first European to see the forks of the Red and the Assiniboine. Peace in 1763 settled the question as to which language would predominate in the area. The fur trade dominated. Then, in the late eighteenth century, in faraway Scotland, landlords found that sheep made more profitable tenants than people, and these landlords destroyed a culture and a way of life by clearing their land of crofters. The Scottish aristocrat Lord Selkirk, deeply disturbed, saw as a solution for the plight of his poor countrymen a new colony in the far west. Selkirk purchased title to 120,000 square miles of land from the Hudson's Bay Company. The first two parties of the Selkirk settlers arrived on Hudson Bay in 1812, a third in 1813, and another in 1815. The Red River Colony in the early years was a troubled place, racked by the divisions between competing trading companies and by the stresses among the French-speaking Metis, the Indians, and the Scots and English settlers. Bloodshed was not infrequent. In 1821, the Northwest Company and the Hudson's Bay Company merged under the name of the latter; thereafter, the Colony developed peacefully, if slowly, plagued by flood, fire, and grasshoppers. Two priests, Fathers Provencher and Dumoulin, arrived in 1818, and soon two little villages looked, and sometimes glared, at one another across the Red River. One was anglophone and largely Protestant, the other francophone and Catholic. In 1832, there were 2,751 people in the Colony, and in 1846 there were 4,459.The first steamboat appeared on the river in 1859, speeding up the mail deliveries, and the first steam locomotive came down the river on a barge in 1877.The Company controlled the life of the Colony until the early 1840s, when the influence of the American settlers around St. Paul was felt and the American Fur Company's station at Pembina offered an alternate outlet for furs. Manitoba became a province of Canada in 1870, a frigid part of Queen Victoria's domains on which she had the good wit never to set foot. AngloCanadian, and later eastern European, settlers flocked in. The immigrants, equipped with superior weapons, strange viruses, and a different moral code, shattered the indigenous cultures in the name of progress and their own god. Winnipeg grew fast: a tiny village in 1871, a brawling frontier town in 1881, by 1901 a crowded unsanitary city bustling with immigrants, where men got rich quick and typhoid quicker. By 1911, the city was

Hippocrates on the Red

prosperous, mildly conservative, and the home of a well-off, largely AngloCanadian middle class and an underprivileged proletariat, that was mainly of eastern European origin. The opening of the Panama Canal hurt Winnipeg, but in the 1920s the city and the province grew prosperous again, only to feel penury at the end of the decade. Since the Second World War, a mixed economy has grown, along with a system of health care and welfare. Winnipeg dominated Manitoba, and its medicine was similarly dominant.

The Medical Revolution It is important to understand that the tale of the development of medicine in Manitoba is set in a narrow frame of time, by chance the same period within which modern "Western" medicine developed. In 1812, when the Selkirk settlers were arriving on the Red River, Wellington had just won the Battle of Salamanca, the flower of the French army was soon to die in Russia, and the railway revolution was about to come. Seven years later, Rene Laennec introduced the stethoscope, one of the first instruments of physical diagnosis in medicine. Medical science and anatomy were almost synonymous; there was an incipient but not yet widespread knowledge of gross pathology. Francois Bichat had recently described the tissues of the human body; cells were described thirty years later. Only a few drugs were effective, as judged by modern standards: opium, cinchona bark, digitalis, the latter quite new. Nothing was known about the causes of infectious disease. Surgeons were becoming bold and soon (in 1826) ventured such operations as radical excision of the rectum, without anaesthesia. Women dreaded pregnancy and the pain of labour, and some women still died in obstructed labour.There were few accoucheurs conveniently on hand with the practised skill to turn a breech presentation. Puerperal fever struck hard in the lying-in hospitals. Anaesthesia was thirty years in the future, and antiseptic surgery nearly sixty. In the century after 1845, the medical revolution brought successful antiseptic surgery, anaesthesia, safe childbirth, and antibiotics. Between 1845 and 1945 in Manitoba, European Canadians kept up with the revolution and built a medical system better than many and as good as any but a very few; they left out the aboriginal peoples, neglected and downtrodden. Not too long ago, the Manitoba medical establishment, a professional oligarchy responsible principally to itself, debated with goodwill and sincerity whether human hearts should be transplanted in one or both of their teaching hospitals. Meanwhile, aboriginal children were dying in the Shamattawa Reserve for the lack of clean water. So, we tell a tale of shining achievement, marred by occasional misplacement of priorities.

7

8

Introduction

We tell the story warm and snug, looking out the window at the snow. In the early days, the wind would have been whistling through the chinks around the window and door of a sod hut, if indeed there had been a window. We have not named or portrayed all the main participants, particularly in the past fifty years.This is intentional.We tell an incomplete tale, partly because of incomplete knowledge and partly because complete histories bore completely, whereas incomplete and selective histories either inspire the readers to find out more or stimulate them to indignant correction. Either reaction increases knowledge and is better than the gentle snore of the sleeping reader.

Healing and Pestilence in the North West: By Bay and Red

i

Aboriginal Healing We know little about health among the aboriginal peoples before European contact. The sparsely scattered people did not surfer the epidemics that were so devastating after European contact was made. Many of the aboriginals migrated seasonally in search of buffalo, game, and fish, notably the prized sturgeon; the migrations often resulted in warfare among the various groups. Trauma, infection, and starvation must have made it difficult to survive into old age. Like pre-industrial people everywhere, Canadian aboriginals developed a healing system that attempted to meet their needs. Disease, in their eyes, was due to either natural or supernatural causes; the latter involved either entry into the body of an evil spirit or loss of the person's own spirit from the body. There were several levels of knowledge of this system, the highest open only to the shaman.The shaman, or healer, man or woman, was often an elder of the group, wise in practical and spiritual ways, and a respected community figure. Priest and healer were often combined in the same person. Shamans used complex religious ceremonies and a variety of plant remedies, some pharmacologically active, and remedies of animal origin, sometimes excremental; they modified mood by psychological or pharmacological means. Magic, charms, and talismans were commonly employed. The close connection between religion and healing in such pre-industrial cultures renders it difficult for those from outside to understand and sometimes leads to a reluctance on the part of those within to explain. The plant remedies used were variably effective. For example, the bark of the Canada balsam tree yields a liquid oleoresin that makes a patient

10 Chapter 1

sweat and pass urine and turns the skin hot and red, if rubbed on. Medicines were given orally, by inhalation, or by enema. The sweat bath and sweat lodge were frequently used as the focus of both natural and supernatural therapy. The sweat lodge consisted of a framework of poles shaped like an umbrella and was completely covered with birch bark or hides. Heated stones were carried inside, the patient removed all clothing, and water was sprinkled on the stones to create steam. Medicine might be added to the water, or herbs might be sprinkled on the stones, and the vapour was inhaled. This treatment was used for respiratory symptoms, fevers, and rheumatism. There were many modifications of sweat lodge treatment; by means of drugs, heat, and magic, profound states of altered consciousness could be produced in both the shaman and patients. A cold water plunge often ended the treatment, and sometimes the patient. Native people used various physical devices in treatment. Some let blood, using sharpened flint instruments or splinters of wood. A series of incisions was made on the temples for headache, and frozen limbs were amputated with knives. Enemas were given by using a syringe made from the bladder of a deer. Teeth were extracted by pulling on a sinew secured around the base of the tooth. Straightforward physical remedies were used for straightforward lesions; wounds were dressed, and fractures were appropriately splinted. Constipation called for a purgative, and it was not difficult to measure the effect.

Doctors on the Bay Contemporary European medicine was no more sophisticated. The first European physicians in the area came with the explorers of Hudson Bay, before the foundation of the Red River Colony. Dr. Casper Casperson, believed to be the earliest, came with Danish explorer Jens Munck in 1620 and died of scurvy on the shores of the bay, unable to help himself, let alone his patients. The Hudson's Bay Company operated through a network of trading posts like York Factory, founded in 1714, each under the supervision of a factor. The factor was responsible not only for all matters of trade but also for the health, discipline, and safety of the Company's employees. The settlement usually consisted of forty to sixty men, mostly labourers and tradesmen; surrounding the fort would be 100 or so natives. In summer, when the canoe brigades and the Indian traders arrived, the population grew to 1 ,000 or so. The factor daily recorded life in the post, sometimes in the winter almost roasting as he sat by the fire while the ink in his pen froze.

Healing and Pestilence in the North West

Two other gentlemen officers assisted the factor; maintaining an adequate food supply was a prime concern, but health care was second only to this, and invariably one of the two assistant officers was a physician of sorts. The Company accepted almost from the beginning some responsibility for the medical care of the aboriginal people in its employ. Almost two dozen surgeons served at York Factory during the eighteenth century, each contracted for three to four years. Many were shipped back to London sooner, and a few lasted longer. There is little evidence as to their training. At least some, however, may have trained in Edinburgh, where the medical school had been founded in 1726; fifty years later, there was fairly systematic teaching in chemistry, botany, anatomy, pathology, materia medica, medicine, surgery, and obstetrics. Most served the Company adequately, in the context of the ineffectiveness of medicine at the time. In 1717, Dr. John Carruthers was involved in attempting to cure the malignant distemper that afflicted a group of Chipewyan slaves who had been bought to serve as interpreters. Despite the nursing efforts of Carruthers and the factor, all the slaves died. Carruthers later led a party to the north shore of the Churchill River where Munck and a number of other Danes had wintered 100 years before; sixty-two of sixty-five of Munck's crew had died of scurvy. It was a continuing problem; in 1753, a physician died at York Factory of scurvy, and it was not until 1770 that York Factory physicians used cranberries to treat scurvy. Scurvy incidence was at its worst in the years after 1783, due to inadequate importing of lime juice. In 1789, the factor noted that only two labourers were free of scurvy. An analysis of the records showed that the death rate, despite the brutal climate, was no worse than it was elsewhere in North America at the time. Death was usually due to infections. The most distinguished of the surgeons on the Bay was Thomas Hutchins, \vho served at York Factory from 1766 to 1773. During this time, twelve deaths were noted among the natives, without information on the causes; of nine European deaths, seven were from drowning, one was from old age, and two were from tuberculosis.The surgeon often worked long hours and dealt with such problems as fractures, amputations, abscesses, tertiary syphilis, pleurisy, pneumonia, tuberculosis, rheumatism, scurvy, freezing, diarrhoea, and epidemics of fevers. He advocated exercise to treat depression and knew of the value of vegetables (sorrel, dandelion, pigweed, nettle, scurvy grass and water cress) in treating scurvy. Bleeding was then a sovereign remedy for many ills. Hutchins was a competent physician, well regarded by his patients. He had extensive scientific interests, he wrote on

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Chapter 1 frost bite, and he carried out experiments on the solidification of mercury at low temperatures, then a matter of great scientific interest. These were reported to the Royal Society in London and won him the Society's coveted Copley Medal, no small achievement for a doctor on the Bay. Hutchins's successor,William Auld, joined the Hudson's Bay Company in 1790 as a surgeon and spent long, cold years at Fort Churchill, successfully treating the regular scourge, scurvy. He rose to be superintendent of Northern Factories. The early European settlers had some sympathy for the natives whom they had displaced; in particular, the Hudson's Bay Company charged its factors and surgeons to care for native people as best they could, not necessarily from altruistic motives. But it seems likely that they did their best, according to their lights.

Red River Medicine On each of the two voyages, in 1812 and 1813, a ship's surgeon reached Hud r on Bay: Dr. Abel Edwards and Dr. Thomas McKeevor, respectively. Dr. Peter Laserre, surgeon on the third voyage, died of "ship fever" (probably typhus) .We know nothing more of them and have no record that they practised by the Red. The individual physicians in the early Red River days are shadowy figures, men employed by the Hudson's Bay Company; their appointments were usually described as surgeon and clerk, or trader. Medicine was not yet effective enough to be regarded as a full-time occupation. The exact dates of the service of these physicians at Red River are not certain. The earliest doctor known to practise in the Red River Colony was James White. He was trained in Edinburgh and, after intermittent service as a ship's surgeon, was engaged by Lord Selkirk to serve as surgeon at the colony. He landed in York Factory in 1814, going thence to Red River to provide medical care for the 419 colonists. He was paid fifty pounds a year, with lodging and subsistence for two years, and a grant of land. Cold and lonely as the place was, it might have seemed a good exchange for the tossing orlop decks of ships fighting the French. Dr. White died in 1816 in the sad little battle at Seven Oaks where Metis and Indians, supporters of the North West Company, routed the Hudson's Bay Company men. We have little information about medical practice in the Red River Colony; there are no detailed medical records. Dr. White treated fevers, scurvy, lumps and inflammations, lacerations, the drunks and the broken bones, and gonorrhoea; chastity was an aspiration of some, rather than universal, in the small community. We know little about the drugs White used

Healing and Pestilence in the North West

and have to assume that medicine in his practice was similar to that elsewhere on the continent. The best account of the practice of medicine in Canada at that time comes from Dr. John Douglas, who was a surgeon in the British Army in the War of 1812. Presumably Red River medical conditions were similar. Douglas joined the British army in 1810 at the age of about twenty-two as a surgeon's mate, became assistant surgeon to the Eighth Foot in the summer of 1813, and served with them through some of the most severe fighting of the war. He gave a vivid account of the war and sickness in it. The diseases were mostly the same as in any war. They included frost bite (the drunk often froze to death), catarrh, pneumonia, intermittent fevers, ophthalmia, cholera, dysentery. Syphilis was rare. The wounded were transported in jolting wagons, grimacing with the pain of amputation stumps inflamed and infested with maggots. Gangrene was rare and tetanus unknown. Intermittent fevers flourished, usually malaria, a disease not recorded in the early Red River Colony. Treatment was ineffective and often harmful, for example, bleeding, which yielded eight pounds usually and sixteen pounds occasionally. Douglas noticed an increase in the buffy (or, as he called it, sizy) coat of blood in pneumonia, no doubt formed from white blood cells, which were increased when infection was present.The hardy colonial troops treated intermittent fevers with bitter vegetable infusions, spirits, pepper, and nutmeg. "Useful in the early stages of the disease, but [they] certainly hastened the period of dissolution," wrote Douglas. Similarly, according to Riddell, in Kingston in 1829, treatments in vogue included riding on horseback, ingesting leaves of liverwort, and drinking decoctions of Caledonia spring water for "consumption." Wheat flour was put on burns and scalds, scotch snuff plaster was applied for croup, alder for dropsy, bark of balsam and birch for ague, snufFfor hydrophobia (rabies), and olive oil and lard as a preventive against plague. Typhus was treated with nitre and oil of vitriol, gout with leek poultices, jaundice with a decoction of carrots, and dropsy by bleeding, tapping, and giving plantain and liverwort by mouth. The ague was treated with Peruvian bark; children were cured by wearing a waistcoat into which bark was quilted. Most of these treatments would be now regarded as ineffective.Tracheotomy, however, was successfully used for respiratory obstruction. In 1830, Joseph Fortescue, a Hudson's Bay Company factor, was treating rheumatism with a powder containing a half ounce each of sulphur, mustard, rhubarb, and guaracin, and using tonics containing strychnine and potassium iodide. Most of his pharmacopoeia was inert, but his remedy for

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Chapter 1 ingrowing toenails probably worked; it was wool saturated with alkali, applied until the nail was so soft that it could be cut. James White's successor at Red River, Dr. Alexander Cuddie, reached York Factory in 1819. In 1821, he was surgeon to the colony, paid an annual salary of 150 pounds and an allowance of fifty pounds for his lodging. He had to find his own medicines and could charge a fee to patients who could afford it but was engaged to attend the poor gratis; he also acted as surveyor. He probably left about 1823. The next physician, Dr. Richard Julian Hamlyn, was engaged by the Company and arrived at Red River in 1824, being in 1831 the only doctor in the Colony. The Colony was fairly healthy at that point, with a high birth rate and little sickness. Hamlyn was prosperous but fell out with Governor Simpson. After 1821, the Red River Colony seems never to have been without a medical man. Doctors Bunn, Cuddie, Todd, Saunders, Fisher, and Hendry are all mentioned in the records. They usually made a livelihood, but the medicine of their time was in general ineffective. Dr. William Todd, an Irishman, entered Company service as a surgeon in 1816, at the age of twenty-two, and served as clerk and surgeon at various points in western Canada. He was surgeon at the Red River Colony in 1818, returning to Europe thereafter. He came back to Red River in 1821 but probably moved off soon after that to serve successively in posts throughout the West, for instance at Brandon House. He was appointed chief trader in 1831 and from 1834 to 1851 was in charge of Swan Paver District. He was a clever, attentive doctor and an honest man, but he was of less value as a clerk and trader. He became the best known surgeon in western Canada before 1850; he was called, simply, "the Doctor." Frances Simpson, Governor George Simpson's wife, had a difficult pregnancy in 1831, which kept her bed-ridden. Simpson had little confidence in Hamlyn or Bunn and sent for Todd, who was then stationed at Brandon House.Todd arrived in September and looked after Mrs. Simpson until her delivery. Simpson himself, when under severe stress, was subject to attacks of apoplexy and wantedTodd to bleed him.Todd had sufficient confidence in his own professional judgement to refuse. Todd was sent to York Factory during the winters between 1833 and 1836 to attend the victims of the "York Factory Complaint," which typically occurred in late winter and early spring. This was a severe relapsing illness, with vomiting, restlessness, and pain, affecting officers rather than labourers.Todd, himself, became sick. In the summer of 1837, he played a part in blocking the spread of smallpox; Indians visiting him at Fort Pelly

Healing and Pestilence in the North West

told him of an outbreak of smallpox at Fort Union on the Missouri River. Todd not only started a vaccination campaign but also taught the Indians to do it for themselves, arm to arm. Todd never achieved his ambition of becoming a chief factor. He, too, fell out with Governor Simpson, who was not impressed with Todd's ability as a trader and regarded him as a radical and overly fond of the bottle. The first locally born physician was Dr. John Bunn. His father was a Londoner in the service of the Hudson's Bay Company, and his mother was the daughter of a surgeon who was in charge of a Company post on Hudson Bay. John Bunn was educated in Edinburgh, including two years as a medical student. He entered in the Company's employ in 1819 and in 1821 was sent to Red River, where he spent most of the rest of his life, apart from a year in Edinburgh (in 1831 and 1832) continuing his medical studies. Bunn's wife died young, and he spent the rest of his days in his home at Middlechurch, bringing up his three sons. His practice involved house calls that took him across long prairie distances to lonely farms, on horseback in summer and by dog team in winter. He looked after most of the population of the settlement, which in 1832 was 2,751. In addition to his medical practice he was active in community affairs; by 1835 he was a member of the Council of Assiniboia and thereafter was coroner, sheriff, clerk of the court, recorder (or magistrate), and governor of the jail. He died suddenly, before breakfast in his room one May day in 1861 after a saunter to watch the Red River in flood; we know few details about his practice, but his reputation as a good physician was widespread.

The Grey Nuns The story of the Grey Nuns and St. Boniface Hospital starts in Montreal in 1737, a year before LaVerendrye found his way through the woods and lakes to the Red River. Mme Margaret d'Youville, who was canonized in 1990, was then a widow who spent her time and substance on social work among the poor and unfortunate, and she eventually founded an order devoted to the care of these people. They were the Sisters of Charity, or Grey Nuns. Father Provencher, who travelled west in 1818 as the first Catholic missionary, knew the daughters of Mme d'Youville and naturally sought help from the Grey Nuns to help him train the local young women to be good housewives and mothers. The Grey Nuns had a reputation for selfless devotion to good causes. So Provencher approached them in Montreal and told them how great was the need. He then called for volunteers; of the

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Chapter 1 thirty-eight sisters, seventeen volunteered and four were chosen.The physical prospect of the journey must have been unpleasant, but the religious dedication of these women was a match for the mosquitoes. Four nuns, Sisters Valade, Lagrave, Coutlee, and Lafrance, left Montreal on 24 April 1844 and spent fifty-nine days on the way by canoe. Their journey was wearying, with portages, cold, damp nights, monotonous food, myriad mosquitoes. By the end of June, they reached the Red River and knelt before the welcoming bishop to receive his blessing. Fort Garry, their destination, in 1844 was a remote spot. Many of the local inhabitants were Catholic Metis, others were Protestant "countryborn," and the rest were Irish, largely Catholic, English, mainly Anglican, and Kildonan Scots, firmly Presbyterian.There was some rudimentary textile manufacture, but people lived for the most part by farming and hunting. Social life, outside the officers' circle in the fort, was rough. The first house to which the nuns were assigned was old and in poor repair, cold in winter and hot in summer. They were next temporarily housed in Provencher s house. Eventually a new house was built, now a museum. It was and is beautiful but it, too, must have been cold. Sometimes seventeen wood stoves were lit in the winter in an attempt to keep the inhabitants warm. The house was threatened in the great flood of 1852, and the nuns were forced to the upper storey, where the world must have seemed a vale of tears as these women from faraway Quebec looked at the flood waters and the lonely land. The need for health care was pressing because of recurrent disease. For instance, in 1846, epidemic measles was followed by dysentery and famine, so that crops were neither seeded nor tended, and the little colony survived with some difficulty on only the meat from the buffalo hunt. The n s were teachers and religious by vocation, but health care was needed as a priority for survival, and they did what they had to. In particular, Sister Lagrave became a nurse. By the time of her death in 1859, she had made over 6,000 home visits; she was helped and then replaced by Sister Ste.Theresa (Soeur Docteur).Their medicine was largely herbal; they used mint, pumpkin seeds, flax, goldenrod, plantain, and cherry-tree bark, simple ointments and poultices. The drugs may not have cured, but kindness, concern, and simple cleanliness must have helped. Sister Ste.Theresa became popular among the Metis, and the unauthenticated tale is that, when she was recalled by her superior to Bytown in 1859, a group of Metis led by Louis Pviel Sr. kidnapped her and gently compelled her to stay in the colony. Father Tache when ill was treated with mustard plaster and eggnog. The latter must have helped.

Healing and Pestilence in the North West

Back to the Bay Our best information on medicine in western Canada in the mid-nineteenth century comes from recent authoritative work by Decker on the only available medical casebooks from York Factory on Hudson Bay. The casebooks date from 1846 to 1852, when two physicians served at York Factory. Dr. William Smellie was the son of an Orkney Free Church minister and had trained and qualified in medicine in Edinburgh. He was probably a competent, but not an enthusiastic, doctor, being more interested in literature than in medicine. There is no information as to where he went after serving in York Factory, or why; even less information is available about his successor, Dr. Wills. Both were surgeon clerks, a position well below the top of the Company's hierarchy, and their medical service was part-time.The two physicians saw 1,653 cases in the period, working about seven days a month in the winter and twenty-two days a month in the summer, and they recorded their practice in 300 or so pages of crabbed handwriting. They examined their patients by use of the stethoscope, by palpation, by feeling the pulse, and by observation of the excreta. Most (ninety percent) of the patients were male, and only five percent were native.Their diagnoses fell under three headings: accidental, environmental, and physiological (diseases classified by the body system involved). The injuries from accidents included lacerations (mainly from axes), sprains, and fractures, and there was one accidental death from gunshot. The doctors set the fractures, dressed the wounds, and sutured the cuts. One autopsy is recorded. Frost bite and snow blindness were not usually actively treated, but one amputation of a gangrenous toe is recorded. There were numerous infections: conjunctivitis, earache, tonsillitis, respiratory disorders. Toothache was treated by pulling the tooth.The children had coughs, middle-ear infections, and diarrhoea, and a variety of infectious diseases, including measles, influenza, chickenpox, and whooping cough. Their treatment was heroic. They physicked, bled, cupped, and sweated their patients, using castor oil, rhubarb, jalap, croton oil, camphor, and narcotics. A hip abscess was treated first by fomentations, then by local incision, and finally by drainage via a needle inserted through the wall of the anal canal, through which six pints of pus flowed per day. One patient's abdomen was swollen with fluid; the doctor removed two gallons of fluid with a needle. Diarrhoea was common, perhaps due to the ingestion of rotten fish or pemmican.The fish may have been the cause of several cases of tapeworm. An outbreak of scurvy in 1849 may have been related to the lack of

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Chapter 1 cranberries that year. Several cases of gout were recorded, and one of urinary stone ("uric acid gravel"), ascribed to a totally animal diet and treated with potassium bicarbonate.The physically active life led to strains, sprains, and hernia. Skin disease included scabies. Cardiac disease was rare; the usual symptom was palpitation and the usual treatment digitalis. One patient with pericardial pain and fainting was treated by cupping, potassium bicarbonate, and digitalis. A case of stroke was recorded in a native. Another patient had a goitre. Others had kidney stones and difficulty in urinating. Syphilis was recorded rarely. Paraphimosis (an unretractable foreskin) was treated by an appropriate incision. Headaches were common, and one patient was recorded as mentally unstable. Women patients were in the minority, about ten percent. Gynaecologic problems included a case of dysmenorrhoea in a native woman who was three months pregnant; she was treated with opium and castor oil and by cupping. A nursing mother had mastitis. The practices of these Company physicians were quite like those of any rural general medical practitioner, biased toward a preponderant male population. Mortality was low, about 0.2 percent. One autopsy was recorded, but its contents were not described. The Army Doctors and the Last Days of the Red River Colony Another source of physicians in the Colony was the British Army. In 1846, there was fear of an American invasion, and the British Sixth Regiment of Foot was quartered in Winnipeg for the next two years; the medical officer was Dr. Duncan. The settlement needed all the doctors it could find in 1846. From 18 June to 2 August, 321 people died of diarrhoea, perhaps related to cholera, perhaps dysentery. The small community was struck with terror by the deaths; there were seven a day, one in every sixteen people. Of these, onesixth were Indians, two-thirds Metis, and the remainder whites. Many houses were closed altogether, the inhabitants all dead. In 1849, a body of military pensioners arrived from Britain, led by Major WB. Caldwell, who later became governor of Assiniboia. On the ship was Dr. William Cowan, a Glasgow graduate. He had contracted cholera soon after he entered practice in Britain and then sought to go to British Columbia but was persuaded instead to go to Red River as surgeon with the pensioners. He became chief trader at Moose Factory in 1862 and was involved in and escaped from the first Riel rebellion, later returning to Winnipeg. He was later first vice-president of the Manitoba Historical and

Healing and Pestilence in the North West

Scientific Society. Somewhat later, in 1857, the Royal Canadian Regiment was quartered in the Red River Colony; the regiment's medical officers were Doctors Stranaghan and Paxton. During the time of the Red River Settlement, the lives of the physicians, like most other events in the colony, were largely controlled by the Company. For instance, Henry Septimus Beddome, born in London in 1832, trained in medicine at Guy's Hospital and went off at nineteen, after completing two years of his course, on one of the Company's ships to York Factory. He returned to London and graduated in 1852. Red River in 1852 was little known; his certificate of membership in the Royal College of Surgeons, London, dated 1852, gives as his name and address: "Henry Septimus Beddome, Hudson's Bay, North America." He returned to Red River in 1852, where he practised until 1859 when, newly married, he was posted to York Factory as a Company surgeon. He returned to the Red River in 1865 and practised for many years in St. Andrews parish. During the six-month outbreak of smallpox among the Icelanders of Gimli soon after their arrival in 1876, he treated the sufferers and endured many hardships and privations. His practice at St. Andrews yielded little remuneration, but nevertheless his life was spent trying to relieve the sick. He died in 1881, a relic of the Red River Colony in the newly established Manitoba. The 1860s were politically difficult years in the Colony. In the earlier part of the decade, there was the threat of an Indian uprising. In 1862, during the American Civil War, a group of refugees had fled along the Crow Wing Trail to Red River from St. Paul, where in a Sioux uprising hundreds of settlers had been massacred. Many of the Red River colonists had come to the Colony by that route and felt threatened. Between 1869 and 1871, the Colony had considerable trouble with civil strife and disease. Louis Riel led a Metis rebellion; the Grey Nuns, now a significant force in the community, must have felt some inner sympathy with Riel's Metis rebels (or freedom fighters) and assisted them with food in 1869. They maintained a reasonable neutrality, however, and extended their care to Sir Garnet Wolseley's sick soldiers in 1871. There was a smallpox epidemic in 1870; the nuns vaccinated 3,323 people, and the government opened a temporary smallpox hospital. There was often poverty in the Colony, and the medical care of indigent people depended on the goodwill of the doctor. Dr. Covenant, who had been attending the poor without charge and supplying them with drugs at his own expense, petitioned the Council of Assiniboia for financial assistance. The Council voted him twenty pounds, once and once only, to buy

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Chapter 1 more medicine, but accepted no responsibility for the doctor's fees. This problem was to recur in the later history of the province. As communications improved, more physicians moved in, some of whom became important in Manitoba in the next decade; for instance, in 1868, Dr. J.S. Lynch appeared along the newly opened Dawson Road. Physicians, as among the best educated in the Colony, naturally sought political office.Two of the most prominent were Doctors Curtis James Bird and John Christian Schulz. Bird was born in 1838 and educated at Guy's Hospital, London; he practised first on the family estate at Red River and then in Winnipeg. He became active politically and eventually became Speaker of the provincial legislature. His political activities once led him to the traditional Western punishment: during a controversy over the incorporation of Winnipeg as a city, he was tarred by some angry city founders, though not apparently feathered. Schulz trained in medicine at Queen's University, Kingston, though there

is some doubt as to whether he ever qualified. He arrived at Red River in 1862 and set up a trading post near the corner of Portage and Main. The post was also a drugstore and medical office, although there is little information on his medical practice other than an obscure reference to his having performed one of the first surgical operations in the province. He prospered and by 1865 had acquired the local newspaper, the Nor'Wester. He became a potent figure in provincial politics, initially as leader of the party advocating Canadian takeover of the Colony at the time of the first Riel rebellion and was jailed by Riel; he was later a federal member of Parliament, a senator, and the lieutenant-governor of Manitoba in 1888. He was knighted in 1895 and died a year later.

Conquest by Pestilence As the fur trade and the Red River Colony developed, the European immigrants brought plagues against which aboriginal people had little or no immunity. Initially, acute infectious diseases predominated: smallpox, measles, whooping cough, influenza, and tuberculosis. Epidemics recorded in the Red River area include smallpox (1781-82 and 1801-02), measles and whooping cough (1819-20 and 1827-28), whooping cough (1834), and influenza (1835-1837).They usually spread from the south to Red River, often along the canoe routes. The European conquerors took the continent and then had to cope with the social and health problems that were caused in aboriginal populations by the conquest. However effective native healing was, it could not cope with the new infectious diseases introduced by the Europeans.

Healing and Pestilence in the North West

The worst killer was smallpox. After the first epidemic in York Factory in 1720, it recurred and was spread by the seasonal migration of native people and by the canoe brigades. In 1837—38, a major epidemic of smallpox killed large numbers of Assiniboine and Mandan.This epidemic arose from infected people on a Missouri River steamboat belonging to the American Fur Company. Dr.WilliamTodd was then at Fort Pelly; when he heard from Cree travellers about the outbreak further south, he obtained cowpox vaccine and taught Indian leaders how to vaccinate their followers, arm to arm. He dispatched vaccine to other posts and saved many Indians who would otherwise have died. His lead was followed by other Company men. Nevertheless, the Assiniboine around Winnipeg were reduced to 400 lodges from a previous 1,200. Another epidemic in 1856 further reduced them, to 200 lodges. Sometimes, when there was a shortage of vaccine, vaccinators would use fresh lymph from a recently vaccinated person. Aboriginal people dreaded smallpox, its foul smell, the sores, the delirium.Whole families would die, sometimes killed by the father, who could not contemplate the degradation that awaited. An account of the history of health care in the area around Baldur contains the reminiscence of one aged Indian, who described how, during a bad smallpox epidemic among the Indians in North Dakota, one came up to visit friends and infected his grandfather, who became very ill. "They had to keep him away from the rest and put him in a tent outside. When he died, he was buried on the prairie, at the 'special place' he had chosen. The stones which mark his grave are still there - on the prairie, at the place where the prairie chickens dance in the spring." In such epidemics, mortality might have been up to fifty percent, though vital statistics do not exist. Tuberculosis was less dramatic but next to smallpox was the scourge of the plains Indians, killing them by tens of thousands. Mortality continued high for many decades. In early colonial days there was no government interest in the health of Indians; any medical assistance that was provided came from missionaries, military surgeons, or sympathetic neighbours. The Hudson's Bay Company made attempts to provide medical care for sick aboriginal people, but, too often, colonists paid little attention to the woes of the aboriginals. This was seldom due to malevolence, but their own medical technology was ineffective, and they had enough to do to put their own house in order. Rural life was often harsh for the European settlers, and medical care was sometimes distant and inferior; aboriginals were increasingly confined to reserves, where life must often have been nasty, short, and miserable. There

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is little in the medical literature about the early medical care of aboriginals, and we know even less about what they thought. In some areas, there was an aboriginal religious organization called the Midewiwin, or Medicine Society. This organization persisted and altered after contact with Europeans; it served as a repository of knowledge about herbs, although healing knowledge was not shared widely among its members. One of its primary functions was to cure, by use of both natural and supernatural methods. Initiates often had a supernatural vision and were inducted at an annual ceremony; healers progressed through several grades of status. The Midewiwin has survived to the present day and been revitalized in some native communities. The aboriginal people suffered the common fate of the colonized.Their land was usurped by inequitable treaties, they were decimated by epidemic disease and herded into reserves, their staple food, the buffalo, was exterminated. Their belief system was destroyed in the name of Christianity, and many of their children were abused in church residential schools. Native people lost their self-esteem and felt worthless, useless, and hopeless, a prey to alcoholism, drug abuse, and violent death by suicide, homicide, or accident. This devastation was compounded by poverty, poor education, and unemployment. It had all started with a dream in sixteenth-century Europe, a dream that proved a nightmare for native North Americans.

Foundations

2 Red River Colony to Manitoba The Red River Colony remained separate from the world, far away and cold, for fifty years. By the early 1860s, change was imminent. In the Colony, an American party favoured north-south affiliation, and English-Canadian settlers from Ontario favoured the connection to Upper Canada.The French Catholic population in St. Boniface remained distinct, and the Metis culture emerged. In 1868, there were little more than 100 people in what eventually became Winnipeg. The streets had no sidewalks and were squelching with the black, slippery Red River mud, and the few small stores had poor goods and high prices.There was one little tavern. Led by Louis Riel, the Metis took up arms in 1869, and for a short time the political future of the area was in doubt. The British Empire would not be gainsaid, and Manitoba became a province of Canada in 1870. In that year there were about thirty buildings in the area, and in 1873 there were 900. In 1874, the legislature passed a bill creating the City of Winnipeg; the new city rapidly set up the institutions of an urban society, including those of medicine. The wagon trains creaked across the countryside of southern Manitoba, bringing land-hungry settlers, progressively increasing the need for medical care in remote rural areas. By 1883, the population of Winnipeg had risen to about 20,000. The buffalo had gone, as had the covered wagons, and steam boats were plying the Red. European immigrants were entering Manitoba in increasing numbers; the Mennonites had arrived in the mid-1870s, and Ukrainians and Galicians were settling, mainly around Dauphin, in the 1890s. As more land came under cultivation, the grain trade expanded.

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Chapter 2 Railways speeded growth.Winnipeg was linked to St. Paul in 1878, and in 1881 the main CPR line reached Winnipeg, setting off a brief but frenzied real-estate boom that fizzled a year later, submerging a few Winnipeg fortunes. In 1884, there was a more alarming development; the Metis, led by Louis Riel, rose once more in armed rebellion. The Dominion government sent a force west by rail to join local volunteers and suppress the uprising. Riel was tried in a Regina court and hanged. God save the Queen, and God help her opponents;justice was another matter.The rebellion was a border skirmish, distant from the city, in a now-faded empire. The Metis had some right on their side, but Winnipeggers feared for their lives and futures and fought bravely for them. Late in the century, immigration slowed, and by the late 1890s it was evident that more people were needed. Great schemes were set up to attract immigrants, preferably from Ontario or Britain. But eastern Europeans would do. British Canadians treated others as inferiors while maintaining their own position as scions of Empire, white citizens of the Great White Queen, heirs of all the ages, in the foremost files of time.

The Start of a Medical System Most of the new immigrants to Winnipeg lived very poorly. During the winter of 1882, many Jewish immigrants were compelled to live in small compartments in one-storey wooden immigration sheds, even in tents. Early Manitoba looked like a Third World country of today, with regular flooding, foul water, poor sanitation, poor housing, inadequate and dirty food, and rampant infectious disease. Tuberculosis and venereal diseases were endemic, and typhoid, diphtheria, and scarlet fever recurrent. Smallpox was greatly feared; it had been an intermittent scourge of aboriginal people and could hit newly arrived immigrants hard. In July 1875, a group of about 100 Icelandic settlers landed at Willow Point, near what is now Gimli, fugitives from volcanic eruptions in Iceland.They survived the first winter, to be joined in July 1876 by 792 more Icelanders. The settlements, already primitive, were now overcrowded and good soil for an epidemic. The first case of smallpox appeared at Icelandic River in late September, and by November three Icelanders and seven aboriginals had died. The colonists appealed for government help, and it came in the form of four doctors from Winnipeg: Baldwin, Beddome, Lynch, and Young. They strove devotedly, vaccinating, setting up a hospital at Gimli, where only one of sixty-four patients died, a much lower mortality than among patients

Foundations

treated in the tents and shacks they called home. The government sent blankets and buffalo robes, and imposed a quarantine, enforced by soldiers stationed at Netley Creek, to prevent infection from spreading south. Over a third of the colony contracted smallpox, and just over 100 died. Three of the doctors contracted the disease. The last case occurred in March 1877, and by July the colonists were desperate; no one could obtain employment, all letters leaving were dipped in carbolic acid, and provisions were running out. They marched peacefully in protest to the quarantine line and held a religious service; on 20 July 1877 the government lifted the quarantine. It had been successful; the disease had not spread, but the Icelandic colony was devastated, and many soon left, seeking new and more fertile land, free of the memory of pestilence. Tall grass now waves over the smallpox graves on Hecla Island. In Winnipeg, a vaccination campaign was started and was widespread by 1883. Later, in 1885, smallpox found its way up the North Shore railway from Montreal to the West. So, there were health problems aplenty; doctors and hospitals were desperately needed. Constructing a medical system was to take time: forty years and more. Several things were needed: licensing and control of medical practice, a medical college to train doctors, and hospitals. Licensing and control of medical practice was a first priority, at least for the doctors. It was important to maintain high standards. At least some of the early doctors had attended medical classes for unspecified periods but never passed any qualifying examination. Travelling quack doctors were a major problem. And doctors always like a closed shop; it may help the patients and certainly helps the doctors by reducing competition.The legislature enacted a statute on 3 May 1871, incorporating the medical profession under the name of the Provincial Medical Health Board of Manitoba, which was responsible for setting examinations for licences to practise and for courses of instruction. The name was changed in 1877 to the College of Physicians and Surgeons of Manitoba. Of the forty-six doctors on the first register, all were male, and thirty-six had been trained in Canada, six in Britain, and two at schools in the United States.The College had the power to admit, censure, and dismiss. The monopoly was set.

The Manitoba Medical College In 1883, a landmark year for the development of medicine, the Manitoba Medical College was founded. Such an institution was badly needed then to train doctors for the province, and this has remained its main function over the years. A major stimulus to form a medical school came from potential students; young people wanted to study medicine without leaving

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Chapter 2 the province. But there were dissenting voices.The Winnipeg Sun believed that there were too many doctors in the province, and the June 1883 meeting of the Medical Board of Manitoba resolved, "In the opinion of this board the time for the formation of a medical school has not yet arrived." Perhaps there was worry about competition. A low-quality, private, medical school might have opened; there were many of these across the United States, and some of them were very bad indeed. Most Manitoba physicians at that time had been adequately trained in British or Canadian medical schools and did not at all like the idea of a proprietary medical school. So, in 1883, thirteen physicians petitioned the government to allow development of a first-rate medical school. They had on their side D.M.Wilson, an elected member of the legislature and secretary to the Norquay government. As a guarantee, degrees were to be granted by the University of Manitoba.The prospective medical students were supportive. J.W. Fawcett, chemistry teacher and principal at the Central Collegiate Institute, volunteered a classroom to be used at night. The founders of the Manitoba Medical College drew upon the classical traditions of medicine, through the eastern Canadian medical schools, Belfast, and particularly Edinburgh. Clinical observation and clinical teaching, a largely herbal pharmacopoeia, and high ethical standards all hearkened back through Leiden, Paris, Montpellier, Padua, Bologna, and Salerno to classical Hippocratic medicine. There was considerable contact with the eastern Canadian medical schools, including such prominent figures as William Osier. The first twenty-five years of the new school were a struggle; money was short, but the founders were well trained and assiduously travelled long distances to acquire new skills. It was an exciting time; medicine was beginning to undergo the cataclysmic transformation from a semi-priestly vocation that offered little but transient comfort to a scientific profession that cured. Much information on the early days of the medical school comes from the Manitoba and North West Lancet, which appeared in Winnipeg in 1887, five years after Ludwig Koch had described the tubercle bacillus. The time was critical for Western medicine; only recently had antiseptic and later aseptic surgery allowed the exploration of the abdominal cavity. The bacterial theory of disease was well established but still not universally accepted, and, apart from digitalis, quinine, and opium, there were few effective drugs. Frontier communities like Winnipeg were still septic places. The idea of preventive medicine was accepted in Europe but had not yet come to North America. William Osier had in 1884 accepted an invitation to leave

Foundations

McGill University to be professor of medicine, first in Philadelphia and then in Baltimore, where he produced his famous Textbook of Medicine in 1892. He wrote of diagnosis and pathology but had little effective treatment to offer.The book was used in the young Manitoba Medical College immediately after publication. James Kerr, the first dean of the Manitoba Medical College, had been trained in Belfast and had been appointed medical officer of health in Winnipeg in 1882. He enthusiastically raised money, and by the fall of 1884 the students were in a small, new purpose-built building at the corner of Kate and McDermot. It took another fourteen years before a new and larger building was constructed. It is difficult to know how competent the graduates of the young school were, but the examination questions in 1900 resembled those set in Toronto or by the Scottish medical schools. Kerr was an able and determined man, who had proved his courage in striking ways. He once jumped off a ship sailing through shark-infested water to prove his point that sharks would not attack a living man unless they were hungry. He contracted nephritis after his experiences during the second Riel rebellion and left Winnipeg in 1887, partly for health reasons, to build a highly successful surgical practice in Washington, DC. Kerr was succeeded as dean by Dr. J.Wilford Good. Good was born in Bruce County, Ontario, some time in the 1850's and, after graduating in medicine from the University of Toronto, came to Winnipeg about 1880, initially in partnership with Dr.J.R.Jones. Good was a founding professor of clinical surgery, lecturer in ophthalmology and otology, and dean from 1887 to 1898. He was a witty, sparkling teacher with deep-set black eyes and a mane of tousled black hair. He made a point of unorthodoxy; at the table he would reverse the order of the courses, starting with ice cream and nuts and finishing with soup. He took up golf late in life; he always played alone and took two sets of clubs, playing right hand against left hand to get balanced exercise for his muscles. At the green he would lay down anywhere from six to a dozen balls and putt; the one he holed in fewest strokes was the winner. In 1898, Good gave up being dean and took the Dawson Trail to the Klondike. He returned to Winnipeg, no richer, to resume practice and in later life was surgeon to the Red Cross and to the Canadian Forces; he spent his time, and his money, in his latter days as a globe trotter. The most persistent early influence was that of Henry Havelock (Harry) Chown. Chown grew up in Kingston, where his father was a conservative businessman, temperance worker, and Methodist. Chown graduated MD (Queen's) in 1880 and registered with the College of Physicians of Manitoba

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Chapter 2 on 22 July 1880; he set up practice in Emerson early in 1880. He was a widely read and scholarly man who would read encyclopaedias for pleasure and retain much of the information. He worked very hard all his life, sometimes to the detriment of his health. Soon after arriving in Manitoba, Chown realized that he needed further training and, as was then common, went to Britain. He sailed on the Allan Line steamship Peruvian, with eighteen cabin and twenty-five other passengers, and was seasick most of the way. It cannot have been comforting to know that there was a case of smallpox on board. He landed at Liverpool on 12 March 1882. Medicine in Britain impressed Chown. He thought the best English doctors far ahead of their Canadian counterparts. He was based at the London Hospital and worked hard to see the main medical figures lecture or operate: Thomas Lauder Brunton, the most distinguished physician of his time, at St. Bartholomew's; Jonathan Hutchinson, surgeon at the London; and Hughlings Jackson, the renowned neurologist. He watched Joseph Lister operate and was not much impressed by his manual dexterity, though he took Listerian antisepsis back with him. For the first time in his career, he saw the ophthalmoscope in use. What spare time he had, Chown spent sightseeing, going to plays, and listening to music. Irish home rule was the question of the day, and he records hearing James Stewart Parnell speak. He noted much drunkenness in the London streets. On Sundays he was a sermon taster, going to two church services. He took it seriously and would write a complete synopsis of a sermon, describing the preacher and the architecture of the church. He joined in the robust singing of the Salvation Army but had some antagonism to Catholicism. When Chown returned to Winnipeg, freshly a licentiate of the Royal College of Physicians, he opened an office in the Young Building, at the corner of Main and Higgins. It was a bustling young town; there had been horse-drawn streetcars since 1881, and these were replaced in 1891 by electric cars. He was at first a general practitioner. Such services as vaccination were greatly in demand. Diphtheria was treated by blowing an astringent through, a quill into the patient's throat. Little surgery had been done in the province; the first recorded operation, a lithotomy, was carried out by Dr. J.H. O'DonneU in 1875. As one of the bright young doctors around town, Chown took his place in the new Manitoba Medical College as professor of anatomy in 1885. When in 1886 he performed the first abdominal operation at Winnipeg General Hospital, it was a considerable event. He married on 27 April 1886

Foundations

and set up his household in a new house on the northwest corner of Donald (344) and Ellice. He was a formidable figure, six feet tall and 200 pounds in weight.

Hospitals before 1900 Hospitals developed in Winnipeg a little haphazardly, as the city did itself. The first two, the St. Boniface General Hospital and the Winnipeg General Hospital, started in the two villages on opposite sides of the unbridged Red River in 1871 and 1872, respectively. The Winnipeg General Hospital

Winnipeg in 1871 was crowded with soldiers from the Riel rebellion, and with immigrants, many of whom were single men. The water supply came raw from the Red River, polluted with sewage, and was distributed by the town water man in coal-oil barrels covered with gunny sacking; Red River fever (typhoid) was common, particularly among the newcomers, who were used to relatively clean water.There were no nursing or hospital facilities. Governor Archibald in 1871 formed a board of health, consisting of Robert Cunningham, James Ross, Honorable A.G.B. Bannatyne, and Dr. J.H. O'Donnell. One of its first tasks was to start a hospital, and by 13 December 1872 the hospital was organized, an appeal was made to the provincial government for funds, and, on 14 May 1875, provincial letters of incorporation were taken out. The first hospital was a little, whitewashed building with a mud scraper made of an old hoe nailed to the doorstep, up a muddy path, on a grassy, unfenced lot, at the corner of McDermot and Albert streets. The nurses were local housewives, and most of the cases were typhoid. After several successive moves into larger premises, the hospital was moved to a house owned by the hospital and located between Bannatyne and McDermot. There was a brief period in 1882 when hospital services were provided in the Dominion Government Immigration Hall on Point Douglas Common, and finally, in 1884, the first building of the present hospital was formally opened. It cost $67,000. In 1884, the Medical Board included most of the medical worthies of the town: Doctors Cowanjackes, O'Donnell, Codd, Good, Kerr,Whiteford, Blanchard, and R.B. Ferguson, with Dr. Mewburn as house surgeon and Mrs. C. Brown as matron.There were separate wards for men and women, and there was a separate isolation ward. The wards were bright, with sun galleries, and there were small kitchens with sinks and hot and cold water. Heating was by steam radiators, steam

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Chapter 2 being supplied by two boilers in the basement. Water came from a well on the grounds. Because the main drain on Bannatyne Avenue had not yet been built as far as the hospital, a large cesspool was built for liquid waste, and there were earth closets for solid matter. There were six private wards, four of them privately furnished, and costing $2.50 per day, including board, lodging, nursing care, medication, and the services of the house surgeon. The Women's Aid Society completely furnished the new building, raising money by sponsoring a ball and a promenade concert. The churches raised money by special Sunday collection. The cost per patient per day was about one dollar, fifteen cents more than a stay in the Montreal Hospital, because many articles in Winnipeg cost more than they did in Montreal, and nursing wages were higher. Costs had to be kept down. The patients, when able, had to help make beds and clean the wards, under penalty of expulsion. The annual general account noted: costs of salaries and wages, $5,453.80; funerals, $270.00; telephone, $10.00; and cow maintenance, $13.95. The receipts included: from paying patients, $668.40; from the City of Winnipeg, $5,000.00; donations, $427.95. During 1884,528 cases were treated (seventy-three more than in 1883): 418 males, 110 females.The average stay was 33.06 days. Sixty-two patients died, sixteen of them from typhoid; there were eighty cases of typhoid. There were deficiencies in the new hospital; there was poor ventilation, and cracks developed between the floor boards as the wood dried. Surgery was dangerous in the early days of the hospital, and major operations required the consent of the majority of the medical staff. In 1884, seventy-nine operations were performed, with only three deaths, one from the amputation of a leg at the thigh, and two from the amputation of a foot. Other operations included ten skin grafts, one removal of a cataract, two removals of an ovary, and two tappings of fluid from swellings around the testis. Nurse Ellen Birtles, who trained at the Winnipeg General Hospital, remembered: During operations we used an invention of the famous Dr. Lister's - the Lister spray. . . . It had to be worked by hand and that was one of my duties. The purpose was to purify the atmosphere around the patient's bed while an operation was going on.Yes, we just operated on the bed — we had no operating tables. Later Dr. R.B. Fergusson went over to Europe and brought back a knowledge of more modern methods of antisepsis and the spray was laid aside. The doctors' hair used to be full of drops of moisture after working under the Lister spray. I remember one abdominal operation in which to ensure non-infection, everything, bed, sheets

Foundations

and so forth, were brought into the hospital new, and all the doctors went and changed into new clothes. Everything was surgically clean, and all the precautions worked admirably.The operation wound healed without pus — as the doctors say by first intention. The young hospital had to deal with the medical problems of war. The assistant surgeon general, Thomas Roddick, co-founder of the Medical Council of Canada, was responsible for the organization of the medical teams for the second Riel rebellion, and he, himself, came west from Montreal. Winnipeg physicians rallied to the cause, led by Surgeon Major James Kerr, the first dean of the Faculty of Medicine, who watched the Battle of Batoche from a buckboard. Hospitals were set up in Saskatoon, Battleford, and Moose Jaw, and ah1 the necessary paraphernalia were transported. Students from several medical colleges, including the Manitoba Medical College, served as dressers, and one, Alexander M. Fergusson, son of Dr. R.B. Fergusson of Winnipeg, was killed. Casualties were transferred back to specially designated wards in the Winnipeg General Hospital. In succeeding years, the hospital grew steadily, despite the problems of the swampy land around the hospital and dissension within the Board of Governors. An outdoor free dispensary was started in 1886; eighty-six patients were treated during that year. In 1887, a training school for nurses was started and a maternity hospital was added. In the basement was a padded room with no windows or lights, which was reserved for delirious alcoholic patients. Standards were enforced by regular external visitations; for example, on 14 March 1902, a grand jury visited and found everything in good order. By 1900, there had appeared a new operating theatre, an x-ray department, a laundry, a new nurses' home, and a system of district nursing visits. The Winnipeg General was the hospital of the anglophone majority. The community grew rapidly and the hospital became closely associated with the new Manitoba Medical College in 1883. A women's hospital soon developed nearby. Dying to Have a Baby: The Management of Childbirth

Little is known about childbirth in the days of the Red River Colony; presumably the accoucheur was usually a wise woman experienced in childbirth, rather than a physician, always male and usually not well trained in obstetrics. It has been suggested that aboriginal women usually bore children with relative ease, presumably because of their active lives. It is believed that two "white" children were born in the Red River area in 1807, and one in a tent in the snow in April 1813 to a Selkirk settler family.

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Chapter 2 Early in the development of the Red River Colony, the need for some sort of maternity hospital must have become evident. From 1872, there was some hospital care in Winnipeg for women in labour. Being pregnant in 1870 was a risky business. A woman had no more than nine chances in ten of surviving several pregnancies, and only one chance in two of seeing the child she was bearing grow to adult life. Maternal and perinatal death rates were very high in the crowded infirmaries in the cities of the Industrial Revolution. Young women dreaded the pains of labour and the risk that they would not survive it. Parents expected to lose several children in infancy. A man or woman might expect to have more than one spouse during a lifetime. Anaesthesia was still quite new. When J.Y. Simpson introduced chloroform anaesthesia in 1847, there were cries from the pulpit that God was being deprived of the deep, earnest cries of women in labour. Those who believed that children should be brought forth in sorrow were, by and large, male. The great killer was puerperal fever, the lethal infection occurring in women recently delivered of a child; it had been seventy years since Alexander Gordon in Aberdeen had suggested that infection was carried by the physician, and more than twenty since Ignaz Semmelweiss had shown clearly that mortality could be drastically reduced by he use of disinfectants. But it was only four years before the foundatio of the Manitoba Medical College that Louis Pasteur had triumphantly grown pyogenic cocci from the cadaver of a woman dead of puerperal fever. So, the knowledge of the cause and prevention of puerperal fever was not yet deeply embedded in the medical consciousness. Less common but equally dreadful was obstructed labour; many doctors did not have the skill to handle it. Nor did doctors yet understand that childbirth was a natural biological process, which usually required as little interference as possible. The first generation of successful antiseptic surgeons were interventionists first and foremost, and obstetrics was regarded as a rather surgical matter. About 1872, babies were delivered in a small whitewashed building at the corner of McDermot and Albert streets. It is not clear where deliveries occurred over the next few years; most must have happened at home, and some in the successive buildings occupied by the Winnipeg General Hospital during the period up to 1884, when it moved to its present site. In 1886, the Women s Christian Union started the drive for money for a separate maternity hospital. They raised $202.58, to which the City of Winnipeg added $1,500 and the Province of Manitoba $500.The total cost of the new building was $7,349.50.

Foundations

The new unit opened in December 1888, a two-storey brick building fronting on Olivia Street, and 200 yards from the main hospital. Fifteen public patients could be accommodated in the public wards, and there were four single-bed rooms for private patients. By the end of the year, two babies had been delivered, and in the first four years there were four outbreaks of puerperal sepsis, fortunately without loss of life. Dr. Andrew McDiarmid, with the assistance of Dr.J.S. Gray, performed the first Caesarean section in September 1895, for contracted pelvis. Dr. R.B. Fergusson was in charge of obstetrics from 1885 to 1893 and was succeeded by Dr. McDiarmid. In 1895, Dr. John Gray took charge of gynaecology; he had received postgraduate training in London and remained in charge until 1917. The extant examination papers of the 1890s show that the medical students received good grounding in obstetrics and gynaecology. St. Boniface General Hospital

The other major Winnipeg hospital was founded by nuns. There was another world on the other side of the Red River: francophone, devoutly Catholic, controlled by other imperatives. Since the 1840s, the Grey Nuns had cared for the sick as best they could, by home visiting and providing food, administering simple herbs and providing nursing care. By 1871, there were some scanty funds for a hospital, and the first St. Boniface hospital opened in that year; there were four beds on the second floor of the wooden building, which was also used to store garden tools and as a repair shop and laundry. The first patient was Louis Thibault, fifty-one, a blacksmith with apoplexy. He stayed in hospital for 309 days and was considered cured on discharge. In 1872, the hospital looked after, among others, a diabetic and a labourer whose face was injured in a sawmill accident. By 1874, there were about eighteen home visits a day, and six beds were available in the hospital. Common problems included paralysis, presumably from stroke, and frozen hands. In 1871, 177 patients were treated and received medication, 886 wounds were dressed, and there were 631 home visits. Board, clothing, and education costs were provided for twenty-nine orphans and twenty-five elderly women. Physicians attended the hospital from its very early days; the first recorded surgical operation, an amputation of a forearm, was carried out in 1873. Finance for the hospital was always a problem, and in 1871 a petition was presented to the first Manitoba Legislative Assembly. The first grant, given in that year, kept the hospital going. In an exchange in the Manitoba

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Chapter 2 legislature, quoted on 20 May 1871 in the newspaper of the day, the North West Weekly, there was opposition to granting public money to a private religious institution. In response, the attorney general replied that it was a "public hospital, as persons of all creeds and nations were admitted and well taken care of by the charitable sisters in charge of the institution In the performance of their good works the most loathsome forms of disease have no horrors for them — smallpox, cholera, fevers." In 1874, an appeal was made by doctors to government that it provide a paid intern service at the hospital, along with fully trained nurses, and thirty-seven and a third cents a day per indigent patient. Even the orphans under the nuns' care sought support from a visiting government delegation. The annual request to government for funding became bilingual in 1876; the continued flow of funds since then has justified the linguistic effort. The hospital remained a privately owned religious institution, ultimately almost entirely funded by public money, providing care in their own language for French-speaking people and representing a distinct medical and religious society. These were hard times: in 1882 the Red River flooded the hospital, and the patients were moved to the nuns' provincial house; the provincial government provided $1,396 to the hospital treasurer. At an early stage, the provincial government believed that patients were being kept too long in hospital and required detailed returns of length of stay. In 1883, the government grant was increased from twenty-five cents a day. A personal shopping list that dropped out of the hospital register for 1883 showed that at that time a man's suit in Winnipeg cost $2.50. The hospital buildings expanded, step by step, from 1877,when a tenbed house became available to which were soon added residential facilities for the sisters, so that twenty-four-hour care could be available. As a result of having to turn away patients due to lack of room in 1886, a public appeal through Bishop Tache raised funds to build a new hospital. The sixty-bed hospital that opened in 1888 had no formal operating theatre; anaesthetics were given and surgery done in a bay window on the private floor.The window served as the reception area, and the instruments were boiled in the kitchen pot. In 1891, an operating chair was purchased for $70 from New York. When in 1894 the hospital was visited by the lieutenant-governor of the province, the official party observed surgery in progress. Between 1881 and 1901, the hospital coped with two outbreaks of typhoid, one of diphtheria, one of scarlet fever, and one of smallpox. As time passed, the hospital continued to expand on its present site. Special provision was needed for maternity cases and for infectious diseases.

Foundations

In 1895, what had been the ice house was restored for the accommodation of the infectious sick. The first such patient was Phillipe Coutu, ill with diphtheria. The space was inadequate, and in 1899 a house was bought, named after St. Roch, patron saint of epidemics, and equipped as a fever hospital, with separate beds set aside for patients with tuberculosis. Brandon General Hospital

One major hospital in the province developed outside Winnipeg, in Brandon, later the second city of Manitoba, a bright, clean place, lying between the uplands of Riding Mountain and those of Spruce Woods, an agricultural centre and much later the home of a small liberal arts university. Brandon in 1882 was little more than a waterlogged hillside, littered with tents. The first physician in Brandon was Alexander Fleming, a Glasgow graduate, familiar with the polluted backlands of the industrial slums of Glasgow and ready to recognize filth when he saw it. As in Winnipeg at the time, there was no sanitation and no clean water; water-borne disease was rife. A proper sewage system was established, and a group of local women set aside a large house for the care of patients ill with typhoid, scarlet fever, and smallpox. Brandon General Hospital was formally incorporated in 1883, but money was short due to a world-wide depression; grain fetched very low prices. The hospital was completed in 1890 at a cost of $24,000. By this time, there were six doctors in Brandon, and the population of Brandon and the surrounding area was increasing. The main problem was infectious disease, and a separate infectious-disease building was opened in 1894 and expanded in 1896. A nursing school was started in 1892. The first patient, Mr. W. Card, was a stableman whose leg was amputated and who spent twenty-seven days in hospital; his hospital bill was $25. Many of the early patients were treated for trauma of one kind or another; in that rough society, broken bones and bullet wounds were common. Frost bite was an everyday occurrence in the winter, and any surgical intervention could be followed by sepsis, abscesses, and gangrene. While money was less scarce by 1890, there was still a constant struggle to raise money for the hospital, which attracted patients from the adjacent developing country to the west, then part of the North West Territories. Money came from voluntary donations, and the Women's Hospital Aid Society, formed at the time the hospital was founded, raised money for individual projects and equipment by holding bake sales and bazaars. A ten-dollar deposit was required in 1900 before admission, preferably in advance. Medical care to indigent patients was given free by the doctor

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Chapter 2 of the month, on a rota basis.This continued until medicare was established in 1969.

Medical Practice in the 1890s The life of a physician in the 1890s was very different from that today. The doctor was nearly always male and practised alone. He would have an office where he would see patients, and he would visit the sick in their own homes; his patients would usually be ill rather than seek help to ward off illness. His diagnostic aids, the thermometer and the stethoscope, fitted easily into his little black bag, along with a few simple surgical instruments and a very few drugs. He would often make up his own prescriptions, which would by the standards of today be largely ineffective. He would often be on the staff of a local hospital, owned by either a lay board or a religious group or order, and would visit the hospital usually daily. The day would be long, and he would often be called from his bed to attend urgent illness. It was a dangerous life. Mrs. Anne Higginson in 1938 recalled the last illness of her husband, Henry Ahern Higginson, over forty years before. Dr. Higginson practised in Winnipeg. Early in June 1895, my husband had two patients very ill with diphtheria when antitoxin was just being tried out. He was examining the throat of one of them, a boy of 12, who coughed directly in his face. Knowing he had been exposed to the infection, he sprayed his throat each day, but the dread germ had lodged in his windpipe. He knew he had contracted the disease, and drove himself at once to the hospital. Alas, at that time there was no more antitoxin in the town. He lived only from Friday to Wednesday. Dreading the disease for myself and the baby, he would not allow me to go to the Hospital. Before the operation for tracheotomy (a last hope) he sent me the message "It's all right, I'll either get better, or go Home," which he did on June 20th, 1895.

He was thirty-nine years old. Medicine in the 1890s was still comparatively ineffective. The instruments of diagnosis were limited to the stethoscope, which was not universally used. The first x-ray was taken in Germany in 1895 and the first in Canada in 1896, but the technique was not widely used in Manitoba until the next decade. Most people died of serious infections like pneumonia, tuberculosis, and typhoid, for which there was no effective treatment. Digitalis had been known for a century for treatment of heart failure but was imprecisely used. Surgery was, however, becoming increasingly effective, with

Foundations

the twin supports of asepsis and anaesthesia. One doctor on the attending staff commenced treatment on every medical case that came under his care by prescribing calomel and jalap, potent purgatives both. In the Winnipeg General Hospital, wrote Dr. SJ. Elkin, "cancers that came under treatment were, as a rule, either in the lower lip or in the breast. Lower lip cancers were treated by 'V shaped incisions and nothing done about glands [lymph nodes] that might be involved. The same treatment was carried out in breast cancers by excision of the lump and in most cases, the lump was large with skin and muscle involvement. At operation a large, circular or oval incision was made with the intention of removing all of the primary growth." The surgeon would then examine the cut surface, and stain it with nitric acid; the fat stained black but cancerous tissue did not. If he reckoned by this crude and inaccurate test that any cancer was left behind, he would remove some more. The wound edges were brought together and left to heal by granulation. In one case, a live, partly plucked hen was brought into the operating room, and at the appropriate time the hen was killed and enough skin removed to cover the bare wound area and stitched into place. But these grafts did not take. There was no attempt to remove axillary lymph nodes, so recurrence was common. A major problem of the time was hydatid disease, acquired when the patient ingested tapeworm eggs after contact with an infected sheep. At a stage in the life cycle of the worm, large cysts, several inches in diameter, would form in the lungs, liver, or other internal organs. The disease was particularly common in Icelanders. The removal of the cysts posed major surgical problems, and as the years passed the local surgeons, notably the Icelanders, became highly competent at it. Due to improved hygiene, hydatid disease has now almost disappeared in Canada. There was no distinction between physicians and surgeons. Each patient was treated by the attending doctor whether the case was medical or surgical. Elkin described how a consultation was called when a surgical patient was in a condition where an operation might, or might not, be indicated. The hall porter notified about half a dozen semi-retired old doctors. Next day the case was presented to this group, which acted as a jury to decide whether or not the operation should be performed. Minor operations were performed at the discretion of the attending physician-surgeon. The hospital had only one operating room and one operating table.The anesthetic was given by the medical superintendent and was generally chloroform unless it was contra-indicated by a weak or diseased heart, and then ether was given. In the theatre, the seats were set in tiers, forming a

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Chapter 2 semi-circle, and they accommodated about fifty student spectators. Generally the assistant was another staff doctor. "Sometimes," wrote Elkin, "the operations that followed consultations were attended by members of the consultant tribunal and these celebrities were given the honor of standing around the operating table, clad in their everyday coat, vest and pants, without gloves or masks and while the operation was in progress they had the privilege of inserting a finger into a cavity and investigating for themselves what the operating surgeon had informed them that he had discovered." While the students received most of their teaching at the Winnipeg General Hospital, from an early stage they also attended the second hospital, St. Boniface.This was facilitated by Dr. Ferguson's troubles. He was one of the original group of thirteen who had founded the Manitoba Medical College, and in 1886 he became professor of surgery. He was on the attending staff of the Winnipeg General Hospital, but, after a quarrel, he resigned and transferred his services to St. Boniface Hospital. Trained in Listerian principles, he had a considerable reputation as a surgeon, so the students followed him across the river to see him operate in the new surgical theatre; its amphitheatre seated eighty. Elkin remembered crossing the river in a van drawn by four white horses, specially ordered by Dr. Ferguson. Surgical practice in the early days of the Winnipeg General Hospital was recalled in 1967, when a man of ninety-one, Kenneth Macdonald, presented to Dr. Kenneth Thorlakson at the Winnipeg Clinic. He had been a patient in the Winnipeg General Hospital when its doors opened on the present site. One day in July 1884, when he was eight, he was tramping hay near a woodpile beside his home in the country when he fell right on his right knee cap on a sharp piece of wood. The following day the knee was painful and swollen, so his father hitched a team of horses to a wagon and took his son over mud roads to Winnipeg. When the boy arrived at the Winnipeg General Hospital, the injured and infected knee was examined by the house surgeon, Dr. F.H. Mewburn, and the patient was subsequently admitted to the twenty-four-bed Ward Two. A plaster cast was applied to the leg, and the patient was confined to bed. At monthly intervals the young patient was taken to the operating room and the cast changed. He was anaesthetized by the open drop-andmask technique with chloroform and ether. The leg was more painful after each change of cast. Summer changed into winter. Dr. Ferguson examined the boy on the ward, lanced the knee, and inserted a rubber tube. In spite of further months of treatment, the condition did not improve and amputation of the leg was

Foundations

considered. In the spring, Dr. Ferguson called in a colleague, Dr. James Kerr, who operated upon the leg under general anaesthetic and removed the knee cap. More than eighty years later the patient's knee was stiff but free of pain.

Rural Medicine The Canadian West in the 1880s seethed with restless migrants rattling across the prairie on the wooden benches of the "colonist cars" of the new railways. Some of the migrants settled, broke the ground, and succeeded in making a living; some failed and moved on, and some sickened and died in the harsh conditions. The sick were cared for by any neighbour who had the skill, and many of the homesteaders had "home doctor" books in their luggage.Dr. Chase's New Receipt Book is such a manual. Published in Toronto in 1889, it contains general instructions for the sickroom and a set of remedies for most of the ills of the flesh. The worst case of smallpox could be cured in an hour by drinking a cold dilute solution of cream of tartar, an ounce at a time. An onion sliced and cooked with slices of tobacco yielded a juice that cured earache. Syphilis was trickier: the specific remedy contains stylingia, corydalis, poke root, yellow dock root, burdock root, and iodide of potash in a simple syrup, four teaspoonfuls of which were to be taken daily, one at bedtime.The same book contains recipes for the kitchen, instructions on how to mend holes in the roof, and an infallible way of curing horses of the habit of pawing in the stable. The settlers sometimes learned the healing practices of the aboriginal inhabitants. In Baldur, southwest of Winnipeg, they learned how to relieve pain with a tea made by boiling the bark of the wild plum and pincherry trees. Seneca root had a wide variety of uses, among them the treatment of tuberculosis, and was an article of trade; the fur traders bought and sold it. "Skunk grease," or "skunk oil," was used as a liniment to treat bruises and sprains. It was prepared by roasting the skunk and retaining the grease. The settler women recognized the skill of aboriginal women in midwifery. One woman who lived near Baldur recruited the aid of two aboriginal women who lived near the shores of Rock Lake. They made her drink hot tea that they had made from some herbs. She afterwards claimed that it was the easiest childbirth she had ever had. The European medicine of the time was not always more effective. Sometimes settlers would find that one of their number, breaking the sod like themselves, was medically trained; he would be pushed and persuaded to practise. More often, a doctor would move into a community as soon as it reached a certain size, keen to make a living that he could not

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Chapter 2 make in Winnipeg, an eastern Canadian city, or Britain. The doctors were often as restless as the others and would move on in a year or two. The medical problems were sometimes acute, with tragic consequences. In 1899, a group of Galician colonists with many young children left Halifax by train, headed for the Strathclair area in western Manitoba, near the southern border of what is now Riding Mountain National Park.They stopped in Winnipeg in May 1899 and were lodged in the immigrant sheds. After medical inspection, Dr. Patterson of the Board of Health allowed them to continue on their way by train. The weather was cold and gloomy for May. A few children in the sheds were already sickening; their mothers did not wish to be left behind and may have concealed the severity of the children's illness. One died on the train as it puffed west, and the rest of the immigrants left the overcrowded train at Shoal Lake and went north on wagons. As they went north, more children sickened, and two more died. Four days out, so many children were sick that the little procession stopped and set up tents at Strathclair. A late spring snowstorm struck, the survey on the area to which they were moving was incomplete, and the children were too sick to go further. As the storm raged, they were held in tents, in three groups: the sick, those suspected to be sick, and those still well. When the storm cleared and they could move on, forty-two children and three mothers had died. The disease was never precisely identified; it could have been scarlet fever, measles, or both.There is a memorial to the tragedy at the mass grave near Patterson Lake, six miles north of Oakburn. Rural doctors had a hard life. The life of Dr. Murrough O'Brien, well recorded as the "saddlebag surgeon" by Robert Tyre, serves as an example. O'Brien failed his medical examinations at St. Mary's Medical College in London and travelled to Manitoba in 1890. After two years in a variety of occupations (as railway ganger, threshing crewman, coal miner), he raised enough cash to return to Winnipeg and enroll in the Manitoba Medical College in 1894. The new college was not prepared to take his English training at its face value. He was initially required to take the full four years of training, but after a little while this was cut to three. Soon after graduation, O'Brien served briefly as an assistant to Dr. Good and in June 1897 boarded a train for Dominion City to set up practice. Dominion City was south of Winnipeg, near the United States border, and the train ran only once a week from Winnipeg, so that it was relatively isolated. Dr. Good's advice rang in his ears:"First thing a smart doctor does when he goes into practice is make friends with the local clerics. As you go through life butchering patients with your knife, and annihilating them

Foundations

with faulty diagnosis, you will need that friendship. You would be surprised, O'Brien, how often the soothing flattering phrases of a funeral oration assuage the grief of relatives, and turn their minds away from lawsuits." The new young doctor was a conspicuous figure in the community; he was a short, broad man with prominent ears, a large nose, closely cropped moustache and wedge-shaped chin. At first, he practised from a windowless lean-to at the rear of a Chinese laundry, rented for five dollars a month and furnished with two chairs, some shelves, and a cracker barrel to hold a wash hand basin. His instruments at first included only a hypodermic syringe, obstetrical forceps, dental forceps, dressing forceps, and a thermometer. O'Brien treated toothache initially at what he thought was the bargain price of fifty cents, only to find to his distress when he raised the price that his later customers were not happy to pay the going rate of a dollar. Patients soon came; they were varied but not always remunerative. "Ma wants you to come and look at the baby - he fell off the cow and she stepped on him." He lanced an abscess on the arm without anaesthetic and was knocked out by the patient's other brawny arm for his pains. On his first day, he earned $3.50. As the months went by, his practice built up; there were maternity cases, circumcisions, appendicectomies, fractures, and bronchitis. The practice enlarged when in August 1897 almost 4,000 middle European immigrants (Galicians, Ruthenians, and Ukrainians) poured in to take up homesteads on unbroken prairie. O'Brien received a government contract to look after major surgery and serious illness for these people. Minor illness was their own affair. The infectious diseases were the major problem: diphtheria, whooping cough, measles, and scarlet fever. There was no hospital in Dominion City until 1901; residents put off getting medical help until the last moment. O'Brien would sterilize his instruments in a basin of water boiled on the stove and perform surgical operations by lamplight, on the bed or kitchen table. A member of the family or a neighbour dripped chloroform on to the gauze mask placed over the patient's face. The doctor did his rounds on a bicycle in summer and would often arrive at a patient's home dirty and dishevelled, to be greeted with a nip of brandy. There was no telephone service, and a summons to visit a patient in the boondocks would often come by a family member, who would pick him up and act as a guide; perhaps they would ride double on horseback. He would often eat with his patients and would sometimes feed one of them. Before the snow fell in the first year of O'Brien's practice, he was able to afford a horse and buggy. That winter, and for many winters to come, his

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cutter carried him many a cold mile over the snow to distant farms.Weather was a formidable enemy; it was easy to die of cold. It was a mixed practice. When O'Brien pulled a tooth and drained an abscess with a two-inch nail and a hammer, payment was a young chicken, plucked and drawn, and a basket of eggs. The immigrants lived rough, and O'Brien delivered babies in many a one-room sod shack with an earthen floor. The older children would be in boxes under the bed, with hens, geese, and pigs around it. In such a house he carried out a Caesarean section; the mother died. The people were tough; one woman, twenty-four hours after being at death's door due to obstructed labour, was moving around and returning to normal life. All of the seamy side of life was there: multiple murders, wife abuse, quack doctors. O'Brien realized the virtues of preventive medicine and gave local school children lectures on sanitation and good health practices. "Nothing was more frightful than to come into a home and find the cruel symptoms of diphtheria - the high temperature, the gasping for breath, the blue skin. There wasn't much I could do for the patient. Sometimes I cut a hole into the trachea to let them breathe. After that they were in the hands of God. ... I was called to a farm home one day and arrived to find two members of the family dead. A third died ten minutes after my arrival, and a fourth went fifteen minutes later." One of the worst outbreaks of diphtheria occurred early in the summer of 1898, and the casketmaker had to hire two helpers to keep pace with the demand. Diphtheria antitoxin came into use in the area that year. There were a few who flatly refused to accept inoculation and chased the doctor with rifle or axe. The next serious epidemic was an outbreak of smallpox on two nearby Indian reserves. The Department of Indian Affairs asked O'Brien to vaccinate, and he did. He sent a bill for $100 and got $7.50 back. He returned the cheque saying that he had not realized that the Department of Indian Affairs as well as the Indians were paupers. Later, the Indians petitioned the Department of Indian Affairs to have O'Brien as their medical officer. A typhoid epidemic in the summer of 1900 cost O'Brien nineteen sleepless days and nights. Treatment consisted of bed rest, cool sponging to bring down the temperature, and a soft, largely fluid diet. O'Brien occasionally attempted quite complicated surgery, such as treating chronic dislocation of the kneecap in a pretty teenager; she afterwards danced and swam. And he made considerable profit out of veterinary operations. O'Brien opened a small hospital in 1901 and in 1909 rented a large house and set up part of it as a hospital with six beds. O'Brien operated and

Foundations

the druggist gave the anaesthetic; one of the first surgical cases was the removal of an ovarian cyst from a woman of seventy-two, who rallied only after she was supplied with a corn-cob pipe packed with tobacco. During an epidemic of typhoid, O'Brien persuaded the local council to provide for the expenses of medical nursing and drug requirements. As the years went by, the doctor's style of living became more expensive; he would go out riding on visits in the winter followed by his pack of wolf hounds. But it was not always easy to collect bills, and he came to live beyond his means.This was particularly evident in the severe drought and crop failure of 1907, and barter again became the order of the day. An appendicectomy equalled a side of beef or load of hay, a tonsillectomy a leg of pork or half a dozen hens; the delivery of a baby was rewarded by a bushel of potatoes, a load of poplar slabs bought the treatment for gonorrhoea, and a rump of deer paid for uterine curettage. Among O'Brien's other duties, he looked after aboriginal patients on a local reserve. Since Confederation, in 1867, administration of Indian affairs had been a federal government responsibility, latterly through the Department of Indian Affairs, sometimes as a charge against band funds. His aboriginal patients suffered diseases similar to those of the settlers, notably infections, and O'Brien provided similar medical attention, including immunization.There was, however, some difficulty in persuading the Department of Indian Affairs to pay. O'Brien left for Winnipeg in 1910 because he was hard up.

Pioneer Women Physicians The first registered woman physicians in Manitoba were Dr. AmeliaYeomans and her daughter, Dr. Lillian Yeomans. Amelia Yeomans was born in Quebec on 29 March 1842 and in 1860 married Dr. Augustus A.Yeomans, who practised in Belleville. They had two children, Lillian and Charlotte. After her husband died in 1878, Amelia joined her daughter Lillian in pursuit of a medical career. Lillian graduated in 1882 and was licensed to practise in Winnipeg in that year, specializing in midwifery and diseases of children. Her mother arrived in 1883 and was licensed on 23 February 1885.They were successful physicians and ardent social activists, campaigning against poverty, unemployment, poor housing and factory conditions, alcoholism, and for womens' suffrage.They moved to Calgary in 1906. For much of the period between 1877 and 1912, the only doctor between Rat Portage (Kenora) and Winnipeg was a tiny woman, barely five feet tall, Charlotte Whitehead Ross. Born in Yorkshire, England, she had come to Canada with her family as a small girl in 1847, the year of the Irish

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Chapter 2 potato famine, and grew up on the family farm at the edge of the Ontario frontier. She was unable to obtain a medical training in Canada but in 1862 went to the newly founded Women's Medical College in Philadelphia. Her medical education was interspersed with childbearing, and she took her younger children with her to Philadelphia; it took her ten years to graduate. When she returned to Montreal after graduation, she met extreme opposition from the male medical establishment, so much so that, while she treated patients in Montreal, she never actually registered with the Quebec College of Physicians and Surgeons. Charlotte's father, brother, and husband were involved in railway construction, and her husband, David Ross, opened a sawmill nearWhitemouth, Manitoba, a frontier Canadian Shield logging town then with three hotels, two general stores, several sawmills, a post office, and a railway station. It was a tough place, with drunks, brawls, stabbings, and murders.When David had built a cabin ready for them, Charlotte and their children went in by rail via St. Paul and Winnipeg, riding the last bit of the way on a flatcar. Ross was not a militant feminist and saw nothing unusual in her work or the acceptance she gained from her male patients. She did not at first register with the College of Physicians because she was not practising medicine primarily to make a profit. She waited from 1881 to 1887 to apply for registration and asked her lawyers to file an application for a private act that 'would entitle her to practise.This never passed second reading, and she was never properly registered in her life. As a gesture of appreciation, a special act of the Manitoba legislature seventy-seven years after her death admitted her to the register. A devout Presbyterian, Ross taught Sunday school and sang in the church choir. In the wilderness, despite the hardness of the life there, she preserved the niceties; her black gowns and white blouses were sent from eastern Canada, and she wore hand-embroidered frilly petticoats. It was a period when settlers were streaming into the area and would take up land and build their log houses in inaccessible areas. Ross would find her way to isolated farmsteads to deliver babies and alleviate sickness by travelling by whatever means was necessary: railway, handcart, canoe, wagon, sleigh. After she had delivered a baby, she would stay to wash the floors or even do the baking. This was a time not long after Lister's great discovery, and Ross was a firm believer in antisepsis, using carbolic acid and iodine, and boiling water. The rest of her pharmacopoieia was simple: Epsom salts and castor oil for constipation and many other ailments, zinc and borax lotions for skin disease, sodium salicylate for rheumatism, and flax seed for poultices. Much of

Foundations

her practice lay in treating lumbermen and railway workers, often providing emergency surgery for gory major trauma. She was good at it, and the patients soon idolized her. She was almost forty when she arrived in Whitemouth, and she served the area as a general physician for over thirty years. After her husband died and when her own health was failing, she moved into Winnipeg. Women in medicine had a hard row to hoe. In 1888, not long after Charlotte Ross arrived in Whitemouth, another young woman, Elizabeth Scott, enrolled in the Women's Medical College in Kingston. Born in Campbellford, Ontario, she travelled west as a child and grew up in Morris, Manitoba. To raise money for a medical education, she taught school. The money lasted only a year, and she returned to teaching school at Poplar Point. Only nineteen, she fell in love with a thirty-seven-year-old man, once sinner, now missionary, John Grace Matheson. Elizabeth married John, and from 1891 to 1916 they lived in the mission at Onion Lake, over the border in Saskatchewan. She bore seven children without expert attention in this remote place (still the site of the sun dance) and endured the hardships of pioneer life: breast abscess, the loss of a child, depression. Realizing that she could not help the sick around her for lack of training, back she went to Toronto, graduating MD (Trinity College) in 1898. Her degree was not recognized by the College of Physicians and Surgeons of the North West Territories in Calgary, so she went back for more training, this time to the University of Manitoba, for the 1903-04 session. Her biographer recorded a conversation with the redoubtable Dean Chown. "You are not graduating. . . . This is a man's profession," said the dean. "You are mistaken, Dr. Chown," said Elizabeth Scott Matheson. She graduated MD (Manitoba) in 1904 and returned to Onion Lake, to the general practice of a pioneer doctor, treating pneumonia, tuberculosis, appendicitis, childbirth, accidents, and investigating murder. In 1916, her beloved husband died, and Matheson travelled to Winnipeg and worked for twenty-five years as a school medical officer, a part of the great and successful attempt to improve public health. Like many other women doctors whose professional careers were apparently wrecked by marriage, she seemed to regret none of it.

Psychiatry Psychiatric illness is still regarded by the general public as somehow different from physical illness and carries a stigma. This attitude was much worse in earlier days.The mentally ill were often treated like convicts. In

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Chapter 2 1871, the Dominion government established the Manitoba Penitentiary at Lower Fort Garry. Until 1877, the mentally ill were confined along with the criminals in one of the stone buildings at the Fort. In 1877, the mentally ill were moved to the newly built Stony Mountain Penitentiary. Official government correspondence of the early 1870s contains various terse statements to the effect that John Jones, having been judged insane, was confined to the Stone Fort, as it was then popularly known, or occasionally that he had been sent in custody to an institution in eastern Canada. Until 1877, only the mentally ill who were considered really dangerous were confined. Female patients were segregated, but the men shared quarters with the convicts. For practical rather than humanitarian reasons, this arrangement was not considered entirely satisfactory to the authorities. In 1879, the federal government pointed out to the then lieutenant-governor of Manitoba that the mentally ill were being confined to the Lower Fort with criminals and urged that he draw to the attention of his government the desirability of the two groups being separated. Criminals and lunatics did not mix. Whatever the motive behind the move was, an order-in-council was passed in 1879 requiring that all cases of mental illness in Manitoba and the North West Territories be admitted and cared for in a portion of the building separate from the convicts. Under the new regulations, families who had been reluctant to surrender afflicted relatives to a penitentiary now allowed them to enter the institution, and the number of confined mentally ill patients increased rapidly. By 1883, it was recognized that further provision was needed for the confinement of the mentally ill. Accordingly, to provide for their proper care, in 1884 the provincial government passed an act authorizing the building of an asylum. The Lunatic Asylum, as it was called in the 1880s, was built at Selkirk, on the site of the present mental hospital. Dr. David Young was appointed first superintendent of the projected institution. At approximately the same time, the Dominion government in 1884 notified the provincial authorities that the insane must be removed from penitentiaries without delay. As the Selkirk institution was not yet completed, accommodation for the mentally ill had once again to be found at Lower Fort Garry, and, in February 1885, thirty-five patients (twenty-seven men and eight women)were transferred there from Stony Mountain. The first building of the Selkirk asylum was completed in 1886, and Young assumed his duties as medical superintendent. A young graduate of Queen's University, Kingston, he came to Manitoba in 1871 and took

Foundations

up practice near Lower Fort Garry. He was head of the Selkirk institution between 1886 and 1912, when he retired. Dr.Young treated the mentally ill with a combination of professional skill, insight, and kindliness, not common in that day. It soon became apparent that one institution was inadequate for the care and treatment of all the mentally ill in the entire province and the North West Territories. New settlers were pouring into the West, and, to meet the increasing demand for additional space, an institution was established at Brandon in 1892. The building at Brandon had been constructed in 1891 as a reformatory for boys. Its first and last criminal inmate was a nine-year-old boy, Billy Mulligan, who was sentenced to five years imprisonment for stealing a letter from Her Majesty's mails.The chief warden was one Archie Campbell. It cost the province $30,000 to run the institution as a reformatory for six months for the sole benefit of one nine-year-old. After six months, Billy Mulligan was moved elsewhere to serve out his time, and in 1892 the building was converted into an asylum for the mentally ill. Dr. Gordon Bell was the first superintendent of the Brandon institution, a post to which he was appointed following his graduation from the Manitoba Medical College in the class of 1890.

The Start of Radiology Radiology in Manitoba started with Dr. Maxwell Stevenson Inglis, who graduated MD (Manitoba) in 1893 and started to practise medicine in Winnipeg.Two years later, he read Wilhelm Roentgen's paper, published in late 1895, and set off hot foot for Germany. He left Germany for home in April 1896 and by spring of 1897 had set up a laboratory and had started to take x-ray prints on glass. Its possible uses were obvious, at least to him. Hospital administration was not convinced: the Board of the Winnipeg General Hospital initially declined to set up an x-ray department in the belief that it would be useless.The use of a radiograph as evidence in court persuaded the board otherwise, and by 1900 the Winnipeg General Hospital started to assemble an x-ray department, with the aid of the city electricians. In 1903, the hospital spent $100, and the first x-ray burn occurred; by 1906, x-rays were being used for treatment. In 1910, 1,290 radiographs were taken and 1,771 x-ray treatments given. Revenue was $1,204 and expenditure $1,384. Inglis himself was one of the early victims of radiation. He had a severe radiation dermatitis, half of his neat Vandyke beard came away in his hand, and he became sterile.

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Chapter 2 At first, doctors who wished would purchase an x-ray machine, particularly out in the country, and physicians who used them often in specialty practice would buy their own. Dr. D.A. Stewart at Ninette used radiology extensively and early on his tuberculous patients.

The First Manitoba Medical Journal: The North West Lancet The Manitoba Medical College opened in 1883; by 1887, the medical school and the medical community became sufficiently well established to support its own journal, the Manitoba North West and British Columbia Lancet, edited probably by John Pyne Pennefather. The journal chronicled the development of the medical school and with it the development of the new game, surgery. Antiseptic surgery was still new; surgeon, and later dean, Henry Havelock Chown had recently visited Europe and sat at the feet of Lister. One after another, there appeared in the journal descriptions of new and dangerous surgical operations that are now familiar: ovariotomy, relief of strangulated hernia, prostatectomy, appendicectomy amputations. On 9 June 1887, in the Winnipeg General Hospital, a patient was etherized, and eighteen ounces of laudable pus were removed from the right kidney. A case of Jacksonian epilepsy was successfully treated by opening the skull. An extract of willow was recommended as a sexual sedative and for the prevention of "nocturnal pollutions." The conditions within the Winnipeg General Hospital were criticized. James Kerr complained, writing from the steamship Polynesia on 23 June 1887 that the Winnipeg General Hospital remained deplorably defective. Infantile diarrhoea and high infant mortality were scandals, attributable to poor social conditions in Winnipeg; the air was polluted and the nostrils offended by disgusting stenches at every turn. Disease was explained by Dr. Matthews of the Hudson's Bay Company on a racist basis: "It is a well known fact that a very large proportion of the Canadian Indians of the NorthWest are saturated with syphilis, hereditary and acquired." A case of syphilitic chancre of the lip was explained by the fact that the patient had contracted it from a speaking tube. Medical politics were played with the gloves off: when a senior surgeon (Dr. A.H. Ferguson) lost his privileges at the Winnipeg General Hospital and transferred his allegiance across the river to St. Boniface General Hospital, the editor drubbed the Winnipeg General Hospital administration. Physicians occasionally advertised inappropriately and were suitably reproved. A protagonist who argued back was likened to a dog returning to his vomit. The journal contained many abstracts or reprinted articles from the outside medical world: selections from medical journals in the United States

Foundations

and Europe, including reviews and original papers. Among these "was a description of the controversy over the laryngeal cancer of the Prince Imperial of Germany, which was misdiagnosed histologically by the great German pathologist Rudolf Virchow and clinically by Morell Mackenzie. In the last year of the nineteenth century, rubber gloves were becoming available, and the best Scotch cost six dollars a gallon. The surgeons of the time were well pleased "with their achievements and with themselves. Racism was rampant, hospital administrators were a dubious lot, and Scotch was too dear. The world changes less than is sometimes supposed.

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Aboriginal people near Dufferin, Manitoba, constructing a medicine house, 1873 (NAG).

Winnipeg in 1870 (L'Opinion Public, 22 December 1870).

John Bunn, the first locally born physician to serve the Red River Colony (WCPI).

A typical Red R Grant (PAM).

r Colony medicine chest, owned by the Metis leader Cuthbert

The Manitoba Medical College opens, the single most important event in the provincial history of medicine, 1883 (Winnipeg Free Press announcement).

Manitoba Medical College and Provincial Laboratory, Kate and McDermot, Winnipeg, 1896.

A dyad of deans: James Kerr, the first Manitoba dean of the Faculty of Medicine (on the left) and his successor, J.W. Good, about 1885.

Winnipeg General Hospital, about 1885 (PAM).

St. Boniface General Hospital, 1887 (AGN).

Operating theatre showing the use of a carbolic acid spray in the Winnipeg General Hospital, probably a posed picture, 1889. From left to right: Miss H. Barber, Mrs. J.R.Todd, J.W. Good, Miss E. Birtles, Miss M. Laidlaw, Dr. Orton, Dr. PorterJ.R. Jones (HSCA, courtesy C. Wolkenstein).

Convalescent Home, Women's Hospital Aid Society, about 1914 (PAM).

Ambulance, about 1900 (HSCA).

Children's ward, Winnipeg General Hospital, about 1914 (PAM).

X-ray room,Winnipeg General Hospital, about 1914 (PAM).

The New Century: Cleaning Up the Mess

3 Chown and the Manitoba Medical College As the new century dawned, the Queen died, and her son ended his long wait for the throne. Winnipeg in that year had 45,000 people; its main streets were paved with cedar blocks or tar macadam and thronged by horse-drawn buggies. A few electric streetcars rattled by. It was a tough place; the policemen were well over six feet tall and needed to be. Many houses had'neither water nor sewer connections; there were many outdoor privies. In summer, flies and mosquitoes abounded. Water came from artesian supplies in the northwest part of the city and was palatable but hard, clogging boilers. At times it would almost run dry. Milk came from many small dairies of questionable cleanliness and was retailed in bulk, without pasteurization. This spread infections such as gastroenteritis, typhoid, and tuberculosis, and caused a high infant mortality.The two general hospitals had wards for infectious diseases, and these were usually full. The Queen's peace had been disturbed by the South African War. Thousands rallied in the street outside the Town Hall in 1899 to cheer the fifty Winnipeg members of the Canadian contingent on their way. But, while Canadians fought there, it was a long way off and did not seem to bode ill for Canada. The Dreadnought race had not yet started, although the more thoughtful might have been perturbed by the personality of the young Kaiser Wilhelm. Physicians could not yet offer cures for many diseases, but the King himself was soon to owe his life to surgical treatment of his appendicitis. Knowledge of the bacterial causes of disease was expanding, and the first effective systemic antibacterial treatment appeared in 1910: the organic arsenical salvarsan for syphilis. The function of the thyroid was being

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Chapter 3 elucidated, but the surgical treatment of thyrotoxicosis was still dangerous. Childbirth was now safer, and the risk associated with Caesarean section was falling, but obstructed labour, haemorrhage, and puerperal sepsis were still feared. The Manitoba Medical College was in the hands of Harry Chown. When Good went to the Yukon in 1898, Chown was appointed professor of clinical surgery and then, in 1900, dean. He became an excellent surgeon but was a little tardy in accepting new ideas; he worked with ungloved hands until about 1910. In 1904, Chown moved his house to Broadway between Smith and Garry. His routine was now set; he was away well before 7:00 a.m., by horse and buggy or sleigh or in later years by model T Ford; on Saturday mornings he would visit the Provincial Laboratory, the Manitoba Medical College, and the General Hospital, all within a stone's throw of one another. As the years went by, he became fonder of Havana cigars and Scotch whisky and would visit the Manitoba Club daily.The years began to tell, and in later life he became an agnostic, a sceptic, and somewhat of a cynic. He was not athletic; holidays were spent at Detroit Lakes, halfway to Minneapolis, reached by sleeper railway car from Winnipeg. His own health plagued him in his latter days, when he suffered a duodenal ulcer and chronic back pain. In 1916, his wife developed pernicious anemia. He took her to Sir William Osier at Oxford, in the hope of a cure, but it was a few years too early. His grief was deep. Chown s other medical interests included insurance medicine, and he was latterly chief medical examiner of the Great-West Life Assurance Company. He was a successful medical politician, becoming in 1901 president of the Canadian Medical Association. A busy man who became busier, he often worked so hard as to make himself ill, with what we might now call burnout. He was widely respected. His colleagues showed their appreciation by a presentation in 1909, and in 1917 he gave up medical practice and being dean but remained in the background and on the University Board of Governors until 1932. He continued to act as medical advisor to GreatWest Life until his death. As Chown looked out on the world from his study window at the corner of Donald and Ellice of an evening in 1901, life must have seemed good. He was the leading surgeon in Winnipeg and a potent figure in the Canadian medical world. But he and the medical profession faced many problems. Outstanding were the need to establish the Manitoba Medical

The New Century: Cleaning up the Mess College firmly and to develop more hospitals, and the need to control the rampant infectious diseases, and in particular child mortality, that afflicted the province, to clean up the mess. The Manitoba Medical College and the Winnipeg General Hospital were still young institutions in a young city, but they were now beginning to be staffed by local medical graduates; the present students were its future leaders. One such doctor gave the flavour of these times in his autobiography; he was Dr. Gordon Fahrni, who died in 1995 at the age of 108, then Canada's oldest physician. Fahrni was born on 13 April 1887, the golden anniversary of the coronation of Queen Victoria, in a farmhouse a mile and a half northwest of Gladstone, Manitoba, the third of six children. He grew up the way many of his future patients and colleagues did. He wrote: My job as a toddler was to gather the eggs from the many hens' nests, feed the chickens, and bring in the cows from the pasture for the older children to milk. As we grew older, all of us took our turn at milking the cows each morning and evening... .All our meat was home grown, and what was not consumed fresh was treated or cured in our smokehouse. . . . All our dairy products were from our own milk cows and from the milk butter and some cheeses were made.

In the garden there were gooseberries and red- and black-currant bushes, and the rest of the fruit came from the wild. When the spontaneous prairie fires struck, nature was enemy rather than friend. In 1904, he registered at Wesley College, Winnipeg, and studied there for two years; he played the trumpet in Barraclough's City Band as recreation and soon earned enough money to pay his expenses. In September 1906, he registered in the medical school, after the initial entrance examination, which included classics. It was the first year of the new five-year course; his traditional medical education, laid the basis for a lifetime. He graduated in medicine in 1911 and served thereafter as senior intern in the Winnipeg General Hospital. He wrote: Interns in those days, after receiving board and lodging, felt well rewarded by the opportunity and training provided by the service... .The medical wards were filled with patients suffering from many different diseases. Pneumonia, rheumatic fever, acute nephritis and typhoid fever were common afflictions— Scarlet fever and diphtheria were epidemic. Night after night I would be hurriedly summoned from my bed and in my pyjamas, rush to see a child just off the ambulance, choking and almost black. With no preparation, I would grab a bistoury off the tracheostomy set tray and quickly open the trachea.

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Chapter 3 In his spare time he helped to build a fishing lodge at Fox Lake, near Minaki, Ontario, with Gordon Bell, Edward Montgomery, and others, a place where the medical elite of Winnipeg relaxed over the next forty years. The Manitoba Medical College was small but firmly established, its teaching was thorough, as can be seen from a glimpse at the examination papers for 1899. The questions often related to infectious disease or to disease caused by bacteria, and imply a considerable knowledge of surgical treatment and the treatment of the complications of childbirth. The graduates of 1899 were expected to do quite complicated surgery in rural communities without having undergone advanced training. The graduate who had satisfactory answers to these questions would be prepared for the front line of the practice of medicine. In 1900, most medical treatment was still ineffective. Opiates relieved pain, salicylates relieved fever, antiseptics were useful in superficial skin infections, and digitalis was useful in heart failure but was not always used appropriately. The rest of the pharmacopoieia was relatively ineffective. So doctors had either to concentrate on prevention or take to surgery. The surgeons soon treated appendicitis by operative removal of the appendix, and did bypass operations connecting stomach and jejunum for peptic ulcer; they removed breast cancers radically, splinted fractures fairly effectively, and removed tonsils and adenoids with abandon. Aseptic and antiseptic practice were usual, and ether or chloroform anaesthesia was routine but often dangerous. In 1900, Dr. Chown, now a successful surgeon, divided most of the reference surgical practice with Dr. R.J. Blanchard, then professor of surgery. Blanchard had grown up in Nova Scotia and became a railway doctor. In the late 1870s, the CPR was hewing its way through the rocks of northern Ontario, and Blanchard was posted to Rat Portage, now Kenora, on the Manitoba-Ontario border, and then in 1881 to Winnipeg. Later in Winnipeg, associated in practice with Dr. Kerr and Dr. Lynch, he taught first anatomy and then clinical surgery. He was a capable and scholarly man, subsequently surgeon to the CPR, medical director of the Great-West Life Assurance Company, and in 1909 president of the Canadian Medical Association. In 1911, in partnership with the young Dr. John Gunn, he opened a private hospital at the corner of Broadway and Donald. In 1914, Dr. Gunn left almost at once with the Third Field Ambulance and in May 1915 was followed by Blanchard, who took command of the Third Casualty Clearing Station. Like many, he suffered from trench infections, bronchitis, and

The New Century: Cleaning up the Mess middle-ear inflammation, and returned with impaired health. He took a solicitous interest thereafter in veterans and their medical needs. Dr. Neil John Maclean was slightly younger. A tall, shy, urbane man, and almost the last of the self-trained surgeons, he had some experience in the United States with Dr. A.H. Ferguson and returned to develop a large, successful surgical practice. He served on the surgical staff of the Winnipeg General Hospital and the Manitoba Medical College. Maclean went into partnership with Dr. Paul Thorlakson, and from this partnership the Winnipeg Clinic later grew. One lack in the medical school in 1900 was basic science. The medical school was still a place where all the teaching was done by clinicians, whereas in the big schools in eastern Canada, and the British schools, there were full-time professors of anatomy, physiology, and pathology writing books and doing research. Of these, anatomy and pathology were morphologic, dead-tissue subjects.The modern enterprise that allowed a dean to hold up his head among his deanly peers was a physiology department, where living tissues were studied. The University of Manitoba had been established in 1877, and teaching was done in the affiliated colleges. The 1900 University Act changed this; the University did its own teaching and appointed its own professors. The University Act allowed the appointment of several full-time professors to the Manitoba Medical College in 1904. These included bacteriologist Gordon Bell, physiologist Swale Vincent, botanist Reginald Buller, and physicist Frank Allen. In 1904, Chown regarded Swale Vincent as a catch; he was the first properly trained medical scientist on the faculty and the first professor of physiology. He was a London medical graduate, already an expert experimental endocrinologist, who set up a successful teaching and research department in the old University building on Broadway. He wrote in the preface of his book about internal secretion in 1912 that he had spent some fifteen years on the subject of the book. "Library facilities in Winnipeg are yet very inadequate, and during the summer of 1910, when I had expected to avail myself of the opportunity of working in the London libraries, I was laid aside with illness for several months." The physiology course was similar to that in British medical schools at the time; there were long hours of lectures and practical laboratories in which the students reproduced famous physiological experiments on muscle twitching and cardiac action using kymographs and smoked drums. In 1905, Professors Vincent, Parker, and Buller sent out a letter with a view to forming a small private scientific club whose members would

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Chapter 3 meet to discuss new and current scientific questions. Science had come to Winnipeg. The group first met on 24 October 1905. Gordon Bell was a founder member. About thirty percent of the communications related to medical science. The Scientific Club of Winnipeg survived until at least 1955, when a golden jubilee dinner was held. Vincent was trained in Edinburgh. Fahrni described him as the "Prima Donna of the four new professors. Stiff in manner, sarcastic and rather unapproachable." He was less than popular and headed the Department of Physiology with a firm and dictatorial hand. He prospered intellectually in Winnipeg, lonely as it must have been at first; papers and a book flowed from his pen, and he became a Fellow of the Royal Society of Canada in 1919 and DSc London in 1920. He returned to London in 1921 as professor of physiology at the University of London at Middlesex Hospital Medical School; he was appointed to several distinguished lectureships and produced several more books. He wrote in all 114 scientific articles, a goodly record before the time of large research teams and word processors. Vincent was a very important figure in the history of the medical school and founded its most important department and tradition. He was highly successful: it was important for the young medical school to be seen as a place from which its professors could go on to greater things. The Department of Physiology as the years passed was the fountainhead of many innovations. The first was a new specialty, biochemistry. In 1910, Dr. A.T. Cameron appeared as lecturer in physiology; Cameron was a biochemist who later became eminent in that profession. The tradition that physiology was the place where things started was already on the way. Most obstetric care continued in the hands of doctors who practised general family medicine and surgery, but specialization was beginning. Dr. Daniel McCalman became head of obstetrics in 1905. McCalman had moved to Manitoba in 1880 and was first a schoolteacher and then an inspector of schools. After graduation from the Manitoba Medical College in 1902, he became professor of hygiene. By 1907 he was professor of obstetrics, holding this position until 1927. Like many obstetricians of the time, McCalman believed firmly that a woman should have her baby on the predicted date and that, if she did not, the obstetrician should take drastic steps to induce delivery. An unduly high number of patients treated in this way suffered severe haemorrhage, and maternal mortality was very high. It was a dogmatic era in obstetrics. The task in the Chown years was still to establish good medicine. Throughout these years there was a struggle to establish the fundamentals, high-grade hospital care and high-grade specialist medicine, and to control

The New Century: Cleaning up the Mess infectious diseases, including tuberculosis. The burgeoning science of bacteriology was of fundamental significance in this. The school had still to reach the first rank as a medical educational establishment. In the Flexner Report of 1910, Manitoba was rated as adequate but not quite first-rate because of lack of specialized teaching facilities and professional teachers. Until then, faculty gave their time and teaching services without fee. But medical teaching eventually became a profession, the entry qualification for which was research experience. Chown sought medical teachers from outside. The first full-time faculty member was Dr. RJ. Evatt, professor of anatomy, in 1909; he stayed for only a year. Chown then thought of the British nursery of medical education: Edinburgh. First, Alexander Gibson was appointed professor of anatomy in 1911, followed later by two of his Edinburgh classmates; the incomers might have wrought change sooner, had it not been for the explosion in the world outside.

The Winnipeg Hospitals after 1900 The problems of providing hospital accommodation to the expanding city were analyzed in 1908 in a report on hospitals and hospital accommodation for the City of Winnipeg by a special hospital commission, composed ofT.G. Mathers, J.R. Jones, and G.R. Crowe. At that time, St. Boniface General Hospital had 350 beds, Winnipeg General had 345, Sherbrooke Street Maternity Hospital (the Misericordia) had 200, Grace Maternity had sixty, Dr. Beath's private hospital had fifty, Dr. Walter's private hospital had fifteen, Drinkwater's private hospital had nine, the Shamrock private hospital had six, and Dr. Gray's private hospital had six. The General Hospital was often overcrowded; St. Boniface Hospital and some of the private hospitals often had empty beds. There were enough hospital beds: 8.07 beds per 1,000 population, a ratio similar to that in Montreal and twice as many as that in Chicago.The cost per day per patient in 1907 in the Winnipeg General Hospital was $1.48, less than the $2.39 in the Presbyterian Hospital New York but more than the $0.91 in St. Paul City and Country Hospital. In their report, the authors preferred large to small hospitals but criticized the organization of the Winnipeg General Hospital and in particular the lack of a board of directors and the lack of an experienced, strong medical superintendent, who should have been "a man of keen discernment, business capacity, resourceful, honest, tactful and a thorough disciplinarian," and a permanent career appointee. The report considered the problems of the sick poor. "All recipients of hospital treatment should pay their way as far as possible, thus preserving their independence and preventing pauperization, which tends to sap their

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Chapter 3 moral fibre. . . . Care must be given over the provision of outdoor treatment, lest there be injustice to young physicians who largely depend for support on the poorer class of patients ."The community needed an isolation hospital, a maternity hospital, and a tuberculosis hospital. The main teaching hospitals had a head start in medical and surgical expertise. The others had arisen either from the distinct religious groups within a diverse culture or from specific medical needs. Three of these had started as maternity hospitals. The Grace General Hospital, which started in 1890 as a Salvation Army Home for unwed mothers, developed delivery and nursing facilities and was incorporated in 1904, thereafter over the years developing into a general hospital. The Misericordia Hospital originated when four Sisters of Mercy arrived on a mission from Montreal in 1898 at the call of Bishop Langevin, of St. Boniface, to care for unwed mothers.This they did first in St. Boniface, then on a site on Broadway, and finally in their present site on the Assiniboine River, between Sherbrook and Maryland. The hospital dealt only with maternity cases until 1917 and developed thereafter into a general hospital. The function of caring for unwed mothers was hived off to the Villa Rosa Nursing Home in 1958. The Victoria General Hospital began in 1907 as a fifty-bed private maternity hospital at 779 Bannatyne Avenue owned by Dr. Thomas Beath. The frame building of his first hospital was not fireproof, so in 1912 he organized the building ofVictoria Hospital, which was fireproof, on River Avenue and began the excavation of the site himself by driving a team of horses and a scraper in his shirt sleeves. He sold the first building to the City of Winnipeg in 1911, to be used for the treatment of scarlet fever cases; it was a forerunner of the municipal fever hospitals. The Victoria Hospital was rebuilt on a new site in 1971. The Winnipeg Municipal Hospital, on the banks of the Red River at the east end of Morley Avenue, originated in the need for adequate accommodation for patients with acute infectious diseases and tuberculosis. In 1911, the King Edward Memorial Hospital came into use, replacing temporary facilities, followed three years later by the King George V Hospital. In 1912, typhoid fever, scarlet fever, and smallpox were prevalent. From 1916 to 1918, diphtheria accounted for the largest number of admissions. As infectious disease has become a less important community problem, the hospitals have been adapted for the care of the long-term sick and elderly. The Convalescent Home of Winnipeg arose from the efforts of the Women's Hospital Aid Society; this society, founded in 1883, gave substantial support to the Winnipeg General Hospital from its inception. Few middle-class women of the time worked outside the home, and voluntary

The New Century: Cleaning up the Mess organizations were the outlet for the energies, emotions, and abilities that now go into women's careers.They raised money by sponsoring bake sales, repairing and selling used clothing, and by selling fine sewing.The chronic overcrowding at the Winnipeg General Hospital reached a peak with the typhoid epidemic of 1905. It became evident that part of the problem was that poor people would be discharged from hospital too early, not yet completely recovered but no longer needing the services of an acute-care hospital. If these patients had no income and no home or family, as was the case in particular with male migrants, they might again fall severely ill and need re-admission. Some intermediate care was needed. The Women's Hospital Aid Society purchased a building, which was formerly the Women's Home, and opened it to convalescent patients from the General Hospital. The operation ran on a shoestring; there was a matron, a servant, and whatever help the women of the Aid Society could provide. They provided food from their own larders and clothes from their own wardrobes, they visited, they helped to find jobs, they raised money by giving charity dances and garden parties. Perhaps not yet liberated, they certainly rattled the bars of the cage. The home they founded runs successfully to this day, and the problem they strove to solve in their time is unsolved today: How many acute-care, as opposed to chronic-care, beds does a society need? Children in early-twentieth-century Winnipeg died all too frequently. For instance, in 1905, 513 children died of diarrhoeal diseases, many without having received medical care. There were only twenty hospital beds in the city for children. In 1908, the Council of Women appointed a provisional board to establish a hospital devoted exclusively to infant and child care in a locality where the infant death rate was highest. The women organized themselves in guilds to raise money to support individual parts of the hospital. They ran bazaars, tea rooms, anything that provided publicity and turned a dollar. A main force was Mrs. Annie Bond, wife of a local physician. The first Children's Hospital was a large abandoned house on Beaconsfield Street, once the house of Lieutenant-Governor Dr. John Schulz, but now rundown and dirty. It opened on 6 February 1909 with one sick baby patient, one nurse, one maid-of-all-work, and a full staff of honorary physicians and surgeons. All the doctors served without fee, and the surgeons brought their own instruments. There were no interns; emergency calls were answered by medical staff. In the first year, 228 patients were admitted and 503 treated as outpatients. Forty-seven died, most from diarrhoea and dehydration, almost all

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Chapter 3 under six months of age. The income in the first year was $10,326.92 from donations and patients' fees, including a grant of twenty-five cents per patient per day from the City of Winnipeg. In 1910, there were 282 patients, of whom seventy-three died, half in July and August due to diarrhoeal diseases. Other causes of death included miliary tuberculosis, congenital heart disease, pneumonia, burns, starvation, and croup. The old house was obviously inadequate and a fire risk, and a campaign soon began to raise money for a new site on the grounds of St. John's Ladies' College on Aberdeen Avenue. The great day of the move was 27 November 1911, but the new fireproof building was only partly finished. One of the wards was named Titanic Ward, in memory of three members of the Real Estate Exchange recently lost. It accommodated up to 100 patients at peak periods; verandahs at the back of the house gave fresh air to convalescents.The cost of $187,503.04 was raised by public subscription. The outstanding figure among the early staff was Dr. Robert E. Rorke, Winnipeg's first paediatrician.The hospital had independent diagnostic services; for instance, Dr. Gordon Chown became pathologist in 1913. By 1918, there were 2,000 admissions a year. Only the very sick were admitted.The medical admissions were mostly severe gastrointestinal infections in babies under one year of age, but there were many admissions for anaemia, pneumonia, rickets, and tuberculosis of lungs and nervous system. There was a notable absence of recorded admissions for cancer and leukemia: child neglect or accidents also went unrecorded but surely occurred. The hospital was still far too small to meet the needs, and staff was short during the war, so that further plans for enlargement were deferred until after the war. Child care still had a long way to go; in 1912, more than one in five newborn children in Winnipeg died. Associated public-health measures were as important as the hospital itself was, notably a milk depot and a centre for well-baby care, and for the preparation and distribution of sterilized milk formula.

The Cleanup The Industrial Revolution in Canada was half a century later than in Britain; to complicate matters, as industrialization occurred, immigrants were flocking in. As in Europe, large cities had few sewers, polluted water, and poor municipal control of housing and sanitary conditions. City dwellers died young as a result of abysmally poor social conditions. The sanitary movements ranged over a wide spectrum of human activity: social reform, liquor prohibition, and women's suffrage. Municipal government often closed its doors and its ears, and reformers often took aim at local governments.

The New Century: Cleaning up the Mess An early stimulus to improvement had been the Gimli smallpox outbreak, which led to compulsory vaccination. By 1886, the Department of Agriculture, Statistics and Health, had been organized, in several stages. Ontario established a board of health in 1883, and Manitoba followed suit ten years later. The 1893 act established a provincial board of health with seven members, one a veterinarian, a secretary, and a bacteriologist. The province was divided into health districts and an inspector was appointed for each. The minutes of the Board of Health, dating from its first meeting on 18 April 1893, delineate the problems and the steps taken to deal with them. An early necessity was the examination of sick immigrants. Two outbreaks of smallpox are noted in the provincial Board of Health Report for 1897, one attributed to immigrants from Austria, and another to Chinese passing through from the Pacific Coast. This stimulated an effective vaccination program. Four cases of leprosy were documented in Manitoba in that year; all were in immigrants who were thought to have contracted the disease elsewhere. In 1898, the Board noted the incidence of the most important diseases affecting Manitobans: tuberculosis, scarlet fever, typhoid fever, and diphtheria, as shown in the following table. Diseases Affecting Manitobans Tuberculosis

Scarlet Fever

Typhoid Fever

Diphtheria

1894

85

224

568

83

1895

93

279

187

112

1896

94

176

147

223

1897

67

276

274

235

Eleven deaths were reported by the Great-West Life Assurance Company during 1897, four from tuberculosis, three from accidental causes, two from cancer, one from apoplexy, and one from internal abscess. Statutory registration of vital statistics began in 1909. Winnipeg grew rapidly in the period between 1900 and 1913, and slum conditions in the city were among the worst in the country. This led to increasingly bitter confrontations between labour groups and owners. Many of the working-class British immigrants had close connections to the far left British Independent Labour Party. Growth outstripped drains by the early 1900s. Only about forty percent of north-end houses had a clean water supply; many were linked to artesian wells, and it was not until 1919

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Chapter 3 that the Shoal Lake aqueduct opened to provide a pure water supply to Winnipeg. In the early 1880s, there were no laws on workers' compensation, and, even in the first decade of this century, fifty workers a year might have died in industrial accidents. There were 100 bawdy houses in Winnipeg in 1909, although there is no note of who counted them and for what reason; and the trade and its attendant disease continued to flourish. Alan Artibise dryly noted that, by 1940, the "trade fell victim to amateur competition." In Manitoba, a cleanup had to come, and it was largely attributable to the Manitoba and Winnipeg Departments of Public Health, working often in unglamorous ways. The story of improvement in the public health in Manitoba is the story of three wise men: Gordon Bell, Alexander Douglas, and David A. Stewart. Gordon Bell

The Board of Health Report for 17 March 1898 stated: "The Board is pleased to report that the Provincial Government has seen fit to appoint Dr. Gordon Bell as Provincial Bacteriologist and to erect a laboratory on ground conveyed to it by the Manitoba Medical College. It is difficult to estimate the immense importance which the establishment of this branch of science is going to be to the people of this province." Gordon Bell was the son of a lumber magnate in the Ottawa Valley; he had been educated at Pembroke Collegiate Institute and graduated BA (Toronto) in 1887. As a boy, and in later life, he found joy in books and in the outdoors, hunting and fishing. He went west to the young Manitoba Medical College because he had heard reports of the excellence of the medical education provided there. As a result of an attack of typhoid fever in 1889, he lost a leg but graduated in 1890 at the top of his class. He said once, much later when his canoe capsized in the lake, that he wished he had two wooden legs. His first three years after graduating in medicine were spent as superintendent of Brandon Mental Hospital, where he left his mark by abolishing the uncomfortable and unnecessary practice of restraining patients, common in mental hospitals at that time; it remained elsewhere for many years. Then he travelled in Europe, initially to learn ophthalmology; he was, however, fascinated by the new science of bacteriology. He married in 1897 and lived in Manitoba for the rest of his life. Dr. Bell set up his laboratory in the grounds of the first Manitoba Medical College building at the corner of Kate and McDermot streets in 1897. It was called at first the Bacteriological Branch of the Board of Health; Bell was paid $2,000 a year through the Board of Health. In its first year (1898)

The New Century: Cleaning up the Mess the Bacteriological Branch reported examination of 283 samples of sputum, 170 of blood for typhoid, and twelve for other reasons; they examined 1,391 diphtheria swabs, sixty-four samples of pus, forty neoplasms, twelve samples of milk, and thirty of water. The laboratory provided a service for the identification of patients with, and carriers of, infectious diseases, and for the examination of the purity of milk and water. It became the diagnostic and epidemiologic centre for the whole province and was the beginning of laboratory medicine in Manitoba. As well as being director of the laboratory and provincial bacteriologist, Bell was a statutory and very influential member of the provincial Board of Health. He was for many years pathologist as well as bacteriologist to the Winnipeg General Hospital. In addition, he was professor of bacteriology and pathology in the Medical College. In 1906, the Provincial Laboratory was moved to new and more spacious quarters at 750 Bannatyne Avenue, in the northeast corner of the building.The main working area was twenty by fourteen feet. An appended animal house contained guinea pigs, rabbits, and two sheep; the building was reputedly intended for the dean's horse. From this building, and under Bell's guidance in the years between 1906 and 1922, the province was cleaned up. Throughout these years, the functions of the laboratory were closely coordinated with the teaching functions of the Manitoba Medical College Department of Bacteriology; in 1922, the laboratory moved again into the new college building at 770 Bannatyne Avenue. Bell played another important role in society. As in any western society, the safety of the public is partly dependent on surveillance of unnatural deaths. From the early days of the Red River Colony, physicians must have carried out the duty of inquiring into the circumstances surrounding unnatural deaths and where necessary carrying out a postmortem examination. In the last decade of the nineteenth century and the first fifteen years of the twentieth century, it was Dr. Gordon Bell who carried out these duties, as coroner's pathologist. Bell himself was a warm, friendly man, most at home outdoors. His shooting lodge at Delta, and later his cottage at Fox Lake, were places of laughter and comradeship. He was a marvellous teller of stories and a light sleeper who woke with the dawn. Gordon Bell's son Lennox said many years later: His medical friends turned hungrily to him for advice. On Sunday mornings, these fugitives from a church-pew would drift into the lab and perch themselves on stools or benches, while Gordon Bell went quietly about

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Chapter 3 his work. They would exchange the medical gossip of the week, swap stories, and engage in amiable debate about the topics of the day. Some would bring in diagnostic puzzles for Gordon Bell to solve. He was regarded . . . as a sort of medical Sherlock Holmes, who could seemingly unravel the knottiest medical problems with intuitive ease. And yet he took great pains not to appear superior in his knowledge, or condescending in his attitude towards the difficulties of his colleagues. He would listen carefully to the clinical details presented, and pretend to be completely baffled by the problem. Then he would bring forth a battered text in German, leaf through it a bit, and invariably come upon the right answer. Many years later I discovered that the marvellous vade mecum was actually a dull and obsolete German treatise on urinalysis.

Bell himself died tragically in 1923, after being called to Brandon to consult on an epidemic of streptococcal sore throat. He examined several patients, took specimens from throat and blood for culture, plated out his cultures and told.the story to his colleague, Dr. Fred Cadham, and then went off to his cottage at Fox Lake. When he arrived he felt vaguely ill and within a few hours developed a violent chill and sore throat; despite help from medical colleagues at the lake, he was dead within forty-eight hours. He died much mourned, as a man, and for what he had done for the province. He was a man of his era, who worked so hard that he never had time to make original contributions to the medical or scientific literature; his medical career began and ended with a severe infectious disease. His name is remembered in the name of a central Winnipeg high school. He was the founder of one of the two great traditions in Manitoba medicine: the discipline of medical microbiology as applied to human infectious disease. Alexander Douglas

Working in tandem with Bell and an equally important figure in the cleanup was Alexander ("A.J.") Douglas, medical officer of health for Winnipeg from 1900 until 1940. Douglas was born in Erkfrid, Ontario, in 1874, and moved to Winnipeg as a small boy. His father owned and managed the Leland Hotel, the most elegant in Winnipeg. Douglas started to study medicine at McGill, but his father lost much of his money in an economic depression, and the young Douglas finished his training in Winnipeg, graduating MD in 1897. After postgraduate training in London, Paris, and Vienna, and a brief period in private practice, he became full-time medical officer of health for Winnipeg in September 1900. Douglas was appointed to a hot seat in the aftermath of a smallpox outbreak six months before. An Australian, Hector Finlayson, on his way

The New Ce ury: Cleaning up the Mess

via Hong Kong to Britain, had taken ill on the train at Brandon on 13 April; Dr. Chown, who happened to be on the train, saw no rash but, because Finlayson was seriously ill, advised him to stop at Winnipeg. He was taken by cab to the Winnipeg General Hospital where he died two days later. Two nurses contracted the disease, as well as several people who had been on the train. Dr. M.S. Inglis, as part-time city health officer, quarantined the hospital, and a vaccination campaign was put under way, delayed by lack of vaccine. There was considerable public fuss. Among the preventatives advised in the press were whisky and cigars. The fate of patients sent to the the smallpox hospital, or pest house, was not pleasant. They were taken in a horse-drawn wagon, past the cemetery in which victims were buried. The pest house, originally a shack, isolated on open prairie, was rebuilt about 1900 on Logan Street a mile west of the city centre, 100 yards away from both road and railway track, near Brookside Cemetery. A high, board fence surrounded the four small one-storey buildings and a tent.Two more tents stood outside the fence. Patients would try to escape, and some were shackled. Those who died from smallpox were buried in tightly sealed caskets and carried to Brookside Cemetery in a special conveyance kept at the pest house. There, a clergyman standing on the windward side of the grave and at some distance from it read the burial service. The precautions were extreme; the disease was terrible. There were sixteen or more cases in the 1900 epidemic, and several deaths, but the outbreak was soon contained. Despite this, the City Council was dissatisfied with Dr. Inglis s services, complaining that on the one hand he had neglected his duties and on the other he had been alarmist and risked loss of trade to the city. Inglis, for his part, complained that he had not been paid. He was dismissed, and on 4 September 1900 the aldermen appointed Alexander Douglas from a field of thirteen candidates. Douglas's first problem was a further smallpox outbreak. In 1900, the Winnipeg professional baseball team played an exhibition game at Brandon. It was a big public occasion; the procession was led by a brass band with carriages conveying the team, mayor, aldermen, and other dignitaries. Next day, the pitcher who had played at Brandon was ill, and a young doctor was summoned.The pitcher had severe backache and two or three shotty papules on his wrists and a red spot on his forehead. It looked like early smallpox; the patient's doctor called in Dr. Douglas, who confirmed the diagnosis. Douglas transferred the patient to the city pest house and vaccinated the other players and allowed them to play, but he instructed them to stay at all times in their hotel until it was clear that no other cases would develop.

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Chapter 3 Strict secrecy was maintained, the press was kept in ignorance, the games at River Park went on, the club was not ruined, and everyone was happy. Douglas had both tact and luck. Smallpox outbreaks recurred in 1911, when there were nineteen cases at Fort Alexander and passenger traffic there was prohibited, and in 1914 and 1915. Over the period between 1911 and 1931, there were 755 cases in the province, but compulsory vaccination was effective and the disease died down. The next major problem that Dr. Douglas faced was typhoid. In 1904 and 1905, Winnipeg was the typhoid capital of North America; in 1905 there were 1,606 cases with 138 deaths, mainly in young people.The incidence rose sharply in the latter half of August, and the disease raged through September and October. The epidemic died as the frosts came. Hospital superintendents put extra beds in corridors, set so closely that a nurse or doctor could scarcely pass between. In 1905, the Winnipeg General Hospital had to open an emergency hospital in the British Columbia building in the exhibition grounds on Dufferin Avenue. Typhoid cases were distributed focally in congested, downtown Winnipeg. This suggested a relation to water or milk supplies. Dr. Douglas advised that Dr. Edwin Jordan of Chicago, a major authority, be called in to investigate and report. Jordan recommended that outdoor privies be abolished within the city limits, that sewer connections be made compulsory wherever possible, and that every effort be made to reduce the number of flies, which acted as carriers. After careful examination and improvement of the sewage system, within two years the number of cases fell dramatically. A typhoid epidemic within the Winnipeg General Hospital in 1907 derived from an infected ten-gallon can of milk contaminated by flies; at that time a nurse in first-year training was fifteen times more likely to contract typhoid than a member of the general population. A vaccine against typhoid was first widely used in 1898 in the Boer War; it was tried in Winnipeg in 1908 and shown to produce protective antibodies in the blood. According to Douglas's daughter, he took a personal hand in the cleanup. His neighbour had a privy at the bottom of her garden, discreetly veiled by lilacs; she would not remove it. One dark Hallowe'en night it was utterly demolished; no one knew where he was that night. Douglas recommended that Winnipeg obtain a good permanent water supply from the Lake of the Woods, a large lake with a rocky basin and little population on its shores. Shoal Lake, an arm of Lake of the Woods, was chosen and the aqueduct completed in 1919. New sewers were laid and connected by intercepting sewers to the sewage disposal plant north of the

The New Century: Cleaning up the Mess

city, where sewage was treated and ultimately led as a less offensive effluent back to the Red River. The scheme was not complete until 1938. The hospitalization of large numbers of patients had risks. During a major outbreak of scarlet fever in 1910, an emergency hospital was set up in the main exhibition building. On 19 October, it caught fire and was soon demolished. Forty-four patients, mainly children, were quickly removed to shelter in the grandstand and within an hour were in Winnipeg General Hospital. About this time, skin tests for scarlet fever and diphtheria were introduced, followed by immunization. A free dispensary for diphtheria inoculations for children opened in the basement of City Hall. Child health demanded urgent attention: in 1912, more than one newborn in five died. A city health nurse was appointed and a milk depot was opened close to the Children's Hospital on Aberdeen Avenue. Medical inspection of children was introduced, carried out by Dr. Mary Crawford and later by Dr. Elizabeth Matheson. Douglas was a modest, unassuming man, scornful of publicity. He was at his happiest among the other worthies of the medical establishment, in the lounge of the Manitoba Club, spinning stories to an attentive audience. He was devoted to his stamp collection and to golf and classical music. He did not take to the new-fangled motor cars; he had bought a Russell motor car in the early 1900s, driven it for two days, backed it into a tree, and went back to his bicycle. When he stopped riding his bicycle, it was stored in the basement of his City Hall office along with his old straw hats. Over the years, notably from 1911 on, tighter control was established over such matters as transporting corpses, extending sewers, handling food and milk, emptying septic tanks, sterilizing rags, and maintaining standards in such various establishments as boarding houses, hotels, and slaughter houses. The testing of milk and water became extensive and routine, outbreaks of infectious disease were investigated in detail, and extensive investigation of venereal disease was started. David A. Stewart

Tuberculosis had been the scourge of western societies for centuries. The sanatorium movement depended on the idea, never disproved, that fresh air, good food, and open windows would cure tuberculosis. In 1882, Robert Koch discovered the tubercle bacillus and later promulgated the idea that tuberculin, an extract of the tubercle bacillus, was of curative as well as prophylactic value; this raised many false hopes. In Winnipeg a sanatorium board was formed in 1904 and became active in 1906; in 1905, the newly formed Women's Anti-Tuberculosis Society

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Chapter 3 provided a visiting nurse. A major international congress on tuberculosis was held in Washington DC in 1908; Koch passed through Winnipeg on his way to the meeting. The delegates from Winnipeg were Doctors AJ. Douglas, Gordon Bell, R.M. Simpson, and H.H. Chown.Thereafter, Douglas recommended to .Winnipeg City Council that there be tuberculin testing of dairy animals and pasteurization because it was now clear that bovine tuberculosis was transmissible to humans. He further recommended the building of a provincial sanatorium and a city dispensary. Progress was held up by lack of money. In 1907, a young local medical graduate, David A. Stewart, was appointed acting medical superintendent of the Manitoba Tuberculosis Society. Stewart was the son of a Presbyterian missionary of Scottish ancestry. First a teacher, then a theology student, he entered the Manitoba Medical College and graduated in 1906. Tuberculosis was his life work, but he wrote movingly and well on many topics, medical and otherwise. Stewart travelled around the province raising funds but contracted tuberculosis himself and went to the well-known American sanatorium at Saranac Lake to recover. The development of effective services for the control of tuberculosis in Manitoba owed a great deal to Stewart, who eventually became a potent figure in Manitoba medicine in the twenties and thirties. Stewart became superintendent of the new sanatorium at Pelican Lake near Ninette, and on 20 May 1910 the first patients were admitted. Investigation at first involved merely physical examination of the chest and microscopic examination of the sputum. Stewart trained a young patient as an expert x-ray technician and over the years trained many medical students, using tuberculosis as a model of human disease. Tuberculin was tried as a therapeutic agent, to no effect, and early treatment consisted of good food, fresh air, sunshine in summer, and an ultraviolet lamp in winter. The sanatorium became a centre for the detailed study of tuberculosis, in all forms; intestinal tuberculosis was then common, partly due to infection from infected milk. In 1914, treatment by collapsing the lung (artificial pneumothorax) was started; soon thereafter, the first x-ray equipment at the sanatorium allowed more extensive use of this technique. The sanatorium, like others of its kind, was a segregated community, where patients and staff came to know one another well, and where treatment involved providing patients with hobbies and entertainment, as well as medical treatment in the narrow sense.There was always the danger that staff or their families would contract

The New Century: Cleaning up the Mess tuberculosis, as Stewart's wife did. The sanatorium was run with a high degree of efficiency, economy, and humanity.

Rural Medicine While in many rural areas medicine lagged behind that in the cities, the best rural doctors practised excellent medicine, for example, Dr. Wilfred Bigelow in southwestern Manitoba. Bigelow started as a rural doctor and became a distinguished surgeon; he has left an enthralling picture of his life in practice. He grew up, a descendant of a distinguished medical family, in Kingsport, Nova Scotia, where he taught school and was lamed for life at the age of sixteen by a bone infection. His brother-in-law, Dr. J.O.Todd, a Winnipeg surgeon, invited him west. He travelled in a colonist car on a harvest excursion train, arriving on Labour Day 1898. At St. Boniface Hospital he assistedTodd five mornings a week, learning to scrub up and soaking instruments in disinfectant solutions. Infection was as near as the horses tied to a railing below the open operating-room window. During one abdominal operation, a fly came in the window and settled on the open surgical wound; strong disinfectants were promptly applied, but some days later Bigelow saw what he never forgot. "The patient was lying with her back acutely arched, practically resting on the heels and back of the head, with a sardonic look produced from the set muscles of the face. She was in tetanic spasm and was dead in two or three days."A telegram had been sent off to Chicago requesting some of the new antitetanus serum. It arrived after she was dead. After graduating in medicine in 1903, Bigelow started practice in the far •west of the province in the small town of Souris and later moved to another, Hartney, where he stayed until December 1905.The pickings were not rich; in his first six months in practice he made thirty-seven dollars. There were few hospitals in southwestern Manitoba but, after 1906, a hospital would occasionally start up in a small town; it was often merely an empty dwelling house with the local doctor, a nurse, an operating table, and a few rooms with beds.The country doctor had to be prepared to visit and treat patients in their own homes, often after a long journey. It was the medicine of the heroic age, with larger-than-life surgeons struggling through the snow to perform dramatic cures. Bigelow rapidly became an adept bush surgeon; in September 1904 he rode thirteen miles to perform his first major operation outside a hospital, in a country shack. The blade of a large knife had accidentally run through a man's belly. The patient was in a room with four or five other people, with a hot fire on the stove.

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Chapter 3 The room buzzed with flies. In my grip I always carried two five-yard boxes of sterile gauze, and in my pocket a small dissecting case of instruments containing a probe, dissecting forceps, a small scalpel, two small artery forceps, some silk, and two or three envelopes containing sterile catgut (one straight and two with curved needles) .To prepare sterile towels, I had a half a dozen well-ironed towels wrapped in paper and put in the oven. It did not take long to make these sterile.The whole thing was to watch that the paper will not get on fire. While this was sterilizing I boiled my few instruments, shaved the upper part of the abdomen and painted this with Churchill's Tincture of Iodine which was our usual skin cleanser. For anaesthesia we used ether. One man amongst the gang could speak English. . . . I elected him as the anaesthetist.

The ether was dripped on an improvised gauze mask, and two women waved pieces of paper at each end of the table to keep the flies off. Bigelow opened the abdomen by enlarging the wound, tied off the bleeding vessels, made up some saline, injected a quart into each axilla, and the patient recovered. Thereafter, he carried out many operations in the home, simpler procedures like removal of tonsils and more complex emergency surgery for obstruction of the bowel, strangulated hernia, ruptured appendix, or perforated duodenal ulcer; as the years went by, he developed a kit of instruments, including a sterilizer, and standardized procedures and techniques for rapid and efficient home surgery. Local anaesthesia was used when possible, alone or with general anaesthesia using ether or chloroform, given from a bottle on an open mask, by a local doctor, or preferably by his own well-trained nurse. There was seldom blood transfusion; before 1910, as elsewhere except the largest centres, saline was given subcutaneously. After 1905, light came from a Coleman gas lamp, suspended by a wire from the ceiling. Surgeons often split their fees with the referring doctor. Bigelow hated this and said so plainly to doctors who asked for a cut of the fee. "You can just go to hell! signed WA. Bigelow." In 1906, he bought a practice in Brandon. The city was relatively prosperous then, but Brandon General Hospital was inadequately funded and overcrowded. Bigelow needed to control his own facilities and developed over the years a successful polyclinic, the first in Canada, modelled after the Mayo Clinic in Rochester, Minnesota. A group of specialists worked together to provide complete examination and treatment and later submitted

The New Century: Cleaning up the Mess a joint bill to the patient.The clinic was a model for later clinics in Winnipeg. The Bigelow Clinic lasted until about 1970. Brandon General Hospital improved fairly rapidly, having by 1912 fifteen doctors on staff; but, characteristically, the first x-ray machine was installed at the hospital in 1913, six years after one had been installed in the Bigelow Clinic. Bigelow soon dominated the Brandon medical scene and had a large practice; he ultimately acquired a high reputation as one of Canada's leading surgeons. He frequently went off for postgraduate training, usually south to the United States, and followed the latest surgical developments; in 1906, he purchased a cystoscope, which was used for examination of bladder disease and treatment of urinary infections by washing out the bladder with disinfectant solutions. He installed his first x-ray machine in 1907; it was a primitive piece of equipment with no protection for the operator. Trained by Gordon Bell, he was an enthusiast for laboratory investigation. He took smears for microscopic examination and culture, using a cotton swab to transfer infected fluid or pus to a sterile test tube. He slept with the culture tube in an armpit pocket in his nightgown and next morning put the tube on the daily train to Winnipeg and then to the bacteriology laboratory. Similarly, he sent tumours to Winnipeg for microscopical examination. He was a pioneer in blood transfusion. The choice of donor was simple: he lined up father, sons, and hired hand and picked the fittest. Later he hired a laboratory technician, one of the first in the province, and then attracted Dr. S.J.S. Pierce from Winnipeg to Brandon as pathologist to the Bigelow Clinic in 1918. Peirce, who had been passed over for promotion when Dr. William Boyd was appointed professor of pathology in 1915, also supervised the laboratory at the Brandon Mental Hospital and developed his own reagents for syphilis tests, an important current development. Specialization was as yet incomplete, so obstetrics formed a large part of Bigelow s practice. One day in 1908, he was called to a small, isolated farmhouse to find an old midwife sitting on a chair by the fire, calmly smoking a clay pipe. The pains had been going for hours; the doctor examined the patient, gave her some codeine, and sat down to wait. Several times the old midwife looked up and said, "Doc, I think we will have to quill her." Bigelow did not know what she meant, but ultimately responded,"Perhaps you're right, we might as well quill her.You go ahead and do it and I'll get cleaned up."

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Chapter 3 The old midwife rose and took a long quill from the wing of a goose, hanging on the wall. She cleaned and trimmed it, dipped it into cayenne pepper, and, inserting the quill into the patient's nostril, blew the pepper up her nose. The patient began to sneeze immediately. "Doc, you'd better get ready."With another few sneezes, the baby was born.The midwife had the last word. "I knew, Doc, that this would make her let go her hold." Transport was always a problem in country practice. Bigelow travelled in summer by horse and buggy; in winter, cozy in a buffalo robe, feet on a foot-warmer, he went by two-horse cutter. Horses were expensive and would be rented from a livery stable; only when in funds would he hire a driver. The car came later, at first a wooden-bodied, three-seater Ford, with a little jump seat behind, and a collapsible buggy top. It had coal-oil tail lights and outside lanterns as headlights, but neither doors nor starter. The provision of nursing care to patients in rural areas was always a difficulty. At first, hospital nurses used to go out to nurse in rural homes, turning over the fees received to the hospital. The nurse would stay in the patient's house to provide postoperative care, often doing the cooking and cleaning as well. Nursing care for seriously ill patients in hospital was on occasion supplemented by private-duty nurses. The doctor's payment might well be in kind: a turkey, or a large basket of vegetables. On the way home in the fall, the doctor might keep a shotgun and shells handy in the back of the car to add duck or prairie chicken to the larder. Several rural medical practices have been continuous for nearly a century. In Hamiota, the earliest medical care in the early 1900s was provided by a Dr. Lawson. He was succeeded in 1907 by Dr. E.D. Hudson. Hudson, like other rural practitioners of his day, did almost everything, delivering babies, performing abdominal surgery, travelling in winter first by pony and trap, and then by the early, unreliable motor cars. He was paid fee for service, often in kind; poor patients often simply did not pay. A hospital was established, funded by local voluntary funds in 1908, and by 1939 this was an eight-bed cottage hospital. Dr. Hudson Sr. served the district from 1908 to 1946, when he was joined by his son, Dr. J.E. Hudson, who was still there in 1997.The elder Dr. Hudson drove twelve miles by cutter one cold February night seventy years ago to suture a wound in the head of one of the authors (R.E.B.), caused by a hockey puck. In rural areas, the local physician acted as coroner; this often involved much travel, interruption of the doctor's normal life and duties, and little reward. Dr. H.M. Speedily was appointed coroner for the area around Pilot Mound in 1905; he covered the area from Pilot Mound twenty miles

The New Century: Cleaning up the Mess north, straight south sixteen miles, west ten to twenty miles, and east twelve, in the time before motor cars. Other duties could conflict. "Once an officious juryman needlessly prolonged an inquest when a primipara 25 miles distant urgently required my services. I appealed to the Jury as husbands and fathers to close useless enquiry, got away, and reached the lady with half an hour to spare!" The country coroner had little chance to become expert, particularly at conducting autopsies, even then an exercise requiring special skill. Speechly recorded macabre tales of violent and unnatural death: the little two-year old girl who drowned in a triangular-shaped trough used for watering cattle, in only three inches of water; the Indians who came to their deaths at the reserve at Swan Lake drinking a concoction of lemon extract and methyl alcohol; the house that burned down, incinerating all the inhabitants, when coal oil adulterated with gasoline was used as a fire-lighter. The autopsies could be noisome: [The body lay down a ravine], just off the track, fully dressed with wombat fur, but in the occiput was a bullet hole from which a little blood had trickled. Most of the lower part of the face and neck, as well as the tongue and trachea, had been gnawed away by a weasel or rat. After careful investigation we carried the body through the bush to a wagon, which could not be brought nearer than about 50 yards away. The body was deposited in a back room in the hotel at Snowflake. It was an odd kind of postmortem examination. The body was frozen, the blood in the cardiac cavities was frozen, and the knife repeatedly gritted on frost. My assistants were the livery man who had driven me, and the resident Anglican minister, who kindly took my notes. We were five hours on that job.

The Long Peace Ends Progress in medicine in Manitoba had been steady for more than forty years.The prairies were being settled and rural medical care was developing; the cities, crowded with poorly housed immigrants and seething with disease, were gradually being cleaned up. By 1913, public health was a little better and surgery improving, though most remedies were still ineffective. The Winnipeg General Hospital was reckoned in the Flexner Report on Medical Education to be, by North American standards, a good hospital; a start was being made to the recruitment of more professional teachers. Even in the city, medicine was still far from modern. A Winnipeg doctor, Dr. C.S.Hershfield, many years later remembered being treated as a child

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Chapter 3 for an abscess on the buttock. The first remedy came from Caminetsky's Drug Store on Dufferin Avenue near Main Street: pyovkes (leeches). They grew fat and fell off; the abscess grew bigger. The abscess was then lanced by the doctor.The patient screamed but was cured.Then, in 1914, Hershfield developed severe abdominal pain, nausea, and vomiting; he had appendicitis. It was treated "without operation and he recovered; he was lucky. Others were less lucky, and particularly in the countryside death from appendicitis was still common. A farmer's diary, now lodged in the Beckoning Hills Museum in Boissevain, poignantly describes death in childhood. On 5 June, the child, Annie, took slightly sick.Two days later she was worse, and the diagnosis of appendicitis was made. On 8 June, two doctors operated, but Annie was dead by midnight and was buried two days later. The farmer was back at work the next day. Effective scientific medicine was on the horizon, but the advances that were coming were slowed or temporarily stopped by the First World War. The long peace had been punctuated by flurries of concern engendered by diplomatic clashes far from Canada. In the last shining summer of the long peace, yet another incident boiled up in the Balkans; few in Canada were prepared for what was to come. The old medicine persisted, the new medicine was slowly evolving, but the guns of August thundered.

Interruption in Hell: The First World War

4 In Canada as in Britain, the recruiting offices opened, the bands brayed and skirled, the King's shilling was pressed into willing hands, and men went off to war and women to worry. This was the war to end all wars. It soon became clear that this war was different; the filth of the trenches, the power of the machine gun and the high explosive shell to maim and kill, the first use of poison gas all posed enormous medical problems. The details of the medical history of the war can be found elsewhere. Here, only enough is described to illustrate what Manitoba medical students and physicians, like many others, 'went through. Military medicine was unprepared for the carnage. There was no precedent for the numbers of wounded who needed emergency surgery, nor for the extensive contamination of wounds by the clostridium of gas gangrene.The unsanitary conditions experienced by millions of men living for long periods in trenches devoid of sanitation were unique, and there was no precedent for the psychiatric casual ties. "Shell shock" still implied cowardice rather than the conclusion that all men must break; the question was not whether, but when. Two hundred and nineteen Manitoba Medical College graduates and professors, and sixty-six students served in the First World War: thirty-six percent of the entire medical profession and fifty percent of the medical students. Eight physicians and two medical students were killed, twentynine were wounded, and eight were gassed.They served overseas in Britain, France, Flanders, Salonika, Egypt, Greece, Macedonia, the Dardanelles, Finland, and Siberia. The Manitoba Medical College was associated with organization of five field ambulance units and two casualty clearing stations,

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the largest unit being the Eleventh Canadian Field Ambulance, commanded for most of the war by Dr. J.D. McQueen, later a leading obstetrician. The medical students acted as stretcher-bearers, carrying wounded men who could not walk to the casualty clearing post and then to the rear. The wounded might put on dressings themselves or receive first aid from battalion stretcher-bearers. Some who had crawled to the shelter of a shell hole or a dugout might remain there through days and nights, unable to help themselves. Stretcher-bearers risked their lives to bring them back to safety. Dr. Johnson and his fellow officers of the Eleventh Canadian Field Ambulance, in a record of their experiences, described the first resort of the wounded: the dressing station. The dressing room staff upstairs busied itself with the wounded who were fast coming in to the big courtyard where the usual apparent confusion reigned. Like most dressing stations it was a medley of sounds — the groans of the suffering, the wheeze of those hit in the lungs, the call for stretcher bearers and requests for something to drink. There was seldom any respite for the [Medical Officers] and dressers during a push of the magnitude of Passchendaele.The business of evacuating wounded in such cramped and dangerous spots taxed body, mind and soul. Fatigue was forgotten and one was conscious only of a fierce burning of the soles of the feet as one handled the stretchers in the constant endeavour to make space for the stream of new arrivals. The approaching death of some poor lad brings a quick call for the Padre, who is about with his water bottle and cigarettes.Then, after that sad interview and the certificate of the M.O., comes a short trip to the little burial ground in the close vicinity.

William Boyd, who later became professor of pathology in the Manitoba Medical College, described similar experiences as a medical officer in Flanders in 1914 and 1915. In his daily round in a hospital at Bailleul, near Neuve Eglise, Boyd saw infectious diseases such as measles, mumps, scarlet fever, diphtheria, typhoid, cerebrospinal fever, and anthrax, which he proved by microscopical examination. He was silent on the scourge of gonorrhea and syphilis, a major cause of depletion in the army's strength. Boyd was among the first to see casualties of gas warfare. On 28 April 1915 he wrote: There is only one word in the mouth of everyone today - gas. . . .The hospital is built around a great courtyard, and in the courtyard were two hundred men on stretchers. Some were lying in a state of stupor, the flies buzzing around their faces; some were sitting up gasping for breath, with

Interruption in Hell: The First World War hands and faces of a deep dusky hue, evidently in the greatest distress; over the countenance of others the pallid hues of death were beginning to creep, whilst a few had fallen back and with gurglings in the throat were passing away into the undiscovered country. They were the first gas cases fromYpres and Hill 60.

Even after the 1918 Armistice, Canadian physicians continued to be involved in European war. The Canadian War Hospital Fund for Serbia, Montenegro, and Macedonia raised money in Winnipeg and other Canadian cities. Dr. F. Burnham organized a White Cross British Hospital in Plevje, Montenegro, served on the western front, and then returned to Salonika. When the survivors of the war returned to Canada they were marked for life, not merely by fear and stress, but also by their experience of deprivation. Necessities denied become luxuries: "You need to be really dirty for a few weeks before you can understand anything of the delight of being clean," wrote Boyd.The camaraderie of service life bound them together; those who had served formed a formidable, exclusive brotherhood and were a little contemptuous of those who had not been in the war. This was as true of physicians as of others.The actual technical advances in medicine made during the war are more difficult to define.Typhoid was less a scourge than it had been fifteen years before in the South African War, because an effective antityphoid vaccine was available. Surgical techniques were undoubtedly honed by the need to practise them frequently, and the standards of Canadian surgery were raised because of exposure to the superior knowledge and methods of European, and especially British, surgeons. People were kept mindful of the war by the need to care for the chronically disabled. Deer Lodge Hospital was opened in 1916 as a military convalescent hospital in the grounds of a wooden deer lodge put up in 1856 on the north bank of the Assiniboine River. The hospital at first housed eighty-five soldiers. Recovery was followed by rehabilitation, exercises, games, and in 1917 wheelchair sports on the lawn in front of the hospital. Rehabilitation medicine began thus. The war left gaps in many households and for many years permeated the souls of the survivors. As the years passed, bitterness often mellowed into a realization of the sadness and the loss.

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Charlotte Ross and family, 1910 (WCPI).

Amelia Yeomans, first woman member of the College of Physicians and Surgeons of Manitoba, about 1896 (PAM).

Swale Vincent, first professor of physiology, 1914 (PAM).

A.T. Cameron, first professor of biochemistry, 1914 (PAM).

Gordon Bell, pathologist and bacteriologist: the broom who swept clean.

Manitoba Medical College lecture, about 1905.There are two women students.

Wilfred Bigelow, surgeon.

A home doctor book, such as was carried by many prairie settlers, 1889.

Manitoba medical "girls" at play: basketball club, 1918.

Memorial at Patterson Lake, commemorating the deaths of forty-five immigrants, mostly children, in 1897 (Ian Carr).

Saddlebag Surgeon: Murrough O'Brien rides his buggy, Dominion City, about 1897 (WCPI).

Joshua Waterson, a teamster, who survived smallpox in the 1914 outbreak (PAM).

Death in childhood: children participating in the funeral of a friend, about 1914 (PAM).

Nurses and babies, Grace Hospital, 1914 (PAM).

Marching off to war. Number Four Casualty Clearing Station, CEF, marches off from the Manitoba Medical College in 1916. The group includes Doctors Prowse, Musgrove, and Rosslyn Mitchell (WCPI, courtesy G.T. Mclntosh).

Ready for war, and thereafter control of postwar medicine: officers of Number Four Casualty Clearing Station, CEF, 1916. Back row, left to right: H.F. Harman, J. Pullar, D.F. MclntyreJ.O.Todd, R.B. Mitchell. Front row, left to right:F.T. Cadham, H.H. Chown; S.W. Prowse,W.W. Musgrove.

Canadians suffering from gas poisoning, in the courtyard of a farmhouse near Ypres, 1915 (from Boyd, 1916).

Stretcher-bearers in the trenches on the advanced road to Courcellette, from a 1916 Canadian field ambulance journal.

Soldiers' ward, St. Boniface General Hospital, 1915 (AGN).

Influenza: Winnipeg Free Press news carriers wearing surgical masks, during the influenza epidemic of 1918-19 (WCPI).

Surgical operation, St. Boniface General Hospital, 1923. Masks and gloves are not worn (AGN).

Between the Wars: Health and Medicine

After the War Winnipeg in 1919 was a mixed industrial city with a population of about 180,000 people, linked to the world by the railway and incompletely by road. The war reduced social divisions and helped women toward equal status, but there was still a chasm between rich and poor, symbolized by the Winnipeg General Strike in 1919. Doctors were well off; one Winnipeg medical professor on a salary of $4,000 a year paid fifteen cents for a movie ticket and twenty cents per hour to a cleaning woman. Theatre, cinema and, by 1930, radio and phonograph made life pleasant. The poor were very poor; thousands of recent Slavic and Jewish migrants lived in shanties, lacking in clean water and adequate sanitation. Outside the cities, an extensive area was now under grain, but immigration continued. By 1924, the province was prosperous, but only for five years, until the stock market crash of 1929 and the subsequent years of drought, dust storms, and bitterly frigid winters. In 1932, twenty percent of the male population of Winnipeg was on outdoor relief, sawing tamarack cordwood at the wood yard. There was less money spent on health and education. During the Depression years, there was little actual starvation but much malnutrition and misery. The doctors, too, felt the pinch and went on strike. Only in 1939 did war bring work. The wheel had gone full circle.

The Progress of Medicine Medicine had progressed since 1900 and was now firmly scientific but pervaded with irrationalities.The worst of the typhoid epidemics had passed because the cleanliness of the water and, to a lesser extent, of milk supplies

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Chapter 5 was now controlled. Tuberculosis still took its toll of the young. Women feared childbirth and died of haemorrhage, sepsis, and occasionally obstructed labour, mainly in rural areas. Child health, while improving, was still appalling. The machine-made cigarette had come in with the South African War and now dangled from many lips, mainly those of men. Cancer of the bronchus, a relatively new disease, was now being diagnosed in the Winnipeg General Hospital. Medical meetings were held in a fog, and young men met at "smokers." It was now understood that many diseases were caused by bacteria, and members of the medical profession realized that good nutrition was important; vitamins were being identified, and vitamin-deficiency diseases like scurvy and pellagra elucidated. Blood pressures were being measured, and the significance of hypertension was recognized. Electrocardiography was first used by Dr. Arthur Burridge in Winnipeg in 1924, twenty-two years after its invention elsewhere. Coronary artery disease was increasingly regarded as a cause of sudden death among middle-aged people. There was some understanding of immunity, and active immunization against diphtheria, for instance, was effective. There were enthusiastic but relatively unsuccessful attempts to transmit immunity passively by injection of the serum of people who had survived serious infections; this method was called serotherapy. The main miracle drugs were yet to come.The first of the antibacterials, salvarsan, was altering the prognosis and treatment of syphilis, but gonorrhoea still required painful washout of bladder and urethra in the male. Pneumonia and tuberculosis often killed. Diabetes mellitus was a sentence of death until 1923 or later, as was pernicious anaemia until 1925. While surgery continued to advance, the absence of effective systemic antibacterial treatment and of blood transfusion kept surgeons out of the central nervous and cardiovascular systems. The problems of infection and postoperative thrombosis still bedevilled postoperative recovery. Payment for medicine was still a problem. Physicians charged the rich, often charging more the richer the patients were. The poor were often treated free as charity patients, but many sick people went without medical attention for financial reasons. Caring for the poor led hospitals to the brink of bankruptcy.

Public Health The importance of prevention was now realized. Gordon Bell's death was a tragedy, but he had built well. His work in bacteriology was carried on by Dr. Fred Cadham, who had been his assistant. The Provincial Laboratory

Between the Wars: Health and Medicine

worked closely with the Board of Health, which was reorganized in 1928 as the Ministry of Health, with Dr. Edward Montgomery, formerly professor of medicine, as its first minister. The mantle of public health, inspection, and control was extended to cover many aspects of life, including hospitals, child and family welfare, health education, industrial hygiene, mental health, infectious and venereal disease, and vital statistics. Smallpox vaccination was compulsory, and inoculation against typhoid fever was provided in mining, lumbering, and other industrial camps. The province was divided into health districts as units of the new control. Behind the dull tale of administrative procedures lay the reality of hour upon weary hour spent inspecting, reporting, and collecting data, a reality reflected in the steady fall in infectious disease.The continuing cleanup was the work of many minds and hands. Tuberculosis was still one of the greatest concerns, most of all among the native population. Dr. F.W.Jackson, a public-health official, drove over 8,000 miles around the province inspecting facilities for himself and found that the incidence of tuberculosis among Indians was 35/10,000 for males and 36/10,000 for females. It was worse in immigrants, particularly those from non-British countries, probably because health screening of immigrants was inadequate. Yet, the Manitoba death rate from tuberculosis, at 58/100,000, was lower than the overall rates for the whole of Canada, which was over 80/100,000, and lower than the rate in the United States. Thoracoplasty, surgical treatment to rest the affected lung, had some success.There was a long way to go; there were not enough beds, especially for children, there was a need for low-cost chronic care, and follow-up was poor. The migrant casual agricultural labourer was particularly vulnerable. By 1930, the Sanatorium Board of Manitoba was responsible for the Ninette Sanatorium, where Dr. David Stewart still reigned. At first, treatment had comprised rest, local and general, good food, and fresh air. In 1930, a central tuberculosis clinic was opened in Winnipeg, followed in 1937 by a sanatorium south of St. Boniface. During the 1920s and 1930s, more effective attempts were made to find cases of tuberculosis; travelling clinics went around the province doing tuberculin tests and if necessary xraying. Mass miniature radiography started in 1944. During the 1920s and 1930s, treatment of tuberculosis gradually improved. The inflamed lung was rendered short of oxygen by introducing air into the pleural cavity to collapse the lung (pneumothorax). Subsequently surgeons caused more permanent collapse by crushing the phrenic nerve to paralyse the diaphragm, or by excising several upper ribs and allowing the rib cage to collapse (thoracoplasty). By the early 1940s, where necessary

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Chapter 5 a tuberculous lung lobe or even a whole lung would be removed. Such surgery was carried out at the Ninette Sanatorium by Dr. A.L. Paine. The abject poverty of slum Winnipeg led to several humane responses, such as the Mount Carmel Clinic, started in 1926 in a house on Pritchard Avenue. Jewish doctors and lay people were prominent in the foundation. The clinic was at first staffed by doctors, working without fee, and City public health nurses. They gave treatment and advice on preventive medicine and the care of children. As the years passed, it acquired x-ray and laboratory facilities, becoming a small polyclinic. It was one of the earliest places to provide contraceptive advice and later became the centre of a storm over this. Two new Winnipeg hospitals opened in the 1920s, both of religious origin.The Sisters of St. Michael,Toronto, conscious of the lack of general hospital beds in north Winnipeg, opened St. Joseph's Hospital, which survived until 1952, and the Mennonites opened Concordia Hospital in 1928, still flourishing, in a new building, since 1974.

Epidemics In 1919, it was still epidemic time. Before the war, epidemics of typhoid, smallpox, scarlet fever, and diphtheria had filled the graveyards, particularly in the spring; improved sanitation now reduced the toll from water- and milk-borne disease, but in 1918 the Spanish influenza epidemic caused many deaths. On 30 September 1918, a returning troop train brought three soldiers with influenza; they were isolated, but on 3 October two of them and one civilian died. On 12 October, several cases were reported. Public concern rose to the point of panic: churches, schools, and theatres were closed and public meetings banned for seven weeks in Winnipeg, and the medical school was closed for two weeks. People serving the public had to wear gauze masks. Volunteer nurses were trained at the medical school. Many thousands were gravely ill, and almost a thousand died in Winnipeg and many hundreds elsewhere in the province. In 1919, King George V Hospital admitted 3,789 patients with influenza, and many more were cared for in the community. Treatments varied, and all were equally successful, or unsuccessful: fresh air, digitalis, alcohol, mustard plaster, orange juice, aspirin. Jewish patients had a wider selection of remedies, including chicken soup, camphor balls placed around the neck, garlic, a black stocking containing a herring. Best of all was a small prayer shawl. The epidemic did not spare rural areas; when it hit Rossburn where Dr. Murrough O'Brien now practised, the three nurses on duty in the hospital all caught influenza, and it was left to Dr. O'Brien's wife to make soup in

Between the Wars: Health and Medicine

large quantities for the patients in the hospital. O'Brien himself, on his rounds to the outlying farms, carried cocoa tablets and officiated as both cook and doctor. Only two percent of those affected in his practice died. O'Brien believed that this was due to his regimen of quinine and whisky rather than aspirin. Medical care was often unavailable. The record of a country coroner describes the death of Marian Eileen Hunt, aged one year and nine months, daughter of a CPR engineer. On 26 January 1920, she became unwell, vomiting, coughing, and with diarrhoea; she died three days later. "No physician or nurse employed.We could not afford to employ a doctor," ran the father's statement. In many places, families lost several members. In Brandon, men with carts and horses went through the town collecting bodies; they could not be buried and were stored in silos for mass burial in the spring.The death rate in remote aboriginal communities was very high, perhaps as high as forty percent. The next plague, epidemic encephalitis lethargica, affected Manitoba during the winter of 1919-20, and in 1923 and many subsequent summers. Some cases may have followed influenza, but most were probably viral and mosquito borne. Fit young people drowsed off, lay stuporose for years. Boyd, the young professor of pathology, described patients with the disease: In the first epidemic the patient was dull, lethargic, somnolent, and showed oculomotor disturbances. He would lie like a log in bed with drooping lids or closed eyes, the lines of expression all ironed out, sunk in a stupor which no external stimuli could penetrate, the flash and speed of the mind gone, the dim rush light of reason hardly flickering. In the second epidemic the picture had changed completely. Body and mind were now keyed to full activity. The muscles were in a state of constant movement, which was paralleled by a condition of mental excitement. Occupation formed the main topic of conversation: the teacher was continually teaching, the merchant was casting up accounts, the builder planning new houses. The first picture was akinetic, the second hyperkinetic.

The disease was ultimately controlled by extensive mosquito surveillance and extermination campaigns. The other terrifying new epidemic was poliomyelitis. The disease was first clearly recorded elsewhere in North America about 1840 and had been on the increase since 1910. The first Manitoba case had been admitted to the King GeorgeV Hospital in 1917, followed by twenty-nine more cases. A major epidemic struck Manitoba in 1928. Of 435 cases between

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Chapter 5 1 July and 15 November, thirty-seven died. Pooled convalescent serum was of some value when administered in the pre-paralytic stage of the disease. There was usually only one case in a single family, but clusters of cases occurred on the same street. Prevention involved isolation and disinfection: child contacts were excluded from school for two weeks.The Medical Research Committee of the University of Manitoba, which carried out an investigation, believed that it was caused by a filter-passing agent, and that was as far as knowledge went. Throughout the 1920s, these and other diseases, including epidemic scarlet fever, measles, as well as tuberculosis, kept the beds in fever hospitals full. Influenza recurred annually, bringing in its train lethal complications.

Medical Practice Most medical practice was still general practice. Some of it was pre-scientific. One doctor in the north end of Winnipeg, "the needle man," treated almost anything with an injection in the buttocks.Yet another doctor's home was always filled, and the patients' sleighs and wagons were lined up for blocks; through the basement windows men and women could be seen lying under the quartz lamp, paying twenty-five to fifty cents for the privilege. Many doctors would make up their own prescriptions, and many would have patients predominantly of their own ethnic origin. Alcoholism had long been a problem, and prohibition came to Manitoba in 1916; in the prohibition years, every third or fourth house on some streets was a bootlegger's. Some doctors readily prescribed alcohol and had a special room in their offices in which sat a "girl" and a pile of pre-signed forms; such doctors would often issue as many as seventy-five to 100 forms a month at three dollars per prescription. Prohibition eased in 1925. A good picture of medical practice of the better sort was drawn many years later by Dr. Paul Thorlakson: Most patients who entered my consulting-room were obviously sick people; . . . a history and physical examination too often revealed that the patient was suffering from advanced or hopeless disease. Symptoms and signs were localized. Intensive investigation was neither available nor necessary. It was the era of inexpensive medicine when very little could actually be done for many patients.Too often they went to hospital to die, not to be cured.The mention of a hospital to the patient's relatives, around the turn of the last century, struck fear into the whole household. There were now a few routine laboratory tests available — blood counts, urinalyses, bloodWassermann for syphilis, blood sugar, blood urea nitrogen,

Between the Wars: Health and Medicine and blood creatinine. Routine chest x-rays were not done, and patients •with active tuberculosis would lie in open wards, infecting others. We had a few specific drugs: digitalis for heart disease; quinine for malaria; salvarsan (606) for syphilis; iron for anemia; and emetine for amebiasis. In addition, potassium iodide was added to many mixtures. Arsenic, in minute doses, was prescribed for a variety of diseases, as were a host of cathartics, stimulants, digestants, and sedatives of variable or doubtful benefit Internists had little to offer or advise except bed-rest, vile-tasting concoctions, placebos, and a trip to a spa or to the sea-shore!

Here the surgeon speaks with less than his usual charity of his physician colleagues — digitalis had been in use for over a hundred years. One hardly walked down a street without seeing a Quarantine sign on some door.... Family planning was not necessary, in those days, baecause diphtheria, scarlet fever, typhoid fever, pneumonia, tuberculosis, poliomyelitis, infantile diarrhoea, gonorrhoea, and syphilis . . . decimated the population.

The general practitioner spent nearly all his time visiting and treating sick people in their homes and understood their family backgrounds and financial circumstances. In the country, such visits could be timeconsuming and fruitless. Thorlakson recalled a day-long trip in the dead of winter, in a covered sleigh with a wood stove to keep him warm; he spent all the next day with the patient, able to offer no more than poultices, reassurance, and kindness. The trip back took him most of another day, and the patient died anyway. Another good picture was drawn by Dr. Sheppy Hershfield, who spent much of his life as a general practitioner in Winnipeg. In the early 1930s, drugs used included digitalis, arsenic, quinine, potassium iodide, aspirin, and iron. Many a normal appendix was removed.The gall bladder was first visualized by x-ray in 1924. Surgeons frequently removed septic foci, like enlarged tonsils, then held to cause widespread disease, and often drained or excised tuberculous glands.There was no blood-vessel surgery, no thoracic surgery, and little urologic surgery. Ear, nose, and throat specialists frequently operated for mastoiditis, resulting from middle-ear infections. The necessary quarantine for children with infectious disease was indicated by a red card nailed to the door. The 1928 and 1931 poliomyelitis epidemics caused widespread fear among parents.The treatment of pernicious anaemia was just beginning. Home care was the rule except for surgical patients. Hershfield worked in St. Joseph's Hospital in 1928 as resident. He received twenty-five dollars a month in the first year, and seventy-five in the

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Chapter 5 second and third years.There was no sick pay; he was once ill for one week with German measles, and his pay was docked by eighteen dollars. Hershfield worked for Dr. James McKenty, who then had the largest surgical practice in Winnipeg. The importance of the fluid balance of the body was now recognized: fluid was given subcutaneously to restore fluid balance, and a tube was passed into the stomach to allow continuous suction of gastric contents in patients with acute gall bladder inflammation. The resident was then, as now, busy. "Hurry, hurry there is a man dying on the first floor. . . . Take this scalpel and cut one of the rings of the trachea." The family physician was sometimes so busy that he could sometimes be found asleep in his car. He rarely sent a bill; if he did, because his records were poor he sometimes had to ask the patient what to bill for. The common laboratory tests done in a small hospital then included measurements of sugar and urea, the Wasserman test for syphilis, analysis of urine for protein, sugar and ketones, and analysis of gastric fluid.The x-ray department of St. Joseph's Hospital contained a small x-ray machine, but routine x-rays were not done. There was no electrocardiography. Blood transfusion was rudimentary; when one very ill woman needed a blood transfusion, there was no grouping or cross-matching; the blood was taken from the arm of the donor fifty cubic centimetres at a time. Hershfield augmented his income by assisting at operations and remembered assisting at five tonsillectomies at Winnipeg Beach, then reached along a rutted, muddy road.There were no suction, sponges, mouth gags, or masks, and there was only a quarter of a bottle of ether for five children. The operations were done in half an hour. As they recovered from the anaesthetic, the children were dazed and stupefied then began to cry, spitting blood. The fee was twenty-five dollars, fifteen dollars for the operator and ten dollars for the assistant. Death was not infrequent after what would now be considered a safe operation like removal of the gall bladder; autopsies would not always be carried out on patients whose cause of death was obscure. Hershfield always carried with him a mask, chloroform, and surgical instruments, including a long-handled instrument with a small scalpel at the end for immediate puncture of the ear drum in patients with severe middle-ear infections. He remembered treating such a patient who later died of brain abscess, and he felt responsible for the death afterwards. Heart attacks were often confused with acute indigestion; it was more than twenty years since the first pathological demonstrations of coronary occlusion, but the condition was not yet widely understood in the medical

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profession.There were few effective drugs and much magic; vitamin injections were given to aid conception. Venereal disease was common, often spread in the flourishing Winnipeg red light district, and its treatment unsuccessful. The wages of sin were at least great discomfort, if not insanity and death; there was some perception that the wages were appropriate. About a third of all men at one time or other had gonorrhoea. Treatment was distressing. The specialist venereal-disease clinic was an unattractive place; patients were ashamed to be seen there and sought, if possible, private treatment. In the clinic the patient would be led along a narrow hall, off which opened small four-foot by four-foot cubicles separated by curtains. A glass syringe with a rubber ball at the end was filled with argyrol (silver nitrate); the solution was forced into the urethra. The patient had to pinch the tip of the penis with his fingers and hold it for two minutes while the irritant antiseptic did its work. It must have been a time for reflection on one's sins, and the chemical itself might produce persistent inflammation. Many patients developed urethral stricture, treated by dilatation with metal probes, or prostatitis, treated with rectal massage or warmed rectal dilators and diathermy to the prostate. Gonorrhoea was a common cause of invalidism in women. Dr. C.H.A. Walton practised contemporaneously with Hershfield from a bungalow on Henderson Highway, a suburban street in north Winnipeg, rented for thirty-five dollars per month, but also as beach doctor at Grand Beach; he later became medical officer of health for East Kildonan, now part of Winnipeg but then an independent municipality, at $100 a year. Doctors charged patients directly, and it was difficult at first for a young physician to earn enough to live on, sometimes hard to collect fees, and not easy to become widely known in an ethical way. In the 1930s, milk was still often distributed by dairymen directly, using horse-drawn carts.The customer's allotment of milk was removed from the metal can with a tin ladle, a common source of infection. Most herds in the area were infected with brucellosis, which could be passed on to consumers. These sources of infection were solved only when milk was distributed by larger dairies, which pasteurized the milk. Infection would spread within households; a woman in her thirties with widespread cavitating tuberculosis was allowed home to die, and she infected her son, who died of tuberculous meningitis. Toothache could be fatal; one woman developed an abscess on a tooth and died of septicaemia. Sulphonamides were introduced in 1935.

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Chapter 5 Whether in the city, in a rural township, or on an Indian reserve, life in medicine meant hard work, dedication, and the continued exposure to tragedy. A doctor had to spend time and money on continuing medical education: Hershfield used to go to the Mayo Clinic or Cook County Hospital in Chicago for refresher courses. He summed up his view of his own life thus: "I enjoy practising medicine; it is my life's work."

The Clinics In Winnipeg, as in other cities, the day of the solo practitioner was passing. The institution of large group practices, the clinics, had a major effect on the lives of doctors and raised clinical standards greatly. In the early 1920s, the able and ambitious young surgeon Paul Thorlakson had sought to establish himself in surgical practice in a competitive market by associating in a clinic run by a senior and established surgeon, Neil John Maclean. After some years Thorlakson managed the enterprise and in 1937 bought a property on the corner of St. Mary Avenue and set up a group practice, the Winnipeg Clinic, with ten initial full-time partners, including such academically oriented physicians as Dr. Lennox Bell, and Dr. C.R Gilmour. Thorlakson put up the initial capital. Members put their fees into a pool, which was divided among the senior partners according to the contributions made by individuals in practice, teaching, and community life. Thorlakson controlled it all firmly. Then, and later, the partners were carefully chosen; the standards of practice were high, and the participants had to be involved in teaching. A research laboratory was set up in 1965. From 1947, a successful clinical journal was published. It was not the only such show in town. Dr. M.R. MacCharles set up the MacCharles Surgical Clinic in 1936, starting with a group of surgeons with a variety of subspecialty interests; by 1946, it became the Manitoba Clinic, with a wide variety of medical and surgical specialists. Members would be invited to become full partners after two years or so. The Manitoba Clinic moved to a new building near the Winnipeg General Hospital in 1955 and was closely associated with the University clinical departments. The senior staff of these two clinics controlled appointments to the medical staff of the Winnipeg General Hospital, particularly in surgery. The two clinics raised the standard of medical practice considerably. Other smaller, similar clinics sprang up around Winnipeg, usually around dominant surgeons: the Abbott, Hollenberg, Kobrinsky clinics, and others. In several of these clinics, family medical dynasties evolved, and such medical families became very influential.

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Rural Medicine Immigrants were still entering rural Manitoba in considerable numbers in the 1920s and settling in fairly remote areas. Many from eastern Europe spoke little or no English. The problems of rural medical practice were compounded by isolation and difficulty in travel; the countryside was a morass or drifted deep in snow much of the year. Most rural areas could keep doctors for only a year or two before (usually) they moved on. Rural doctors delivered babies at home and still carried out surgical operations in the home under primitive conditions. Often the patient could not pay and would not call a doctor. The 1920s and 1930s were the high noon of classic heroic rural medicine, a smidgeon of science, a lot of art, and a great deal of hard work. As settlement spread throughout the province, both doctors and hospitals were needed. The doctors were attracted by the needs of patients and by the opportunity of making a living. Hospitals developed in several ways. Sometimes the local doctor (almost always a man) would set up a hospital, run by himself and his wife. Sometimes, as in Souris, the rural municipality would initiate the process. Often the first response to a local need would be a mission nursing station, followed after a number of years by a mission hospital. The churches, both Protestant and Catholic, played a significant part through their home mission boards. Rural hospitals were difficult to staff and often relied on immigrant doctors. Vita, a little town in the southeast corner of Manitoba, eighty miles from Winnipeg, provides a good example of the development of a rural hospital. Now a thriving community,Vita was founded in 1898 and colonized largely by Ukrainian and other eastern European settlers in the succeeding years. It was inaccessible by car in bad weather and even in good weather only by a car ferry until 1940. In Vita, medical care developed from a mission hospital. In 1922, when the hospital was founded, the area was dismally poor. The Methodist Mission reports noted that in one year eighty percent of the deaths were in children under four, forty percent under one year, and more than ten percent under two weeks. Of the 8,000 people in the surrounding area, many lived fifty miles or more from the nearest doctor. In one year there were 177 births and sixty-four deaths noted, but only four doctor's visits. The new hospital was funded by the home mission boards of the Presbyterian and Methodist churches. It measured sixty-eight by thirty-six feet, including a solarium, and had twenty-two beds, running water, and electric light powered by a generator. For a long time it was the only hospital in the

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Chapter 5 area from the Red River to the Ontario border. At first, patients would not come, because they spoke little English. The first doctor, in 1922, was a McGill graduate, Dr. W.W. Read. In 1925, Dr. Harold Waldon, formerly a medical missionary in China, took over; he stayed for over thirty years. The staff consisted of a matron, three trained nurses, and domestic staff. Waldon was dedicated, religious, and devoted to his patients and his family of five. He was on duty twenty-four hours a day, every day of the year. His workload can be gauged from the hospital statistics. In the year 1940, 542 patients were admitted to the hospital and 2,414 were seen in the out-patient department; there were 188 trips to the country and ninety-two house calls; seventy-seven x-rays were taken, forty-nine major and fifty-five minor operations were performed, and fifty-five tonsillectomies. There were 106 maternity cases, 103 births, and seventeen deaths from all causes. People in those days died at home. The doctor would vaccinate, inoculate against diphtheria and typhoid, and pull teeth. A trip to see a patient in a remote area could take over twenty-four hours.The doctor would often be accompanied by a nurse, particularly in the winter. The roads were poor and the motor cars of the day unreliable. In the winter, they would use a horse-drawn sleigh, with a change of horses halfway; or the railway foreman would take doctor and nurse, wrapped in buffalo coats, on a handcar or motorized jigger, to a predetermined spot where the family of the sick person could pick them up. Babies were usually delivered at home; women would not come to hospital because of the language barrier. When Waldon came back, tired out from a day in the country, he often could not sleep and would go to his bench and do woodwork; he made the bassinets for the hospital. Waldon sometimes had a junior doctor or medical student to help but was usually on his own, particularly during the war years. These assistants greatly benefitted from the educational experience. The costs were borne by the patient, by a provincial grant of forty cents a day per adult and twenty-five cents a day per infant, by a municipal grant toward hospital treatment but not medical services, and by a contribution of eighteen percent from the United Church Home Missionary Board. While Waldon had a basic salary from the church, he was partly dependent on direct payment by the patient; one man came to have his appendix out and brought a pail of cucumbers to pay for it. Medical practice was basic, picturesque, and sometimes gruesome. A patient with twin babies would put them on the kitchen table side by side and lean over the table to breast feed them. Elderly men who lived and worked in the bush would be given catheters to catheterize themselves in

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case of acute retention of urine; on one occasion the catheter broke in the patient's bladder when he was miles out in the bush. A young man cutting timber in the bush went missing and was found dead under a fallen tree. A bear came into town and was treed; someone poked at it with a hay fork. Dr.Waldon was called as coroner to the gruesome sight of dead man and dead bear, their blood and entrails mingling on the halffrozen ground. It was easy for a country doctor in isolation to lapse out of date, and sometimes out of sobriety. Doctors' offices were often fusty, malodorous places: many years after he had worked as an assistant for the elderly doctor in Rossburn, Dr. S.S. Peikoff, a Winnipeg doctor, remembered the office as a one-room shack about fourteen by twenty feet, situated on Main Street opposite the drugstore. There was a heater, with split wood and coal piled nearby, and a cot covered with a brown blanket for the doctor. Across the room stood an examining table and two small tables with instruments and a wash basin. Three shelves on the wall were laden with bottles containing patients' urine specimens, many of them old, some cobwebbed. The smell was characteristic of a small-town doctor's office: "The fermentation of the forgotten urines blended with the volatile ether and iodoform vapor. It was as constant as the heavy perfumes of a bordello." The young Dr. Peikoff was not content with this; he borrowed $5,000 to construct a new thirty-by-eight-foot building with a glass front and a full basement. It was to be a small hospital, with a waiting room, an operating room, two offices, kitchen, x-ray, and small laboratory; the rest of the space was partitioned off to make private cubicles for patients. An announcement in the local paper one day stated that the hospital would open in three weeks. The women of the town secretly formed a ladies' auxiliary and showered the new doctor with vegetables, jams, pickles, blankets, sheets, and many useful household items.The local Mounties contributed game confiscated because it had been shot out of the hunting season. The hospital soon filled; often there was standing room only in the waiting room. The existence of the hospital saved the doctor many long drives and hours of waiting for maternity cases, but the combination of maternity cases, country calls, office practice, surgery, and continuous postoperative care kept him busy from dawn to dusk, and often after. It was difficult to find a competent assistant to give ether anaesthesia, and postoperative care was rendered more difficult by relatives who, despite warnings, would give patients food immediately before anaesthesia. Patients vomited pieces of cabbage, baloney, and beans all over the anaesthetist and the operating room.

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Chapter 5 It was hard to find nurses.The local farmers' daughters happily came in for a practical training and at the end of six months they would be competent. "Unfortunately, the long, quiet, convalescing period of the patient was an ideal atmosphere for captivation by a husky, young farmer, recuperating while in excellent physical condition. . . .We were running a virtual marriage bureau." The most common emergency was acute appendicitis. Farmers did not worry about a belly-ache for twenty-four hours and then would use the standard old-fashioned remedy; a good dose of castor oil. The delay, the castor oil, and a fifteen-minute ride by wagon over rough, bumpy roads to the hospital could lead to perforation of the appendix. Sometimes six or seven patients with ruptured appendices would be in the hospital at the same time; they would stay for up to three months while the local peritonitis was treated by draining the pus through a tube. If the patient was indigent, as many were, there was no charge, either for medical and nursing attention or for room and board. The profits of the practice went to subsidize the hospital. PeikofF's bank loan reached peaks of $30,000 to $40,000, but he was doing well in the stock market. The standard of medical and in particular of surgical and obstetric practice varied. PeikofF himself was very competent but was horrified when as a student he watched another older colleague carry out a Caesarean section: [He] began with a long incision, plunged his clumsy hand into the abdomen, at the same time explaining his findings, "Some loops of bowel are plastered by adhesions which I am separating with my hand."... Somewhere along the clumsy operation he had torn a large artery. Pools of blood welled up into the wound. He packed it with large gauze packs, hoping the blood would clot from pressure. He finally pulled out the gauze, and blood again welled up. He flew into a rage in his attempt to find the injured artery. Meanwhile, the anesthetist warned him that the patient's blood pressure was dropping and her pulse was getting shallower. The place began to resemble a slaughter house - bloody sponges everywhere, pools of blood on the table and on the floor.

Medicine was heroic, but there were some ham-fisted heroes.The control of standards of practice by the College of Physicians and Surgeons was as yet inadequate, and the standard of medical practice was uneven. Some distance away, in Winkler, a community in the Mennonite West Reserve of Manitoba south of Winnipeg, Cornelius Wiebe practised good medicine from 1925 until 1972. His remedies were often home remedies

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and his practice common sense.The Mennonite society was male-dominated, and contraception was illegal: Dr.Wiebe advised, "Sleep with your backs together." He paid many home visits, using a horse and sleigh well into the 1940s. Medical fees were still paid directly into the doctor's hand, when he was lucky. The care of a woman in labour would often be paid for from her cream money. As new machinery came into use, especially for harvesting cereal crops, accidents from machinery became more frequent. Amputations were sometimes required. Other cases would be complicated by severe bone infections (osteomyelitis). Occasionally, to avoid amputation, Dr. Wiebe would use maggots to clear up sepsis in a injured limb.The maggots were washed and put in the wound, and the incision was closed; when the maggots were removed, the wound had healed and the infection did not recur. And, like all family doctors, he dealt with the recurrent childhood epidemics of measles, mumps, and chickenpox. Practice in a small community was never confined to treating humans. When a young boy appeared at the hospital one day with tears in his eyes and in his arms a pet dog with a nose full of porcupine quills, Dr.Wiebe interrupted his rounds to take the dog to a barn on the hospital property, subdue it with an anesthetic, and carefully remove the quills one by one with tweezers. Wiebe gave much to the community in the development of the local hospital (the Bethel Hospital) and a home for intellectually impaired children, and as a provincial legislator. He performed many tasks for the community: sanitary inspection of back yards, alleys, closets and stables, and of refuse collection, drainage, and water and milk supply. He was admitted to the Order of Canada in 1999 at the age of 105. Not far away, in Morden, Dr. A.F. Menzies practised and founded what was to become a three-generation practice. He saw the whole range of human disease: goitre, tuberculosis, diabetes, post-encephalitic Parkinson's syndrome, Raynaud's disease, multiple sclerosis, angina, anxiety neurosis (perhaps caused by too much hard work and too little rest), vitamin deficiencies, dental caries, rickets, and bronchitis. Like many a country doctor, he did an appendicectomy with the local nurse as anaesthetist, often in the small hospitals that were increasingly common. Bizarre accidents led to injuries that could not have been successfully treated anywhere. A mother brought her five-year-old daughter in fifteen miles to see the doctor. Under her other arm she carried the child's right leg wrapped in a newspaper. The child had been riding on the back of a buggy and her foot slipped through the spokes of the buggy wheel, which completely wrenched off her right leg about the knee joint.

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Chapter 5 The young rural doctor was often trapped in a country practice by economic necessity; he had to buy his own equipment, office, transport and home, ending up deeply in debt and unable to afford continuing education to keep up to date. Menzies wrote in 1933,"The doctor looking for a practice in the country is like the fly looking over the different pieces of sticky paper. As soon as he settles down he is there to stay, and just like the fly he doesn't know that he is stuck until after he has settled down." One of the problems of the rural physician was collecting fees; this was alleviated by the Municipal Doctor Scheme, which was established in 1922 after an act, passed in 1921, permitted local municipalities to vote to tax themselves to pay a salary to a doctor. Until 1922, the doctors fee was paid across the counter; there was no system for pre-payment. Many people sickened and died without medical care because they could not pay for it. Often, medical care was provided but the doctor was not paid. The provision of free care to the indigent was part of the ethos of medicine, and most doctors were indeed ethical about it.The last municipal doctor was appointed in 1962. For example, Baldur, in the Rural Municipality of Argyle, had subsidized its doctor in the early 1930s because he had found it hard to collect his fees.The municipal council decided to pay him twenty-five dollars per month towards his living expenses. This was inadequate, and in 1936 the council after due study submitted a bylaw to the ratepayers, assessing them on the value of their land and houses for the cost of a municipal doctor. The bylaw was carried by a large majority. The doctor appointed was Dr. A. A. Keenberg, then practising in Cypress River. He was paid $3,500 per annum and some expenses. Rooms for his office were provided in the home of a retired farmer. The scheme helped the poor in particular; a poor family might for four dollars per annum receive medical attention. The doctor had a better chance of making a living and staying in the area.The rules and regulations governing access to the services were clearly laid down and fairly strict. For instance, in the Baldur area, the patient had to come to the doctor when possible. The patient paid for drugs and dressings used by the doctor and for the anaesthetic. The doctor would do minor operations, like tonsillectomy, but major operations had to be done by a surgeon selected by the patient at the patient's own expense. Matters of dispute would be adjudicated by the municipal council. Only residents of the area had access to free medical care, not tourists, travellers, visitors, or construction gangs. The municipal physician in Argyle had clear public health duties. In an outbreak of smallpox, he was responsible for vaccination and quarantine;

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during one epidemic, there were twenty-four cases in a district with an area of eight square miles and containing eleven infected homes; the doctor had to drive from ten to eighteen miles on each visit. All those exposed were vaccinated, and the whole settlement was placed under quarantine, under the supervision of three efficient constables. They enforced the law and saw that those quarantined were properly supplied with food. The doctor personally supervised the cleansing and disinfecting of the infected homes. Only one patient died. Municipal Doctor Scheme or not, the life of the rural doctor was hard. Many moved on from one practice to another; others stuck it out, taking great satisfaction in giving their patients dedicated and competent medical care. Their medicine was often heroic medicine, but more than heroism was needed for the future.

The Medical Care of Aboriginal People If there were problems in the medical care of rural people, aboriginal people did worse. Their care was administered at various times by different federal government departments, including Mines and Resources, and Pensions and National Health, even by the Royal Canadian Mounted Police. While there was little social contact between aboriginal people and EuroCanadians, treaty rights called for an annual visit by a treaty party, consisting of the Indian agent, an RCMP officer, an interpreter, one or two doctors, and several native canoeists. The doctors, often newly qualified, examined and treated the sick, brought the vaccinations up to date, and usually pulled many teeth; dental health, particularly among the younger people, was poor. The party would travel in the north by canoe for as much as three months, taking a chest of cash to pay the reserve Indians their treaty money and a medicine chest. Public health nurses visited or lived on the reserves, serving as doctors, family counsellors, social workers, lawyers, and even occasionally dentists. The housing conditions were often appalling. Dr. E.W. Montgomery described in 1936 how the Cree lived in winter in log shacks chinked with moss, with ill-fitting doors and windows, when indeed there were windows. He described one such such hovel: "A hunter and his family, composed of children, nondescript adults and dogs, huddle together through the long winter nights. The head of the family is out following his line of traps, sometimes not returning to his hut for a week." The physicians who were sent to the reserves by provincial or federal organizations worked devotedly in trying situations and have left

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Chapter 5 descriptions of health conditions. For instance, Dr. F. Walkin lived in Ashern, in the Interlake, for seventeen years as physician to the Manitouwapah Indians and looked after four reserves. He described the impoverished social life of the Indian population, their poor living and sanitary conditions, and their indifferent diet, particularly in the winter. Other doctors in other areas told similar stories. Like others, Walkin's descriptions are coloured by the racist attitudes of Canadian society at the time. Maternity work is usually done by the older squaws and the mother faces labour stoically. During pains they whine a peculiar chant. Pre-natal work is unknown.Very few will undress and suffer an examination. Any examination is done by palpating through several layers of dresses and petticoats. The child born in the fall will never be bathed nor see the outside world until the following May or June. The Indian mother always nurses her babies. Most infants suffer from bronchial, nasal, aural and skin diseases. Any treatment prescribed by the physician or nurse is usually neglected. The color of the medicine is more important than the drug it contains. For example, argyrol, being black is taboo. Any red pill will go over in a big way and will be in demand for all sickness - ranging from pulmonary tuberculosis to small abrasions. Lately, some progress has been made by the local nurse in infant welfare. In one clinic I saw some wellfed babies dressed very neatly. The answer to this was that the local nurse bribed them to do it by giving them a small trinket.

Disease patterns were those to be expected in a poverty-stricken and poorly housed society not yet dependent on a western diet. Tuberculosis was the biggest killer, particularly the lethal miliary (disseminated) and meningeal forms, and pneumonia was frequently fatal. Measles and whooping cough often led to pneumonia and killed many children. Infantile diarrhoea was common, and lethal. Scurvy, tetanus, and rickets occurred in children. Scabies and impetigo were common, as were infestation with lice and tapeworms. Gonorrhoea was common, syphilis less so, often acquired from trappers and fishermen. Appendicitis, peptic ulcer, and gall bladder disease were uncommon, as were typhoid, diabetes, and kidney disease. Diphtheria, scarlet fever, and poliomyelitis were rare, as were major allergies, cancer, and serious cardiovascular disease. The aboriginal people still resorted frequently to herbal remedies. There were times of disaster: the 1918 influenza epidemic struck the aboriginal population hard. Smallpox still visited. One old man remembered the smallpox epidemic at Big Sandy Reserve in 1933, when he was

Between the Wars: Health and Medicine

in his early twenties and a member of a four-man survey team. When they arrived by train at Amaranth, they discovered the epidemic in full swing. The reserve and railhead were in quarantine; the RCMP sergeant would not let them proceed, and they stayed for several weeks. They were drafted into nursing; there were about fifty people with smallpox, a number of whom died. The survey team helped to bury the dead. People from the south were not allowed to go in on the train, but eventually two nurses and another doctor arrived. They were then examined, found to be clear of disease, and allowed to go on, despite the fact that they had not been vaccinated. The biggest continuing health problem was tuberculosis.The tocsin was sounded by Dr. P.H. Bryce, who was appointed chief medical officer of the Department of Indian Affairs in 1904. Every year until 1914, he wrote an annual report on the health of the Indians and in 1907 made a special report on the conditions in the three Indian schools in the three prairie provinces. He described the sanitary conditions and state of health of the inmates: a quarter of the pupils died while there or soon after leaving. The residential schools were hotbeds of tuberculous infection, but Bryce's recommendations for improvements in care, notably in relation to tuberculosis, were never published and certainly never followed. Bryce showed that a catastrophic epidemic of tuberculosis was affecting the aboriginal population; the federal government ignored him, and he was retired in 1921. He published a pamphlet in 1932 that showed clearly that he had seen the problem and that the federal government had quite deliberately ignored it. Aboriginal people died from tuberculosis at a rate twenty-four times higher than that for other Canadians. There were some attempts to improve matters.Tent sanatoria and nursing stations were set up. A travelling clinic run by Dr. C.H.A.Walton found Fort Alexander, one of the nearer and better reserves, near the hydroelectric station at Pine Falls, to have mediaeval conditions. Dr. E.L. Stone was appointed medical director in 1927, and more surveys were carried out. In 1939, a small sanatorium for aboriginal patients was established in an old hospital at Dynevor, near Selkirk, and, finally, after the war, Stone's successor, Dr. Percy Moore, set up case-finding teams that explored the whole of northern Manitoba and the adjacent Arctic in search of patients with tuberculosis.The patients were compulsorily admitted to sanatoria at Dynevor, Clear Lake, and Brandon. It was a drastic solution that went only some way to solving a drastic problem. Moore, archetype of the benevolent and effective medical bureaucrat, became director of Indian Health Services and then director of Health Services for the Department of National Health and Welfare.

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Public health proclaimed: the Temple of Health, public health display at the 1917 Brandon Exhibition (PAM).

Taking the cure at Ninette, 1910. Interior of sleeping pavilion (PAM).

The travelling tuberculosis clinic. Physicians, nurses, and x-ray technologist on the mail boat Hamlet, Riverton, Manitoba, 1936 (WCPI).

The dead instruct the living: anatomy dissection rooms, about 1925.

E.D. Hudson, winter house call, 1928 (courtesy J.E. Hudson).

Some of the books that gave the medical school its name in the 1930s.

The drugs that failed: antiphlogistine for pneumonia. Drug advertisement, Manitoba Medical Review, 1939.

A.T.Mathers, psychiatrist and dean of the Faculty of Medicine.

Clockwise from top left: Robert J. Blanchard, early professor of surgery; William Webster, pioneer anaesthetist; Alexander Gibson, professor of anatomy and thereafter the leading orthopaedic surgeon in the province; P.H.T.Thorlakson, surgeon and visionary.

Winnipeg General Hospital, about 1925. From left to right: Miss Syme, Dr. Burns(?), Dr. Webster, Miss Louth, Dr. Halpenny (courtesy Philip Halpenny).

Jasper Halpenny, surgeon (courtesy Philip Halpenny).

Oliver Waugh, neurosurgeon.

William Boyd, pathologist, about 1932.

J.C.B. Grant, anatomist, dressed for war, 1916.

E.W. Montgomery, physician and public health pioneer, in his garden, about 1920 (courtesy Jane Montgomery).

David A. Stewart, pioneer tuberculosis physician.

Olafur Bjornson, obstetrician.

The Saddlebag Surgeon grows old: Murrough O'Brien, about 1955 (from Tyre, 1954).

A.J. Douglas, medical officer of health for Winnipeg (courtesy J.D. Adamson, physician, 1944 (PAM).

Margaret Fast, Department of Health, Winnipeg).

Between the Wars: The Medical School and Specialists

6 After the War Medicine improved in the 1920s and 1930s in preparation for the spectacular breakthroughs of the 1940s and later. The medical school, as well as being the place where unspectacular but important improvements occurred, was the place where the next generation was trained, the generation of breakthrough. The generation of the founders was passing from the scene. New brooms were appearing. The new dean was Dr.Willis Prowse. Prowse was born in Prince Edward Island, graduated in medicine in Edinburgh, obtained a higher degree in medicine and trained as a surgeon, and became a Fellow of the Royal College of Surgeons Edinburgh (FRCS Ed) in 1898.This was an unusually good medical education for a Canadian doctor of his generation. After rural general practice in Scotland, he came to Winnipeg and practised eye, ear, nose, and throat surgery, becoming professor of otolaryngology.Thus, in the 1920s the ethos of the school was firmly controlled by a surgeon trained in Edinburgh.The professors were either local graduates, secondarily influenced by Edinburgh, or themselves Edinburgh trained. The Scottish influence had two sides. Scottish medicine was then among the finest in the world, but the Scots were, despite a superficial plebeian veneer, too often arrogant, dogmatic, and racist. Prowse, then treasurer of the Faculty, was commanding officer of the Faculty ambulance unit, but he was invalided home in poor health after being in the thick of some of the worst fighting in Flanders. Power in medicine, as in many other areas, lay in the hands of those who had survived Flanders. In 1919, the College became the Faculty of Medicine of the University of Manitoba. It was still a small institution: Medical Faculty

100 Chapter 6 Council met on occasion in the home of the dean. The faculty was composed largely of local men, with an infusion of Scots: in 1919J.C.B. Grant was professor of anatomy, Swale Vincent was still professor of physiology, Gordon Bell was professor of bacteriology, and William Boyd professor of pathology. Edward Montgomery was professor of medicine, and Jasper Halpenny professor of surgery, while Daniel McCalman from the last generation still reigned over obstetrics. Prowse himself still practised surgery, mainly ear, nose, and throat surgery, although the duties of the poorly paid deanship consumed much of his time. They were mostly able men who eventually made national reputations. By 1929, Prowse was suffering from severe angina pectoris; he died two years later. In August 1931, a faculty meeting was held for the purpose of selecting the new dean. Seventy doctors and other teachers attended the meeting, and a write-in ballot was held.The four names most often written would be candidates in a second ballot. Fifty-two out of seventy wrote in for Mathers; the choice was made with less influence from the University than from practising physicians. Dr. AlvinT. Mathers was born in Neepawa in 1888 and died in 1960. He taught school to scrape up enough money to go to medical school; after a brilliant undergraduate career, he graduated MD in 1913. He served first as assistant superintendent of the Municipal Hospitals, and then (in 1917-18) with the Royal Canadian Army Medical Corps in Winnipeg. In 1919, the provincial mental hospital services were reorganized, and Mathers became provincial psychiatrist and director of the new Psychopathic Hospital. This was a significant step for an able young physician, and he did much to develop psychiatry in the province. He was a tubby, dignified man, with spectacles dangling on the end of a ribbon. He had an encyclopaedic knowledge of medicine and served as dean for a long time under trying conditions, at a time when deans were singletons, not yet surrounded by coveys of associate deans. He was influential in Canadian medicine and achieved eminence in the profession, being involved in the foundation of the Canadian Association of Medical Colleges and of the Royal College of Physicians and Surgeons of Canada, and was ultimately president of the latter. Within his own medical school, he served with great industry and single-minded dedication and was responsible for some innovations: he set up clinical clerkships and rural preceptors. He has been damned by some, because he introduced the quota system of selection of medical students. His virtues were his own; his prejudices were those of his day.

Between the Wars:The Medical School and Specialists

Medical Students Medical students were still trained, here as elsewhere, in the pattern of Scottish medical schools in the 1890s.They studied basic science first, attended many lectures, and took clinical training later. Pre-medical students trained at the University of Manitoba campus on Broadway, a mile and a half away from the medical school; seventy students enrolled in the first year, and about fifty graduated each year. The medical buildings were connected by corridors and, most important in the winter, by a subterranean passage to the Winnipeg General Hospital. Recent immigrants, often Jewish, now entered the school. Dr. C.S. Hershfield, later a successful Winnipeg doctor, recorded how as a student he worked in a drugstore in his free time; in the window was a glass bottle filled with coloured water and a brass mortar and pestle. Hershfield remembers the pre-medical initiation in 1921, held in a large empty barn on Notre Dame, a noisome event at which the blindfolded and naked initiates were sprayed with cold water, and made to slide down a chute filled with animal intestines into a large vat filled with stinking ordure. Those who objected were tarred and feathered. Such student hazing was then not unusual. Anatomy dominated. Hershfield wrote:"The dissecting room was a long wide chamber, and placed at equidistant spaces were the tables on which cadavers lay ready for the knife and forceps of the soon to be busy student. . . . The stench of the formaldehyde soaked cadavers was thick in one's nostrils. . . . Professor Grant used to stand at the blackboard and with coloured chalk illustrate an anatomical dissection. A word of praise from him at the dissecting table was to be a cherished event." Pathology was taught compellingly in the new pathology museum, amid specimens of diseased organs. Physiology lectures were less memorable, but Dr. A.T. Cameron managed to plant some of the elements of biochemistry through a haze of cigarette smoke, illuminating them with flashes of sardonic wit through his slow delivery. Dr. Fred Cadham was a favourite, as he talked of the tubercle bacillus, the gonococcus, and the spirochaete pallidum, whose effects were seen regularly in the wards. The students were a serious lot: Professor Boyd was most impressed by the decorum of the Manitoba students and their serious view of life. But, out of the professors' sight, they played, often informally; the trophy in cuspidor hockey was a spittoon. They played craps in the basement, occasionally caught and stopped by the dean on the prowl.

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102 Chapter 6 As the years passed, there was a change in emphasis in teaching, away from the didactic lecture. By 1933, pathology was taught partly by student presentation, moderated by the professor. Dr. Alex Andison remembered his days as a medical student in the early 1930s. Even Saturday mornings were spent in the dissecting room. "What a tremendous feat of memory it was to master all the details demanded of us." Life was hard: in an examination, "every two minutes a bell rang and the student advanced to the next station.We were all under great stress. . . .And we all knew that the failure rate would be about 50 percent." Students remembered the features of syphilis from the graffito on a piece of furniture: "There was a young man of Bombay, Who thought chancres just faded away, Now his wife has got tabes, and sabre-shinned babies, While he thinks he's queen of the May."The students were persistently drilled in the manifestations of syphilis. Clinical demonstrations were important; a patient was brought over from the hospital, and a member of the medical staff would present the case. Equally important, on Saturday mornings during the students' third and fourth years, Dr. Boyd conducted a clinical-pathological conference. The senior resident in medicine would write on the blackboard the details of the patient's history and the clinical, laboratory, and radiological findings. Dr. C.R. Gilmour, the professor of medicine, would discuss the differential diagnosis and arrive at a decision as to the likely cause of death. Dr. Boyd then presented the autopsy findings. There was no bookstore, except for Colcleugh's drugstore at the corner of Sherbrook Street and Notre Dame Avenue. Old Mr. Colcleugh kept a room at the back of his store where he had a stock of the prescribed textbooks as well as a few other volumes. There was no cafeteria. Lunch, in a brown bag, was eaten in the dingy basement common room, which contained an old piano, but no radio. It was a formal time: all the male students wore three-piece suits to classes and to clinics and wards; less formal attire was frowned on. Occasionally, a class of student nurses (all women) would pass by, clad smartly in blue uniforms, starched white aprons, and caps.The male medical students were always interested, as many lifetime partnerships attest. The Depression brought problems to the medical school. There were inevitable budget reductions: on 13 June 1933, a ten-percent reduction in part-time salaries and a thirty-percent reduction in departmental finance. Dean Mathers, in a report to the faculty, spoke of a forty-three-percent failure rate and of a faculty discouraged almost to the point of rebellion by the necessity of trying to teach too many students with inadequate space

Between the Wars: The Medical School and Specialists

and equipment. This "was followed by a limitation in the intake of students. For the University of Manitoba, the problems of the Depression were rendered worse by the sad Machray affair. John Machray, KG, respected churchman and lawyer, became honorary bursar of the University of Manitoba in 1903 and financial agent in 1907. He held a similar position in the Anglican Church. Over many years, he embezzled $900,000 from the University and $800,000 from the Church, a large proportion of the fluid assets of each institution. The Faculty of Medicine was badly affected. The Rockefeller Foundation had given $500,000 to the Faculty in 1920; this yielded $27,500 annually: twenty percent of the income of the Faculty. In 1932, Machray stole $475,877, which represented most of the Rockefeller money. The loss strained relations between the University and the Foundation and stultified further growth in the medical school for twenty years. It was a devastating blow. Yet all was not dark.The medical school was still well rated as a teaching institution: in 1933 it was graded A, one of only three in Canada, and its students continued to do well in external qualifying examinations. Its professors spread its fame by their writings. Boyd, Grant, Cameron, Gilmour, William Webster all had written standard texts. Research was less in fashion than it is now, but there was some investigation in the pre-clinical departments into differences in anatomy among Cree, Saulteaux, and European people, on the production of hydrochloric acid by the stomach, and on the effects of drug extracts of various wild plants. The study of allergy was just beginning. In the Medical Building there were now good facilities and laboratories. The medical library in 1928 had 6,000 volumes and received 135 periodicals. Teaching was formal, didactic, and thorough and was similar to that in other Canadian and in British universities of the time.

The Scientists The future of the medical school, and therefore the future of medicine in the province, depended on improvements in teaching. Alexander Gibson, Grant, and Boyd had been hired by Dean Chown to help raise the Manitoba Medical College to the first rank.They did. On 15 November 1923, the American Medical Association Council on Medical Education and Hospitals wrote to Dean Prowse: "Your medical school has now been entered among our class A medical schools." His colleagues held a public dinner for him in the Fort Garry Hotel to express their appreciation.

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104 Chapter 6 The Department of Anatomy was led by Dr. J.C. Boileau Grant, a brilliant Edinburgh graduate who was devoted to teaching but was also deeply interested in anthropological research. While in Winnipeg, and even more so after he left for Toronto, he made a major reputation with his clearly written texts, which shone as bright lights amid the tedium of the overdetailed classical anatomy books. The Department of Physiology had been headed by Swale Vincent until 1922, when he returned to England. Thereafter, Dr.V.H.K. Moorhouse taught physiology in a less than exciting way; physiology did not again become a dynamic part of the medical school until the late 1940s. Biochemistry was still in its early days, but Dr. A.T. Cameron, another Edinburgh graduate, was an able exponent of the new discipline. He had been heavily influenced by Swale Vincent and researched and wrote on biochemical endocrinology; with physician Dr. C.R. Gilmour he later wrote an influential text on clinical biochemistry. He had charge of the biochemistry service in the Winnipeg General Hospital, which played an increasing part in the management of patients. Grant's initially less brilliant classmate William Boyd was professor of pathology in the University and chief pathologist to the Winnipeg General Hospital. An excellent lecturer with a pronounced Scottish accent and a gift for vivid language, Boyd developed a pathology museum, which occupied by 1937 about 7,000 square feet, and which was a good teaching tool, rich in correlation between clinical history and pathological specimen.The students flocked to it; Boyd and his colleagues were there frequently, discussing and explaining. Pathologists now had an increasing role in advising surgeons on treatment, particularly discrimination between benign and malignant tumours; Boyd wrote a book on surgical pathology in 1924, with a preface by none other than Will Mayo. The book was well received. This was the first of his series of successful and profitable texts. The pathologist increasingly monitored the cause of death in patients dying in hospital. Cancer of the lung was recognized in the Winnipeg General Hospital in the 1920s as the cigarette-smoking epidemic gathered momentum. Pathologists were responsible for investigating unexpected deaths, or those occurring under suspicious circumstances. In 1929, Dr. H.M. Speechly succeeded to the office of provincial coroner in Winnipeg, on the death of Dr. H.M. Cameron. Speechly was the only coroner in Manitoba to receive a salary and was on duty twenty-four hours a day, every day of the week. It was a full-time job; some 470 deaths annually were referred to him. He held from forty-five to fifty inquests a year. By now, automobile accidents

Between the Wars: The Medical School and Specialists

were a common cause of injury and death. In the 1930s, urban gas supplies made suicide by carbon monoxide very frequent. Speechly's outlook was humane: "In my opinion, . . . there is no good purpose served in drawing attention to suicides provided that the Coroner consults the Police Chief concerned and takes into consideration the wishes of the friends. In relation to suicides I have always advised the friends not to tell lies about the cause of death, but to tell the truth to their own circle of acquaintances, and so protect themselves against all sorts of unpleasant false rumors." Gordon Bell had died in 1923, but his successor, Dr. Fred Cadham, developed the Provincial Laboratory, later named after him, as a centre of diagnostic bacteriology and serology, whence came the program of vaccination against diphtheria, which significantly cut childhood mortality. Cadham also carried out pioneer studies on allergy. It was one of the most influential parts of the medical school. The laboratory physicians had less opportunity than did their clinical colleagues to supplement their salaries by private practice, but they tried. Medical Faculty Council on 22 November 1922 argued about whether Dr. Daniel Nicholson might open a private laboratory for the Medical Arts Building.

The Specialists There were no full-time clinical professors in 1919. Clinical faculty, all practising physicians and surgeons, earned most of their incomes by collecting private fees. They were mostly locally trained, with postgraduate training elsewhere, and were competent clinicians and devoted teachers rather than exciting intellectuals. Inevitably the central faculty control of teaching standards and content was imperfect. Most medical teachers were specialists, who retained at least some general practice. Most academic medicine was practised in the Winnipeg General Hospital, which was recognized as an excellent hospital and was the main teaching centre. St. Boniface Hospital, the largest hospital in western Canada, was in a secondary position, formalized in 1925. The Children's Hospital was developing a reputation for good paediatric care. Doctors would specialize in one major branch of medicine, but only after several years in general practice. There was as yet no systematic, organized pattern of postgraduate training, nor was there a national Canadian specialist qualification. Before the First World War, it had been common for physicians to go to Britain, Germany, and Austria for training; after 1918, the usual destination was Britain, but an increasing number went south to the United States.

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106 Chapter 6 The British Royal Colleges offered diplomas of specialization after administering stringent examinations. Physicians would become members of the Royal College of Physicians and add proudly the letters MRCP after their names. Surgeons would become Fellows of the Royal College of Surgeons: FRCS. Such colleges existed in Edinburgh and London. A similar college, the College of Obstetricians, appeared in 1929. The Canadian specialists founded a unitary Royal College of Physicians and Surgeons of Canada in 1929 and, over the next decade, specialist training and certification in Canada developed. Such diplomas increasingly marked out the specialists, but until after the Second World War they were not necessary. Even professors had no scientific training beyond that built into the primary medical degree; in Britain there was a distinct postgraduate degree, which was given after a candidate prepared a thesis based on research. This did not exist in Canada. Research experience was not necessary for a clinical professor, although professors of medicine in particular were beginning to be oriented toward research.

The Physicians In 1919, in Winnipeg, with the exception of a very few surgeons, all doctors had a general practice. A few, because of their diagnostic skill, would be called in frequently by their colleagues as consultants in difficult cases and might be able ultimately to limit their practices to hospital practice, teaching, and other such consultations. If the patient was not well off, there might be no fee, or only a trivial one; if the patient's income was large, the fee might be proportionate. Only a very few of such "internists," as they eventually came to be called, had special training and had passed a higher examination. Clinical excellence was a first requirement for such success. The professors of medicine between 1919 and 1939 exemplify the change. Dr. Edward Montgomery graduated MD (Manitoba) in 1892, after teaching school to save up for his medical tuition. After a short time in country practice, he practised at the Winnipeg General Hospital as a general physician and taught in the medical school. As the years went by, his students came to respect his diagnostic skills, and his consulting practice burgeoned. Like most of his generation of physicians, he was no research worker and published little. Montgomery became the first professor of medicine when the Manitoba Medical College was reorganized as a faculty. At that time, medical, as opposed to surgical, remedies were often ineffective, and he was deeply interested in prevention. In 1927, he was elected to the Manitoba Legislative

Between the Wars:The Medical School and Specialists

Assembly and became first minister of Health and Public Welfare, in the Bracken government. He was not entirely happy in the confrontational atmosphere of politics and retired in 1932 to chair the Board of Health; he held this post to his death. He had no specialist training but contributed a great deal to the public health of Manitoba, fostering such developments as immunization of school children against diphtheria, proper services for care of childbirth, cancer, psychiatric illness, and tuberculosis. He was succeeded in 1927 for a year by Dr. Charles Hunter, a short, irascible Scot, well trained for the time, with experience in London and Berlin and a Member of the Royal College of Physicians, London, the hallmark of the trained internist. In 1917, he published the first clinical description of the rare childhood disorder called gargoylism in two deaf, dwarfed brothers; this was an important early example of a disease resulting from a genetic abnormality of metabolism. An excellent clinical doctor, he became the leading consultant internist in western Canada. Less attractive was his reputation for scathing criticism of his colleagues. He did not enjoy administration, and in 1929, after a year as professor of medicine, he quit, perhaps pushed a little by his successor. Dr. Clifford R. Gilmour was a very different man, a McGill University graduate who came to Winnipeg in 1904. He developed a successful medical practice, ultimately as a consultant, although he had no specific training or higher qualification as an internist. He did not tolerate fools gladly and was described as extremely blunt, with no bedside manner. His few papers mainly related clinical medicine to biochemical findings; with A.T. Cameron he produced an outstanding textbook that gives a good picture of the role of clinical biochemistry in the mid-1930s. Renal function was being measured by urea clearance tests, and several endocrine diseases were being assessed biochemically: diabetes mellitus by measuring blood sugar, parathyroid function by measuring blood calcium. The steroid hormones were not yet fully understood, but adrenal cortical extracts were being used to treat failure of the adrenal cortex, hitherto lethal. Gilmour was succeeded in 1939 by Dr. James Douglas Adamson, who grew up in Manitoba and graduated MD (Manitoba) in 1914. After war service, he trained in Dublin and London and became a Member of the Royal College of Physicians, Edinburgh. He published numerous papers on hypertension and basal blood pressure, tuberculosis, encephalitis, and poliomyelitis and was noted in 1938 as one of the six leading medical research workers in Winnipeg. By 1939, it was clear that internists should have a specialist postgraduate diploma and that research was an integral part of the life of an academic physician.

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108 Chapter 6 Adamson's personal life was sad and illustrates the problems of the time; his first wife died of pernicious anaemia; his second wife had a severe postpartum depression from which she never recovered, and he lived alone and dependent on alcohol for his last fifteen years. Alcoholism was common among the leaders of that and succeeding generations of the Manitoba medical community. Sub-specialization was still to come, but one area in internal medicine was separating off. The care of sick children was becoming a specialty, practised in the Children's Hospital; specialist paediatricians were now emerging, including Dr. Rorke and Dr. Day, and cousins Dr. Gordon Chown and Dr. Bruce Chown.

The Surgeons Surgery was now clearly a specialty, the most effective part of medicine. The medical school had a considerable tradition of competent surgery started by the founders, and postgraduate training was developing, ahead of training in other specialties. Surgeons still trained largely by apprenticeship; there were no carefully organized courses. Most sought training outside Canada, usually in Britain. Many surgeons did not possess a recognized higher diploma in surgery, though possession of one was becoming more common. In 1930, of 449 physicians in Manitoba, thirty-six were surgical specialists; the designation "surgical specialist" did not necessarily imply possession of a higher diploma. The University head of Surgery from 1919 to 1927 was Dr. Jasper Halpenny. Halpenny graduated MD (Manitoba) in 1900 and trained further at Johns Hopkins Hospital in Baltimore, which was then a mecca for Canadians because of the presence of William Osier, the famous Canadian physician. After he returned to Winnipeg, Halpenny had worked in the evenings with Swale Vincent mainly on the thyroid and parathyroid in the University Physiological Laboratories, and himself later set up an experimental laboratory for trainee surgeons. Halpenny was an extraordinary man. He was more than just a good surgeon; he was a dedicated surgical teacher, grounded in surgical science, with a visionary view that went far beyond the tip of his own scalpel. He had a great concern for his students and a good memory for names and faces and tried very hard to know individual students by name. Halpenny took great trouble over training his juniors and emphasized the need for postgraduate training of surgeons. "Surgery," he wrote, "has now arrived at a position beyond the reach of the family doctor, and, unless in exceptional conditions, he should not, in the interests of his pa ent and

Between the Wars: The Medical School and Specialists

himself, perform surgical operations." He regarded hospitals as training schools for the surgeons of tomorrow. Surgeons did not then routinely investigate patients before operations; Halpenny advocated proper pre-operative investigation and record-keeping, and he believed that a large hospital ought to have a senior and influential medical superintendent as well as organized postgraduate training. His views on the training of surgeons were enshrined in a new set of regulations for the degree of Master of Surgery, turning it into a guarantee of postgraduate surgical training and experience. It had previously been an additional degree conferred on highly able students who had taken an additional examination at the time of the final medical examination. The years soon took their toll; he used to make the long journey to Brownsville,Texas, in search of warmth and relaxation in winter. He retired in 1926, still only 56, and went off to grow grapefruit in Texas. Like many another in the 1929 crash, he was bankrupted and died soon thereafter. Halpenny lit many candles.The experimental surgery laboratory that he set up laid the groundwork for Dr. Clifford Abbott, who for the thirty years after 1931 carried out extensive experimental research on thyroid disease, on the formation of bone in surgical wounds, on the treatment of the potentially fatal aortic aneurysm (stretching of the aorta), and on replacing the ureter with a loop of small intestine. Halpenny's interest in surgical endocrinology kindled the same in Dr. Gordon Fahrni, who was destined for fame and longevity. After internship and then military service in Canada during the First World War, Fahrni set his mind on being a surgeon. His training consisted of a trip to Mayo Clinic in Rochester, Minnesota, and to Chicago to observe the current masters at work. His specialist diploma was the newly revamped University of Manitoba Master of Surgery degree. He was soon operating at the Misericordia Hospital, St. Boniface Hospital, and the Winnipeg General Hospital, and in 1923 he became head of surgery at St. Boniface Hospital. After ten happy years there, Fahrni returned to the Winnipeg General after disagreements with a newly appointed sister superior. Fahrni made a significant contribution to the development of thyroid surgery. In the 1920s, many patients died immediately after thyroid surgery. Fahrni wrote: "An individual with starey eyes, usually young, sometimes older would be admitted to hospital, nervous jumpy and apprehensive. As I wrote the history and examined the patients I was impressed by the hot skin, the fast heart, the nervous jumpy movements and general agitation. .. .The thyroidectomy would be performed, with, it seemed, a lot of blood loss in a prolonged operative session. Twenty-four hours later this patient

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110 Chapters [was] thrashing about in bed, pulse racing and temperature ascending, the orgy to end in death forty-eight to seventy-two hours following operation." Fahrni was able to report fifty consecutive thyroidectomies without a death, even before the introduction of pre-operative iodine, due in part to the use of local anaesthesia and meticulous operative technique. For several decades, he regularly performed five or six thyroidectomies each morning, five days a week. Using forceps liberally to clamp bleeding points, he was able to render the field almost bloodless. He operated remarkably quickly; when he addressed the assisting intern, of either sex, as "sweetheart," the assistant knew to speed up, fast. By 1934, surgeons were operating aseptically in all the body cavities, but when sepsis happened the only solution was a combination of drainage and cauterization. Death from spreading infections of the skin and soft tissues still occurred frequently. Carbuncles were excised with electrocautery. Tenure of University headships of surgery after Halpenny's stint was invariably short, and overall academic direction was imprecise, lacking in Halpenny's vision. Halpenny was succeeded by Dr. Brandur Brandson, of Icelandic stock, an expert on surgery on patients with the cysts of hydatid disease, which was derived from animal tapeworms. Brandson was succeeded by Dr. John Gunn, who was remembered chiefly for his speed, which he learned during war service. An appendicectomy might be complete, skin to skin, in five minutes. But speed sometimes ran beyond caution; a single long incision by a gleaming scalpel on one occasion opened not only the abdominal wall but also the distended colon below. Like many another, Gunn lost his considerable savings in the Depression and eked out his latter years in general practice. Most surgeons were general surgeons, but the surgeons sub-specialized earlier than the internists did. The first orthopaedic surgeon, Dr. H.P.H. Galloway, was joined in 1919 by the brilliant and well-qualified Gibson, who became one of Canada's best known orthopaedic surgeons. Gibson had come to Winnipeg in 1913, as professor of anatomy, but returned from the war determined to practise surgery rather than teach anatomy. His main interest was in orthopaedic surgery. The orthopaedic surgeons were now beginning to attempt to relieve sciatica by removal of intervertebral discs, but the treatment of such infectious lesions as bone and joint tuberculosis was still a large part of their practices. Treatment of diseases of eye, ear, nose, and throat in Victorian times, in Canada as in Britain, formed one specialty, primarily surgical. In the 1920s and 1930s, the two specialties had still to separate definitively. Dr. Good

Between the Wars:The Medical School and Specialists

had practised thus, as did Dr. Prowse.The mainstays of such a practice were removing tonsils, often for no good reason and with an occasional fatality, and draining suppuration in the nasal air sinuses, or draining middle-ear and mastoid suppuration, which was often fatal. The specialty was financially remunerative, leaving time for academic pursuits. Urological surgeons separated early and derived from two traditions. American surgeons investigated and treated disease of bladder and prostate by passing a tube up the male urethra (perurethral endoscopy), whereas in Britain, in the 1920s, surgeons would be more likely to operate on the prostate by the abdominal route. Dr. Harry Morse established urology at the Winnipeg General Hospital. He graduated from McGill University then trained in the Mayo Clinic, obtaining an MSc in urological science, which involved among other things training in venereal and skin disease. As men lived longer, their prostates celebrated longevity by enlarging, and the practice of urology boomed. The common treatment for an enlarged prostate was the "cold punch" prostatectomy; there was often profuse bleeding from the operation site within the bladder, and nurses in urology wards over the years developed muscular forearms as they pumped bladder washouts to clear the blood clots. Morse was a shy man who loved nothing more than a game of cribbage after lunch. He hated flying and made long journeys by car or train to play a part in the administrative networks of his specialty. Many a dram went down as the miles flitted by outside the train window. He retired in 1953 and died in 1966. Neurosurgery had started in Glasgow in 1879, when the first surgical operation to open the skull (craniotomy) was performed. The difficulties, before antibiotics, were great, but by the 1890s several successful craniotomies had been performed. The first craniotomies in Manitoba were done in 1927, on the same day, separately, by Dr. Alexander Gibson, by then a successful orthopaedic surgeon, and Dr. Oliver Waugh. Both patients died soon thereafter. Waugh, trained first at McGill University and afterwards in Baltimore, had been in contact with the great neurosurgeon Harvey Gushing during the war. He developed his interest in neurosurgery on his return to Winnipeg and by 1930 limited his practice to neurosurgery. By 1938, he was recognized as the first neurosurgeon in western Canada, and he and a colleague, Dr. Hugh Cameron, were devoting most of their time to neurosurgery. Waugh was University head of Surgery during the war years, 1939 to 1945.

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The Anaesthetists Expert, specialist anaesthesia in Manitoba started with William Webster, who was born in Manchester, England, and came to Manitoba in 1888 as a rural teacher. He then went to medical school and graduated MD (Manitoba) in 1895. After postgraduate training in pathology in England, he practised both general medicine and pathology in Winnipeg but gradually specialized in anaesthesia, becoming honorary anaesthetist at the Winnipeg General Hospital in 1905 and lecturer at the Manitoba Medical College. In 1907, he became, at the Winnipeg General Hospital, the first full-time anaesthetist in western Canada. He held this position continuously until his death in 1934, with the exception of a brief leave of absence during the First World War, taken to serve overseas. In 1919, he became associate professor of clinical surgery (anaesthesia) and chief of Anaesthesia at the Winnipeg General Hospital. Dr. Webster took the administration of anaesthetics out of the hands of general practitioners, studied it scientifically, and showed that safe anaesthesia depended on basic physiological and pharmacological principles. By 1920 he was a recognized expert, and in 1924 he wrote the first Canadian textbook on anaesthetics: The Art and Science of Anaesthesia. In it he gives a picture of the then current practice of anaesthesia. The main gases used were nitrous oxide, ether, and chloroform. Ether, which was most often used, might be given "open," that is, using a rag and bottle, or "semi-closed, or closed," using a mask and rubber bag that could be inflated manually, giving the anaesthetist some control. Increasingly complex anaesthetic machines were in use. He also used local rectal and spinal anaesthesia. He clearly delineated the major complications: circulatory collapse (or shock) and disturbance of the chemistry of the blood (acidosis).The figures accepted at that time for death during anaesthesia were: nitrous oxide/oxygen, one in 20,000; ether, one in 16,000; chloroform, one in 3,000; and spinal, one in 500. From 1905 until 1934, the year of Dr. Webster's death, the specialty of anaesthesia grew steadily. He influenced several other physicians to become full-time anaesthetists during the 1920s and the early 1930s, notably Dr. Edith Ross, who practised anaesthesia at the St. Boniface General Hospital until her premature death in 1932. She was a granddaughter of Dr. Charlotte Whitehead Ross. Webster regarded the anaesthetist as the handmaiden, the surgeon's first assistant. This fitted better with Webster's world view than with that of some younger anaesthetists. Webster died tragically in 1934 when his motor cruiser exploded on the Red River.

Between the Wars: The Medical School and Specialists

Outside Webster's immediate ambit, giving anaesthetics was rarely a science, and often it was not even an art. The rag and bottle were still emblematic of anaesthesiology in the 1920s as much as they had been at the turn of the century. Dr. Hershfield remembered giving an anaesthetic, as a student, wearing street clothes and street shoes, in a small operating theatre. The patient on the table, a big man, had a large carbuncle on his neck. Hershfield dropped six drops of chloroform onto a mask on the patient's face and followed this by some ether, until the patient was breathing evenly and quietly and his pupils were 1/8 inch in size and equal. Hershfield gave the go-ahead, and the surgeon turned the patient and began to incise the carbuncle. Hershfield wrote: To my horror and consternation, suddenly the patient lifted himself off the table, flew on to the floor and in his dazed state started to run around the room. Harry [the surgeon] and the nurse ran after him and were able to put the man on the floor."Finish the anaesthesia," Harry commanded. I, also in a dazed state, put the mask on the patient's face and poured the entire bottle of ether onto the mask. Harry continued the incision and excised the necrotic areas.The patient slept for the next fifteen hours.

Cancer Treatment Surgeons were becoming bolder and more successful but, by 1920, it had become evident that radiotherapy was effective in the treatment of many cancers; the provision of radium and radon for treatment of cancer raised problems both of expense and of provision of safe transport and storage. Cancer relief was emerging as a problem, now that people died less often of infectious disease and survived long enough to develop cancer. A deep therapy (radiotherapy) machine was installed in the Winnipeg General Hospital in 1926.The cancer problem was examined in 1929 by a committee headed by Prowse and was dealt with in the Cancer Relief Act 1930, which set up the Cancer Relief and Research Board. At the first meeting of the Board, Dr. E.W Montgomery, then minister of Health and Public Welfare, met with representatives of various interested medical, hospital, and public bodies, including John Machray, then still a respected figure. Their first responsibility was to provide radiation therapy and radon seeds.The plant was finally located in the Medical College over the protests of a number of professors who regarded it as a health hazard. Dr. Nicholson gave the assurance that the plant was safe because the routine blood counts of the occupants remained normal. Subsequently, the laboratory was transferred to Memorial Boulevard. When this laboratory

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114 Chapter6 was eventually dismantled, even the plaster on the walls was so radioactive that it had to be buried. The radium and radon seeds were delivered by a member of the Institute staff in summer on a bicycle and in winter by streetcar. A large amount (700 mg) of radium was bought at $67.20/mg with a loan under a bond of $100,000 from the Great-West Life Assurance Company. The funding arrangements were precarious, depending in part on voluntary sources such as the Rotary Club and Kiwanis. Physicians were responsible for radium treatment to their patients, who were charged from $25 to $250, depending on the extent of radiotherapy required. As many patients were unable to pay, the Institute absorbed the costs into debt. The Treatment Committee hired Dr. Nicholson as part-time registrar to establish diagnosis and follow-up recording. Pre-treatment biopsies were read by Professor William Boyd at fifty cents per specimen. Finances remained a problem.There were penny boxes in all public schools by 1935; and tumour clinics were set up at the General and St. Boniface hospitals, as well as a travelling clinic.The Board was uneasy that not enough doctors were using radium but restricted its use to doctors with at least two months of training. There was considerable debate about whether a special hospital was needed and whether the physician in charge of radiotherapy need be a surgeon. Other discussion centred around the possible use of ensoul, a bacterial extract pioneered at Queen's University, a faint harbinger of tumour immunology. One physician, Dr. J.R. Davidson, had unorthodox ideas about the treatment of cancer; as well as prescribing a diet rich in vitamins, he injected cancer patients with embryo extract; he was not a trained investigator, and the treatment was ineffective and ahead of its time.

The Management of Childbirth In 1919, and indeed in 1939, too many mothers still died in childbirth, and too many newborn babies did not survive the first year of life. Most obstetrical care was in the hands of general practitioners, who were often not competent at dealing with normal labour. But more doctors now specialized in obstetrics, and the management of childbirth was improving. The pre-war obstetricians had been interventionists; the next generation tended to err in the other direction, leaving labour to go on too long. By 1927, there were maternity departments in several Winnipeg hospitals, at the Victoria, the Grace, and the Misericordia, as well as at the Winnipeg General Hospital and St. Boniface, but public obstetric wards where students could witness deliveries were available only at the two major hospitals and sometimes at the Grace.

Between the Wars: The Medical School and Specialists

The students learned practical obstetrics in groups of a dozen or so. When a birth was imminent, a telephone call would go out to the designated contact student, who would then call the others and finally a taxi. The students crammed into the taxi and went off to the hospital, where in the case room they stood, gowned and masked, to watch. The accoucheur would lecture informally during the delivery.When the deliveries occurred at night, and babies often come at night, students and staff would then repair to the ward kitchen for "the fourth stage of labour": toast, coffee, and perhaps a fried egg. Often the teacher would talk on, until the yawns became overmastering. Daniel McCalman was succeeded in 1926 as head of the University Department of Obstetrics by Dr. Olafur Bjornson, later described by Dr. Elinor Black as a "large happy Viking." Born in Iceland, he had graduated from the Manitoba Medical College in 1897 and had the typical postgraduate training of the time, in Dublin, London, and Vienna. A tall, broad man with a rather flat face, usually smiling, he looked a bit like "a large, pleasant comforting rag doll, with glasses on." He had an excoriating derisive wit. Bjornson was a conservative obstetrician; in contrast to those of the previous generation, he was reluctant to interfere. When looking after a pregnant woman, he would give careful attention to the position of the baby but much less to such matters as the mother's weight and blood pressure. The result was failure to detect the early stages of eclampsia, which could be lethal to the mother. He would deliver patients lying on their left sides and was unwilling to perform an episiotomy (to enlarge the vaginal orifice surgically) or to apply forceps to help the baby out. He would allow labour to go on for a long time; this exhausted the mother, caused risk to the baby, and probably resulted in a high incidence of uterine prolapse. He would rarely do Caesarean sections. In 1926, obstetrics and gynaecology were combined into one department under the headship of Dr. D.S. MacKay. MacKay was a small, gruff man, with a bristling moustache, a Nova Scotian trained in medicine at McGill University and subsequently in Britain, qualifying FRCS Ed. His surgical training gave him a great interest in his latter years in operative gynaecology, treating prolapse of the uterus and removing the uterus for tumours. He operated wearing a long pink rubber apron; often the operative field would be kept clean by a continuous stream of running water, and the floor was awash with water. The operating theatre was kept very warm so that everyone sweated profusely. After the operation, the patients would

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116 Chapter 6 have at first only ice chips to suck and were kept lying flat until the tenth day after the operation; we now know that such immobility conduces to lethal postoperative thrombosis. MacKay had some quaint unscientific beliefs. He believed that an extract of mammary glands would relieve menorrhagia and injections of boiled milk into the buttock of women with pelvic inflammatory disease would help to clear it. He had an explosive temper and an enormous fund of stories; listening to these was a duty for his juniors. His first coronary attack, in 1939, made him retire as professor, and his second attack, in 1943, killed him. Puerperal fever still threatened. In 1936, an outbreak of puerperal fever in the Winnipeg General Hospital killed seven women. The infection probably came from a doctor who had operated on a patient with acute purulent appendicitis just before delivering a baby. Over eighty years after Ignaz Semmelweiss had discovered the cause of puerperal fever, such an outbreak should not have happened; it was not the last. Dr. Cadham swabbed the throats of patients and staff, took blood cultures from the sick women, and grew streptococci. The maternity unit was closed for a month, and was scrubbed and disinfected; Cadham prepared an antistreptococcal serum, but it was ineffective. Sulphanilamide became available, only a year or so later, with dramatic effects.

Psychiatry By 1919, medical care for physical illness in most parts of Manitoba was comparable with that in many other parts of the western world, but psychiatry was rudimentary. There were only two psychiatrists in the province: Dr. A.T. Mathers and Dr.T.A. Pincock. Conditions had been very bad in the mental hospitals before the First World War. A survey was conducted in 1919 by Dr. Clare Hincks, then the major Canadian authority on mental health, at the request of a group of concerned Manitobans. The survey found appalling conditions. In one hospital, "some patients were badly bruised, others had blackened eyes, and many were in beds with iron gratings covering them." In another hospital, 700 patients were under the care of one psychiatrist; among them was a squad of "the roughest men [he had] ever seen." A third institution was a dumping ground for unwanted family members where one woman was kept in a cupboard for two years. One of the authors (R.E.B.) remembers an open ward in such an institution, filled with naked patients who were smeared with faeces. The war influenced opinion. As a stretcher-bearer, Dr. Pincock had seen his comrades break down under stress, and he had been near breaking

Between the Wars:The Medical School and Specialists

point himself. He felt it a pressing duty and a responsibility to help the mentally ill. The mental hygiene movement added to the pressure to treat the mentally ill as sick, not mad. Legislation formed the basis of change. The Mental Diseases Act replaced the Lunacy Act in 1920, and more money was allocated for the care of the mentally ill. Patients could now be admitted voluntarily to a mental hospital rather than formally committed. In 1919, the Winnipeg Psychopathic (later Psychiatric) Hospital was opened, a small thirty-two bed unit on the grounds of the Winnipeg General Hospital and sharing its diagnostic facilities. It was intended for the early, "recoverable," patient, in the belief that many patients would leave after a fairly brief stay and go back into the community. This worked at first; only eight percent of the patients were involuntarily committed, and up to forty percent returned home. It was the beginning of community psychiatry. But the hospital was too small; it was overcrowded with a bed occupancy rate up to ninety-nine percent, and it was expensive. At the same time, the facilities in the older asyla were improved, and training was improved; two-year psychiatric programs were started for nurses, and shorter courses were set up for aides and attendants. Medical students now had part of their training at the Psychopathic Hospital. By 1930, mentally ill patients, at least in the Psychopathic Hospital, were regarded as being in a hospital rather than in a custodial setting and were looked after by trained staff. Further improvements in organization included travelling outreach clinics, and a teaching Department of Psychiatry at Winnipeg General Hospital. In the 1930s, treatment of the mentally ill was drastic but only sometimes effective; shock treatment included the drug metrazol, electroconvulsive therapy, insulin coma, and, from the late 1930s,lobotomy so-called psychosurgery. The milder and ancient treatments persisted: hydrotherapy, and wet and cold packs. Restraint was now milder, except under extreme circumstances. Nevertheless, many schizophrenics and severe depressives still languished in asyla for long periods, often in poor conditions. Effective antidepressives and antipsychotics came later.

Medical Celebrations The Manitoba medical community was now firmly established, with strong links to medical organizations elsewhere in the world, and in particular within the British Empire, on which the sun still set with reluctance. The British Medical Association meeting in Winnipeg in 1930 was a grand occasion. A Winnipeg doctor, Dr. William Harvey Smith, was elected President of the British Medical Association. Traditionally, the Association met

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118 Chapter 6 in the president's home town. Winnipeg, and particularly medical and socially aspiring Winnipeg, felt that after sixty years it had arrived. Despite the Depression, there was extensive preparation and considerable expenditure. There was concern over the formal style of letters to titled persons. Delegates were billeted in private homes, and there were not a few Winnipeggers who wanted titled guests but not people with dark skins. Three thousand doctors attended civic receptions and lectures, and perhaps listened to an address by the Archbishop of Rupert's Land, in full regalia. The problem that engaged most of their attention was poliomyelitis. Doctors love to parade in academic robes: fancy antique clothing. This time, they strutted into "a skating rink turned into an auditorium, the arches gay with green and white bunting, the walls hung with flags, a platform crowded with dignitaries in scarlet robes or in sombre morning attire." Honorary degrees were conferred on well-known British doctors: Lords Moynihan and Dawson and Sir Farquar Buzzard. Dr. J.D. Adamson read the names and branches of the delegates from elsewhere in the Empire as they advanced to the platform; they were from Mesopotamia, Assam, Punjab, Tasmania, New South Wales, New Zealand, South Africa, and the United States of America. "Who, sixty years ago, would have predicted that such a meeting as this could have been held on the banks of the Red River?" The doctors went in formal procession along Broadway, dignified, splendid in bright academic garb, halting at the Cenotaph, where the president laid a wreath. A bugler played the "Last Post." Under a clear blue sky they met a delegation of Indians, with their red blankets, eagle feathers, peace pipes, and wampum. Automobiles by the thousands lined the roads as the King-Emperor's physician met a Cree chieftain. The participants left at midnight; the Winnipeg hosts in evening dress went to the station platform at midnight to bid farewell to their guests as they clambered into the long line of sleeping coaches. As the train puffed away, hands waved, and there was a chorus of goodbyes: "See you in London 1932."The British Empire was still alive, and Manitoba was red on the map. As an encore of a slightly different kind, the Manitoba Medical College celebrated its jubilee, between 14 and 19 May 1934, in a week of lectures and clinical seminars. Again, the delegates discussed the medical perplexities of the time. They puzzled about how to treat infections, septic hands, and above all tuberculosis; they worried about the best treatment for fractures and acute abdominal emergencies; they were perturbed over the best

Between the Wars: The Medical School and Specialists 119

therapy for obstructed labour and toxaemia of pregnancy. The Friedman toad test for pregnancy had just come into use, as had radium therapy for carcinoma of the cervix; hypertension, and its effects on the arteries, were now causing concern, though coronary artery disease had not yet achieved the top of the bill. Many of the early students, and some of the early teachers, were still around, and they believed with some cause that their fiftyyear-old medical school was doing the province some good.

The Winnipeg Doctors' Strike A doctors' strike would probably have been anathema to the generation before.The doctors' attitude was new and a harbinger of things to come. In the 1920s, before the Depression struck, doctors had not been too badly off. The patient paid the doctor and the hospital directly, with the exception of a few schemes like the one run by the railways. The doctor was usually paid, but debt collection was sometimes a problem. Dr. Bjornson discussed the problem of debt collection with his students. He told them that patients were "often quite well-to-do but relatively poor. Their car has more cylinders than yours, they belong to a fashionable golf club, and they take their families to Florida for the winter. This naturally takes a great deal of money, so that when your account comes in, they find themselves rather pinched and volubly explain how poor business has been and how tardy collections are, and that you would do them a great favor by letting this stand until things pick up." Many doctors treated indigent people without fee. One old man recollected being treated for a crushed foot by Dr. Alexander Gibson in the 1930s; the patient was an agricultural labourer, and there was no fee. Medicine was a competitive profession, and the first years were often thin, but most doctors eventually achieved comfort if not wealth, and some specialists, notably surgeons and obstetricians, became wealthy. Doctors spent their earnings on pleasant, large houses, concerts, ballet, opera, recordings of classical music; in the 1930s many doctors acquired radios. Motor cars liberated city dwellers from the city to cottages on Lake Winnipeg or the Canadian Shield lakes. Dr. Lennox Bell remembered many years later how one band of medical friends had "acquired a choice property on the south shore of Fox Lake where the rocky road from the station ends. He remembered not just the chance to loaf and swim in pleasant surroundings, but . . . the influence and tutelage of the two most stimulating men I have ever known.These remarkable personalities were my father, Gordon Bell, and Doctor Edward Montgomery." Manitoba physicians were acquiring tradition and a corporate myth.

120 Chapter 6 The Depression changed many things.Times were hard for most people; lawyers were selling shoes, and many doctors were not far from the relief line. At this time a doctor charged one or two dollars for an office visit, two or three dollars for a house call; fifteen dollars for maternity care, twentyfive dollars for surgical care. There was competition for patients, and doctors preferred patients who belonged to such organizations as the Independent Free Loan Association and the Hebrew Sick Benefit Association, who paid part of the medical bills for their members. After 1929, bills were low, and sometimes, particularly in the country, payment was accepted in kind. Relief for the indigent during the Depression was organized by the Relief Commission, who provided food tickets in return for wood-cutting. The doctors, however, were not being paid for attending the indigent, and many became very hard up. After a year of unsuccessful complaint to government, the Winnipeg Medical Society, the doctors' professional organization, finally took action. In March 1933, nearly all (129/132) Winnipeg hospital staff doctors signed a document saying that they would not attend hospital patients who were receiving unemployment relief but would attend indigent patients not on relief, those referred by another doctor, or emergencies. The decision was almost unanimously (320/340) ratified two weeks later by a mass meeting of medical practitioners in Greater Winnipeg. The meeting empowered a Special Relief Committee to negotiate with the aim of preventing the city council from hiring additional full-time or part-time doctors on salary and force the acceptance of a fee-for-service plan. It was a strike, but the doctors' position was a nice balance of economics and medical ethics.They felt compelled to attend patients in an emergency and to care for their own former patients, but they believed that, if the City gave financial relief to the patient, it should pay the patient's doctor. All other relief recipients in hospital clinics, hospital wards, or doctors' offices should be turned away. After some months, the City gave in and set up the Greater Winnipeg Medical Relief Plan, whereby the doctors were paid at half the minimum fee schedule.The doctors celebrated at a party in the Fort Garry Hotel. Dr. Corrigan described many years later how Dr. Gordon Fahrni conducted an orchestra of physicians, while one of their number performed as a "bellydancer who was billed as Madame Fluff-Fluff, who rendered a routine of lascivious gyrations, being naked except for little more than strings of beads strategically draped in a tactical arrangement."The press was sniffily cr cal next day.

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There was much further haggling over the exact sums to be paid, and unsuccessful approaches were also made to both the federal and provincial governments. Nevertheless, the Greater Winnipeg Medical Relief Plan endured in one form or another for almost thirty years. When the doctors went on strike, they did not guess that they were helping lay the foundations of state medicine.

Distant Drums As the 1930s passed, change was afoot. Radical changes in the transport of people and ideas was evident at the beginning of the decade. People still trailed across the country to Ottawa or Toronto by train, yet on 16 February 1931 a Western Canada Airways plane made a record trip to Central Manitoba Mines at Bissett and brought out a severely injured miner. At 3:00 p.m., word was received of the injury, and at 5:40 p.m. the plane was back at Stevenson Field after a 300-mile trip. A waiting ambulance rushed the miner to St. Boniface Hospital; he was found to have two skull fractures and was operated on immediately. Dr. Lynn Falconer of Central Manitoba Mines accompanied the patient and rendered first aid en route. Only one day later, in the early morning of 17 February, a plane from Winnipeg, battling through a foggy prairie night, landed at Moose Jaw, bearing serum that was rushed to a patient with gas gangrene in Gravelbourg Hospital. The airplane signified change in less happy ways too. Quite early in the decade, bombers were assaulting Shanghai and soon attacked refugees on the beaches at Guernica. The drum roll had started. Radio broadcasts had transmitted the sound years before of Nazi feet marching into the Rhineland. By 1938, most people had guessed that there was going to be another major war in Europe. J.W. Dafoe's warnings in the Free Press had reminded Winnipeggers that they could not avoid the issue. The medical system, if it could be called that, had been strained in the First Wo rid War by the problems of dealing with casualties from the western front, admittedly mainly convalescent. This time, there were dark fears that it would be worse because of aerial bombing. By the end of the period between the wars, the scenes had shifted. Several discoveries had rendered it easier to treat disease successfully. Insulin for diabetes, liver extract for pernicious anaemia, and sulphonamides for bacterial infections presaged the revolution to come.There were still problems; paramount among these were poverty and malnutrition, even in the world's breadbasket, and failure to organize medicine so that care was available and affordable for all. Hospitals were still privately funded, charitable organizations. Out-patient departments were still being developed, and there

122 Chapter 6 was still inadequate provision for the continuing education of the physician. Tuberculosis was as great a problem as ever. By 1939, many of the players, too, had changed.The professors of medicine, surgery, and obstetrics were all newly appointed, although cast in the same mould as the old. Boyd and Grant had gone. David Stewart, who had been behind the campaign against tuberculosis, was dead. A new power centre had appeared in the clinics. Sulphonamides, the first of the antibacterials, had appeared. Medicine was becoming more effective, but it was clear that the future lay with research-based scientific medicine. The man who more than any of the dominant figures of the 1920s and early 1930s had been a research worker as well as a writer of books was still there: A.T. Cameron, brooding, crotchety, cigarette-bound. He was dissatisfied with the lack of research, but it was not until the tempest of war had blown itself out that major changes happened.

Return to Hell: The Second World War

7 The Second World War was not unexpected. The drums had been beating for ten years. The Japanese invasion of China, the Italian invasion of Abyssinia, the feet of Hitler's Wehrmacht marching across the Rhine bridges, the Spanish Civil War, and, as momentum gathered, the invasion of Czechoslovakia and Poland. Canada this time took a mature decision to enter the war. Manitoba became a centre for training aircrew and for the manufacture of munitions. The Winnipeg garment industry largely converted to making uniforms. Despite the anxieties and shortages, war generated employment. Winnipeg during the war was altered by the absence of its young men and by the presence of numerous servicemen, mainly from other Commonwealth countries. Food was rationed and many household commodities were scarce. People clustered around the radio for news, especially of Canadians in Hong Kong, Dieppe, Sicily, Italy, Normandy. Health services were under strain due to staff shortages and the need to provide convalescent care for wounded servicemen. The epidemics of poliomyelitis continued, and in 1941 there were epidemics of poliomyelitis and encephalitis. Doctors were overworked; about half of Winnipeg doctors volunteered for military service, leaving their practices. There was a military hospital in Tuxedo; a national military procurement and assignment board ensured adequate medical enlistment in the armed services, and maintenance of essential medical services at home. The hospitals and the medical school were seriously short of staff. Almost all the students of the classes of 1939, 1940, 1941, 1942, and 1943 enlisted, as did those in the class of 1944, which had been speeded up to graduate early because of the lack of doctors.They were paid, given uniforms, and received basic military

124 Chapter 7 training, which was compulsory from 1942.They were not called up until they completed the medical course. The men received ninety dollars a month, but the women, in the Canadian Womens' Army Corps, not the Medical Corps, only thirty-three dollars a month. On graduation they automatically became lieutenants, and the pay differential disappeared. Dr. Ellen Taylor, who was in charge of Winnipeg infectious disease hospitals, wrote of the problems of caring for infectious disease in war time: In the civilian world the scarcity of nurses, the closing of the smaller hospitals with the consequent over-crowding of the larger and the neverceasing cry against absenteeism force the average physician to pause and decide how much of the elaborate medical set-up can be discarded with safety. Already he has bowed to the loss of the special nurse, dainty meals and a long convalescence for the majority of his patients and has adapted himself to the untrained helper, rationed food, and the demand for a quick return of his patient to work.

Canadians served in many theatres of war. Several of the Winnipeg physicians who served in the SecondWorldWar left striking stories, from Normandy, from Italy, from Hong Kong. Their stories are only examples that illustrate the experiences of many and tell what sort of men and women were involved in the reshaping of medicine that followed the war. They trained for the European theatre in Britain, where Number Five Reserve General (Canadian) Hospital was set up in September 1939, a hospital about the size of Winnipeg General Hospital at that time. In Normandy, Dr. John Hillsman, an American surgeon who practised in Winnipeg, was attached to the Number Eight Canadian Field Surgical Unit. After the war, he wrote: We operated in Secqueville for ten days and covered the attack that took the City of Caen. During those ten days we changed from mere soldiers to war-wise veterans. We saw the tragic sights from which we were never to be free for ten long months. Men with heads shattered and grey, dirty brains oozing out from the jagged margins of skull bones. Youngsters with holes in their chests fighting for air and breathing with a ghastly sucking noise. Soldiers with intestines draining feces onto their belly walls and with their guts churned into a bloody mess by high explosives. Legs that were dead and stinking - but still wore a muddy shoe. Operating floors that had to be scrubbed with lysol to rid the theatre of the stench of dead flesh. Red blood that flowed and spilled over while life held on by the slender thread of time. Boys who came to you with a smile and died on the operating table. Boys who lived long enough for you to learn

Return to Hell: The Second World War 125 their name and then were carried away in trucks piled high with the dead.

Dr. Charles Walton wrote of similar conditions in Sicily, complicated by heat (a temperature over ninety degrees Fahrenheit, with near to 100percent humidity) and by water shortage, malaria, and dysentery. Mepacrine turned their skins yellow. Dr. Cecil Corrigan, a distinguished Winnipeg surgeon, described how in Sicily in the latter months of 1943 the precious new penicillin first became available.Two Canadian soldiers each had both legs amputated after a shell burst nearby; sepsis set in, and two dozen twoounce phials were flown in by a Mosquito bomber from England. It saved both men; at the bottom of the package lay the bill: $500,000. There were other hells. Dr. John Crawford, medical officer to the First Battalion, the Winnipeg Grenadiers, wrote of his experiences in Hong Kong and in a prisoner-of-war camp, where a hospital was set up in a small leaky warehouse, black with flies from the adjacent garbage dump and from the unburied bodies that stank on an adjacent beach: We remained at North Point Camp until September,'42. Dysentery ravaged the camp continually. Pellagra and beriberi began to manifest themselves in March, and continued to become more severe. In August, we began to discover cases of Diphtheria... .Almost everyone had avitaminosis in some form or another. By the end of October, I had admitted 283 cases of diphtheria to this hospital, as well as 198 cases of dysentery and 47 cases of avitaminosis. On the 3rd of October I managed to purchase a little antidiphtheritic serum through the agents of the black market. On October 5th I was issued with a further small supply by the Japanese. One of the most difficult decisions we ever had to make now faced us.That was the decision as to which of our numerous cases of diphtheria were to receive serum and which were not. We had only a very little. All cases could not have it, some must do without. We felt that such a power over life and death should be the prerogative of the Deity, but at that moment He seemed to have forgotten us. Our final decision was simple, and I believe fairly sound. Any man who had shown membrane forty-eight hours before serum became available, did not receive any. We gave serum only to fresh cases, where we felt a small quantity might do some good. Our maximum dosage at that time was 2,000 units, our usual dosage 1,000 units. And this minute quantity saved life.

In October 1941, forty-one Canadians died, and other allied prisoners were dying at the same rate. There were two or three funerals every day.

126 Chapter 7 Dysentery, malaria, pellagra, beriberi, and all combinations of them were rampant: the neurological changes resulted in numbness, severe pain, paralysis, deafness and blindness. "But what bothered most of us more than anything else was the over-crowding, the complete lack of privacy." When the survivors returned to Winnipeg, it took long years to nurse them back to health; veterans were still complaining of neurological symptoms in the 1970s, many unable to obtain appropriate pensions. Civilian missionary doctors, too, suffered at the hands of the Japanese. Isabel McTavish, who graduated in 1915 (the fifth woman to earn an MD from the University of Manitoba), left right after graduation for China and on a visit to Winnipeg in 1937 told the Winnipeg Tribune of her experiences in a darkling, uncertain world. The only woman doctor in the Honan mission hospital, she practised medicine, surgery, obstetrics, paediatrics, and child health, trained local women in nursing, and taught in Cheeloo University. The countryside was isolated, the villages were scattered, and secret societies abundant. Bands of brigands would capture people, Chinese and foreigners alike, and hold them for ransom; often there was no ransom and another body would lie in the ditch. The Japanese eventually captured her in 1940, and she spent three years in a Japanese prison camp. Isabel McTavish was a medical missionary for thirty-five years and returned to Winnipeg to retire in 1950. Surgeons were better able to keep dreadfully wounded casualties alive than in the First World War. Dr. Hillsman wrote: "This man hated me A shell had burst in front of him. Both arms blown off just below the shoulders. One thigh shattered with a muddy shoe holding a dead foot up against his side.The other leg hanging by a large tag of skin. All had to be removed. God only knows how he ever left the table alive. . . . Now he lies a lump beneath the blanket. No legs. No arms.Just a body with a head on one end. ... His whole future was in a Veterans' Hospital, condemned for life, being carried around in a basket." Rehabilitation, often hard, was sometimes impossible. By the end of the war, there were strains between those who had answered the call of Empire and Dominion and those who felt that their duty lay at home, sometimes because they saw Empire and Dominion in a different light.The physicians left behind were the older ones, the average age was about fifty-four, and they were grossly overworked. Rationing and controls irked, even in relation to simple tasks like maintenance of a motor car. They felt that they, too, had served. Those who were abroad could not help but wonder sometimes whether there would be openings for them when they returned.

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Medicine learned more in the Second World War than in the First. By the end of the Second World War, physicians knew the importance of replacing body fluids in severe trauma, and blood transfusion was practical and semi-routine. Many infections were preventable and treatable, and many physicians had experience of arranging the kind of highly organized emergency medicine and surgery that eventually became a regular part of large hospitals. The control of infection had given many surgeons the type of experience of traumatic thoracic, abdominal, and intra-cranial surgery that led to major advances in peace time. As before, a cadre of experienced physicians emerged, forged in the same fire and slightly contemptuous of those who by choice or chance had escaped the fire. They were similarly bonded and controlled medical institutions for a generation. War had driven medical research into transfusion of blood and other fluids, into prevention of malaria, into treatment of infections and production of antibiotics in commercial amounts. Burned fighter pilots needed skin grafts; the results were modern plastic surgery and cellular immunology. The biological revolution in the 1940s was led from the United States and staffed in considerable measure by European migrants, often Jewish, who had been fleeing Nazi barbarity since the thirties. The doctors who returned from war had acquired valuable international contacts. The stage was set for the postwar boom in medical research. Equally important, many ordinary citizens in uniform had come to expect competent free medical attention. If such care had been available in war time, why not in the piping days of peace? Thus, the war was a significant factor in the evolution of medicine.

Royal Canadian Army Medical Corps stretcher-bearers, near Enna, Sicily, 1943 (NAC).

Number Five Canadian General Hospital, Royal Canadian Army Medical Corps, Syracuse, 1943 (NAC).

King GeorgeV Hospital,Winnipeg, in the 1950 flood (PAM).

The 1953 poliomyelitis epidemic. A recovering patient in a wheelchair reads to children in respirators. Recovering patients formed a band called the Merry Menders, to entertain their fellows (UMLA).

The solution to the problem: oral vaccine, 1963 (UMLA).

Department of Pathology, Winnipeg General Hospital, 1918 (HSCA).

Department of Clinical Biochemistry, Health Sciences Centre, 1997 (HSCA, courtesy J. Dalton).

They hunted for shadows: mobile x-ray clinic, 1963 (WCPI).

Joe Doupe, physiologist, about 1955. Premier DufFRoblin, architect of Manitoba medicare, being given a tuberculin test, 1964 (WCPI).

Peering into a glass darkly: Lennox Bell, internist, and Ross Mitchell, obstetrician-historian, 1966.

Elinor Black, obstetrician.

Jack Hildes, Winnipeg Tribune Man of theYear, 1953.

Reuben Cherniack, respirologist.

Jack Wilt, medical microbiologist.

Bruce Chown, paediatrician, pathologist, discoverer, about 1965.

Harry Medovy, paediatrician, 1968.

John Gemmell, internist.

Surgeons look back: Gordon Fahrni, P.H.T.Thorlakson, and M.R. MacCharles at Faculty of Medicine Centenary, 1983.

Mark Nickerson, pharmacologist.

John Bowman, paediatrician, with two children who survived Rh incompatibility, 1986 (HSCA).

Harold Rice and electroencephalograph equipment, Winnipeg General Hospital, 194243 (courtesy R. Hay).

Electrocardiograph unit, Fort Osborne Military Hospital, 1944 (PAM).

No greater love hath any man than this; repair of a congenital defect in a child's heart while cross circulation is established with the parent (from Cohen, 1955).

An early open heart operation, performed at St. Boniface General Hospital, 1959.

The patients and the gadgets: monitoring after heart surgery, St. Boniface General Hospital, 1979 (UMLA).

The specialists come together, emergency care, Health Sciences Centre, 1979 (UMLA).

Neonatal nursery, St. Boniface General Hospital, 1970 (UMLA).

Overcrowding at Winnipeg General Hospital, 1954.The overcrowded open wards have been replaced by overcrowded corridors forty years later (UMLA).

Lord of the rings: Arnold Naimark, physiologist, dean of the Faculty of Medicine, and president of the University of Manitoba.

Guardian of the frontier: Henry Friesen, physiologist and research administrator, president, Medical Research Council of Canada (MRC).

Medicine after the Second World War

8 It was 1945.The bonfires blazed; the war was over. People danced in the streets, and the warriors, or most of them, returned home. Winnipeg in 1945 was a city of 230,000 people, with a mixed industrial base. Its isolation was reduced as progressively the Trans-Canada Highway snaked across the country and air transport became routine. Winnipeg became a hub for transport, business and finance, and diversified manufacturing. While economic growth was slow, particularly after the election of Duff Roblin as provincial premier in 1958, things happened. The development of social services and later, in the 1960s, medicare generated jobs, and the apparatus of provincial government, ever more complex, gave employment. Highrise expansion of the city core provided premises for ballet, opera, theatre, orchestra.The suburbs spread as a harbinger of the consolidation of Greater Winnipeg in 1972. In 1945, medicine was more effective than it had been twenty years before. The discovery of sulphonamides had started the temporary conquest of infectious disease, but infectious diseases were still the main health problems, notably pneumonia and tuberculosis. Cardiovascular disease was now a major cause of death. Abdominal surgery became fairly safe; insulin had rendered diabetes melritus less acutely dangerous, and pernicious anaemia was treatable. Vitamin deficiency diseases such as pellagra, beri-beri, and scurvy were seen in the returning prisoners of war from Japanese camps who were convalescing at Deer Lodge Hospital but had largely disappeared in peace time because of better diets and vitamin concentrates. Epidemics of encephalitis and poliomyelitis stimulated virological services and rehabilitation medicine. Neurosurgery was still an occasional venture, thoracic surgery was developing, but the heart was still beyond the surgeon's reach.

130 Chapters Maternal mortality had at last fallen, but infant mortality was still high; the first attempts to deal with haemolytic disease of the newborn were being made, but many premature babies died. Infection in infancy was still a major problem and congenital heart disease a major cause of death in children. Psychiatric services were limited. The return to peace was brief; the Iron Curtain dropped across Europe. The period thereafter was dominated by the financially ruinous arms race, which led to some technological advances in medicine, counterbalanced by the poverty and malnutrition engendered indirectly by spending on arms. Within Manitoba, poverty and squalor persisted, particularly among aboriginal communities, in single-parent families, and among old people.

The Medical Revolution The greatest achievement of medicine in Manitoba after the wars was for physicians to keep up with the medical revolution. Just keeping up was success in itself and required prolonged dedication. Young physicians were driven by new visions of success, both for their patients and for themselves. It was a competitive business; the meetings, the postgraduate courses, the reading, the travel, and contact with colleagues elsewhere all took time and effort. Many senior physicians were too busy or too tired to travel, but the generation returning from the war ventured afar with vigour and competence. At first they went the long weary miles by train, but soon the new and relatively cheap airways reduced isolation and gave speed and comparative ease to their journeys. After 1945, physicians had to be involved in research to keep up with modern advances in diagnosis and treatment. Since 1945, the great success of the Manitoba biomedical community is that it has kept up, and, by 1983, medicine in Manitoba was generally as good as anywhere in the world. Many went south, to the Mayo Clinic, to Minneapolis, and to other American centres; others went east to Toronto, which has always influenced and beckoned.The doctors knew that if they did not go, the patients would, when they could not find what they wanted in Manitoba. As time went by, fewer Manitoba doctors went to Britain for further training, but after 1948 there was a flow of immigrants from the British National Health Service, some embittered but most bringing reports of the systematic organization of medicine and of new or improved concepts and techniques. As members of the biomedical community of the Western world, Manitoba physicians shared in and contributed to these advances, usually by following rather than leading; but the Manitoba medical school was the oldest and, at least until the 1970s, the leading school in western Canada.

Medicine after the Second World War 131

One shining instance of Manitoba research was the virtual abolition of haemolytic disease of the newborn, a major discovery made largely by a small group in Winnipeg.

The Ringing Grooves of Change After 1945, change progressively accelerated. Dying had been cheap; the cure was often expensive and the prolongation of life ruinously expensive, particularly during the last few months of a patient's life. Hospitals, once places to die in, became places where there was a good chance of cure, where complex and expensive apparatus was at hand, and where research went hand in hand with cure and had to be planned for. Hospitals had to advance to keep up with medicine. As in many Western countries, the state had to pay; the money came at first in a trickle, but by the 1960s, there came a good flow, if not a flood. By the late 1970s, there were signs that the well might run dry, or at least that its flow would be carefully monitored. Change was to be impelled from many directions.The provincial government in 1945 realized that change was needed in health care. Within the University there was a small but powerful lobby for more research; the clinics, notably the Winnipeg and Manitoba Clinics, were dominating specialist medicine. Several main architects of change stand out among many. PaulThorlakson, surgeon, was a power behind the development of polyclinics and the Health Sciences Centre. Joseph Doupe was a physiologist who stimulated medical research. Lennox Bell as dean, on one influential committee after another, fostered the development of the medical school. Harry Medovy, paediatrician, improved child care. Jack Hildes, physician, brought modern medicine to northern Manitoba. Morley Cohen and Colin Ferguson developed cardiac surgery. It did not happen all at once. Between 1945 and 1950, the returning veterans were settling back to peace and their places in medicine, and the key players of the next era were sitting down at the levers and learning to pull them. In the 1950s, research was being established, to grow and consolidate in the 1960s. Public funding of the new, expensive medicine was improving, culminating in medicare in 1969. Late in the 1970s, booming research and improving medicine began to strain the purse strings, and by the early 1980s there was financial constraint. The doctor's role changed. Physicians had been personal counsellors, often unable to cure; now they gained the ability to manipulate patients' physiology and biochemistry, often before serious disease was manifest. Hospital accreditation developed in the 1950s, and doctors had willy-nilly

132 Chapters to accept greater accountability and surveillance.The hospital accreditation committees and the medical staffs of accredited hospitals ruled in 1961 that every doctor must call in a specialist consultant in all cases of critical illness. The nature of the consultation changed; Dr. Vaisrub, editor of the Manitoba Medical Review, described the old-style consultation, as a formal, "awe-inspiring event." He went on to say: The attending physician and the consultant would arrive at the bedside simultaneously, and after an impressively thorough examination often performed within the sight of awe-struck relatives, and a subsequent lengthy discussion in camera, they would apprise the parties concerned of their conclusions, and with the air of great actors departing the stage after a superb performance they would take leave together in a cloud of dignity. . . . The consultant too was different. Not necessarily a specialist — a sine qua non in a modern mandatory consultation which recognizes only specialists as bona fide consultants — he was as often as not a man with a background of knowledge and skill not dissimilar from those of the attending doctor.

Paying the Piper: The Evolution of Medicare Sickness in the past usually meant, at the least, financial worry and often penury for the patient, who had to pay directly both hospital and doctor. Medicine in 1945 was largely funded the old way. Doctors still made their living by direct billing to the patient. While there were exceptions, physicians were on the whole altruistic. The rich paid well, the average patient paid a moderate fee, and the poor were charged little or nothing; most doctors made an adequate living, a few were well off, and others hard up, particularly in times like those of the recent Great Depression. The Winnipeg General Hospital was still staffed largely by physicians and surgeons who earned their bread by treating both rich and poor, billing the rich and treating the poor gratis. It developed into an integrated medical teaching centre with facilities for all kinds of patients on the one medical campus with closely related basic science and library facilities. While Winnipeg medicine was never richly endowed by continental standards, for a short time in the 1970s, there was enough funding. The new medicine and the new research were expensive; the patient was increasingly unable to pay. Systems of funding had to develop. First came private insurance, mainly doctor sponsored: the Manitoba Medical Services Incorporated (MMS). Public funding followed: medicare. Social conscience stirred; many of the public realized that in a healthy society the rich cannot live in the middle of dearth.

Medicine after the Second World War

As medical diagnosis and treatment became more effective, the relative cost of hospital care rose. Hospitals, particularly modern teaching hospitals, became very expensive places. The Second World War was a watershed in the control of public health. In 1945 came major change. The Health Services Act was passed, implementing the Manitoba Health Plan for health unit services including laboratory and x-ray diagnostic services, and the establishment of medical care districts and hospital districts.The change was to be gradual and voluntary and the cost covered by the Manitoba Health Plan. As the years passed, new health legislation affected nearly every aspect of human life. The planners envisaged a prepaid family physician service; the physician's income might be provided by salary, capitation fee, or direct fee for service. To provide the medical and social apparatus of a modern and humane state, over the next forty years provincial legislation progressively encompassed hospitals and local health centres, laboratory and x-ray facilities, public health nursing, health education, some dental services, psychiatric care, care of the mentally handicapped, pensions and housing for the elderly, and shelter, food, and clothing for the indigent. From conception to cremation, the hand that rocked the cradle dug the grave. In 1956, the federal government recognized the need for universal coverage by passing the Hospital Insurance and Diagnostic Services Act, which provided cost-sharing for provinces prepared to set up and administer a universal, portable hospital plan. Manitoba conformed in 1958, setting up the Manitoba Hospital Commission to administer the plan. The next problem was to find an efficient way of paying the doctors. Prior to the establishment of health-care plans, illness often meant financial hardship for the patient, and serious illness could lead to destitution. Many doctors were hard up because of unpaid bills, but there is no record of a physician refusing attention because a bill had not been paid; on the contrary, most physicians treated the poor gratis, often at their own expense. Dr. Alexander Gibson, an orthopaedic surgeon, successfully operated upon one man in the 1930s for major trauma to his legs.The patient recollected many years later that Gibson would not accept payment and indeed sent him off with a twenty dollar bill. Others were not so fortunate, and particularly in rural areas people died without medical attention because they felt that they could not afford to call a doctor. As a partial solution in rural areas in the 1930s, doctors were recruited and paid a salary as "municipal doctors." Many doctors were greatly in favour of this scheme; others pointed out that it was prone to abuse and led to overwork and underpayment for the doctors.

133

134 Chapters During the 1930s, an urban general practitioner, Dr. E.S. Moorhead, proposed a scheme whereby patients who subscribed to the plan paid a premium to an agency that in its turn paid the doctors. A group of doctors applied for a charter, and in 1938 the provincial government created MMS as an experimental mechanism.The members of the Winnipeg Firefighters Union subscribed, and during the war years, between 1939 and 1945, they took part in a pilot project. The scheme expanded after the war, but initially only general practitioners were involved; as specialism developed, the specialists had to be brought into the scheme, and they had to be attracted by a fee larger than that given to their general practice colleagues. Doctors in the scheme were paid by the MMS for medical care provided to its subscribers. They were not able to charge the patient any additional fee. Gradually, all doctors came to have an increasing number of MMS patients. The board of the MMS comprised about thirty members, of which at least sixteen were medical. The rest were subscribers or representatives of business and labour. By the mid-1950s, eighty-five percent of Manitobans in rural areas and ninety percent in urban areas were enrolled in the plan. There were conflicts; the doctors wanted more money and control of benefits and the patients wanted lower premiums and increased benefits. The premium income failed to keep up with costs. It had been intended to pay the doctor ninety percent of an approved schedule payment; the scheduled payments became inadequate, and ultimately only sixty-seven percent was paid. When a patient visited a general practitioner in the office, the doctor received three dollars, not a princely fee. After studying similar schemes and problems in other countries, in December 1964 a special general meeting of doctors was called at the International Inn in Winnipeg. Over 600 of the approximately 700 practising physicians in the province attended.The doctors voted to accept the scheme, and significant change followed. Doctors would be allowed to opt out, patients would be allowed to assign benefits to their doctors, the benefit target was set at eighty-five percent of the Manitoba Medical Association fee schedule, and extra billing was limited to fifteen percent. The position for Manitoba doctors improved, but meanwhile national changes were afoot. In 1961, in response to pressure from the Canadian Medical Association, the federal government appointed a royal commission, chaired by Justice Emmett Hall, to enquire into the delivery of healthcare services; it recommended in 1964 the provision of a comprehensive universal health-care plan administered by government and portable across Canada.The federal government in 1966 passed the resultant Medical Care

Medicine after the Second World War

Act, guaranteeing a fifty-fifty sharing of national per-capita costs with provinces that met federal criteria. In Manitoba, Premier Duff Roblin immediately called a meeting of Manitoba Medical Association officials and members of his government, and an agreement was drawn up in Roblin's office. The plan would be universal, portable within Canada, comprehensive, and administered by the Manitoba Health Services Commission. Manitoba doctors had to opt into the plan if they wished to be paid by it; if they did not, they were regarded as having opted out. The plan benefits were then paid to the patient, and the doctor could collect from the patient. The doctors escaped from the always difficult and sometimes unpleasant task of collecting their fees. The price they paid was accepting that their paymaster, the commission, was in fact their master.The benefit was a thirty-percent initial increase in average income. On 1 April 1969, Manitoba met the federal government's conditions. The Manitoba Hospital Commission, transmuted in 1970 into the Manitoba Health Services Commission (MHSC), took over the responsibility for paying the doctors and meeting hospital costs. Amid paranoid suspicion among many of the doctors, and financial forebodings among hospital administrators and the like, medicare had started. By 1971, the provincial Department of Health and Social Services oversaw a wide variety of health and social services and supervised MHSC, which funded and controlled the actual services. It was led from 1970 by Dr. James Morison. Events in Manitoba were in happy contrast to the bitter and divisive doctors' strike in Saskatchewan in 1962. After the introduction of medicare, MMS ultimately evolved into Blue Cross supplementary health insurance. The funds remaining with MMS upon introduction of medicare were used to endow Manitoba Medical Services Foundation, which has become a significant benefactor in the support of medical research and education. There were all sorts of problems. As the years went by, doctors' incomes failed to keep up with inflation. The Manitoba Medical Association could set fees, but the government through MHSC held the purse strings. The Hall Commission had recommended binding arbitration as a solution to disputes on fees between government and the doctors, but governments have been reluctant to accept the results of such arbitration and sometimes refused. Meanwhile, the federal government has been gradually decreasing the transfer payments, despite the original agreement to provide fifty-percent of the cost. The provinces toed the line, eager for the carrot of federal subsidy. By 1971, all provinces had adopted hospital and medical insurance programs

135

136 Chapters that met the basic conditions set out by Parliament; services were to be comprehensive, access reasonable, and coverage universal and portable from province to province. In 1977, increasing medical costs led the federal government to abandon fifty-percent cost sharing; the resultant reduction in federal transfer payment caused problems for the poorer provinces like Manitoba. A possible solution was to allow the doctor to bill above the scale, so that the patient still paid something directly, and to impose hospital user fees. In 1983, the Canada Health Act banned both expedients.The initial problem, how to pay for good health care, remained and has become even more difficult over recent years. The changes proceeded for many years, and the money was spent, often without comprehensive planning, until around 1973 when the University of Manitoba Department of Social and Preventive Medicine changed its aims and, under the leadership of Dr. David Fish, evolved into a centre for the study of the improvement of the health of the province. What worked? What did not? The MHSC controlled the funding of health care in the province and was able to provide statistical data. By the 1980s, an investigative centre for health policy was analyzing the data and providing advice for the future, sometimes cautionary, sometimes encouraging. There was a progressively increasing attempt to provide adequate long-term care, although chronically ill people still occupied expensive acute hospital beds for too long, as they still do. The new society was, at least for a while, a better and a kindlier society, but it cost money. Many public servants planned and worked devotedly to improve health care, notably Dr. George Johnson. Johnson graduated MD (Manitoba) in 1950 and practised as a family physician in Gimli. He was elected to the provincial legislature in 1959 and as minister of Health presided over the development of the Manitoba Hospital Plan, the Manitoba Hospital Commission, the development of northern health care and the provision of free poliomyelitis vaccination. After retiring from the Legislative Assemby, he became deputy minister of Health, and finally lieutenantgovernor. He was the local founder of health care, a man very much in the right place at the right time.

The Evolution of Hospitals and Clinics In 1945, Manitoba hospitals were not ready for the changes that were to come. One, the Winnipeg General, was run by a board that had some pretence of being able to tackle the problems. By 1975, the main hospital had evolved with many strains into a largely academic institution, the Health

Medicine after the Second World War 137

Sciences Centre; the specialist hospitals for children, women, respiratory and psychiatric disease, and for rehabilitation, had been incorporated, with varying degrees of reluctance. The other hospitals were organized largely by separate religious organizations, with a secondary and variable degree of commitment to academic ideals. St. Boniface Hospital in 1945 was a teaching hospital in the sense that medical students had been taught there for many years, but there was little research. By 1975, it had taken a big step towards true academic status by setting up a research foundation. There were persistent tensions between St. Boniface Hospital and the Faculty of Medicine, ostensibly mainly in relation to academic status funding; it was often personal and ultimately not unrelated to the religious ownership of the hospital. The peripheral hospitals were left behind and did not realize how far behind they were. The hospitals in Winnipeg, like Topsy, had "just growed." A planned health service required planned hospitals. The idea of a unified medical campus in which university and hospital would twine together was appealing and had been actively promoted in the 1940s by the visionary surgeon Paul Thorlakson and others. Many conflicting interests had to be reconciled. The Children's Hospital had grown up independently and had many able staff and a most independent women's auxiliary. The idea of building a new university hospital had its protagonists in the 1950s and 1960s. This happened in British Columbia and in Newfoundland and might have been a better long-term solution for Winnipeg than the random upgrading of a core-area public hospital.Those who controlled medicine had grown up in the long shadow of the "Winnipeg General" and chose to build on what was there. Of the hospitals scattered around Winnipeg, only the General, the Children's and the Women's were close geographically to the medical school. The dream was of a Manitoba medical centre, based on the axis of the medical school and the Winnipeg General Hospital and incorporating such specialized facilities as care for cancer patients, patients with tuberculosis, women, children, and the mentally ill.There were many vested interests; no board of management likes to see its collective reason for existence merged, and no board member likes to be amputated. The process happened step by step, and the conservatives won. The decision to build around the old public hospital was an important one, heavily influenced by the powerful and conservative interest of the medical staff of the Winnipeg General Hospital.The Manitoba Medical Centre was formally incorporated in 1945, and by 1953 a joint building fund made it possible to appeal for and collect funds.The 1956 Federal Hospital Insurance

138 Chapters and Diagnostic Services Act set the national stage. By 1967 it had become clear that the projected cost was near $100 million. Finally, in 1973, an act of the provincial legislature founded the Health Sciences Centre as a new corporate entity, largely because it was the most economical outcome. During the 1960s, there was sufficient public money available for health care. Supported by a combination of locally raised money and federal and provincial government subvention, the new buildings went up, including a new basic medical science building. Old hospitals were re-housed in new buildings. Seven Oaks, a new general hospital, opened in 1982. All was well while money was freely available, but by the early 1980s the well began to run dry. The clinics, or polyclinics, evolved differently; they were organized and run by doctors, and, as public officials increasingly controlled public hospitals, doctors banded together to control their own clinics. The day of the single-handed practitioner passed early in the twentieth century; two different but not always separate pathways existed for association.The staffs of universities and of their teaching hospitals, either willingly or willy-nilly, came under the control of university and hospital departmental administration, and doctors associated freely in groups, polyclinics, which they controlled. The latter pattern developed widely in the United States and was exemplified at its best by the Mayo Clinic. The Winnipeg Clinic and the Manitoba Clinic were such polyclinics and had a great and largely beneficial effect on the medical life of the city, although there were occasional significant clashes between their interests and those of the medical school. Soon there were enough medical specialists in Winnipeg, mainly in these and other clinics.These clinics were dominated by surgeons, men with strong personalities and large earnings. The clinic surgeons controlled appointment to the surgical staff of the Winnipeg General Hospital. Fortunately, the surgeons of the 1940s often showed vision and played a large part in the development of the new health-care system.

General Practice and Family Medicine In 1945, most Manitoba doctors were general practitioners. In the mid 1940s, general practice was, at least in an organizational sense, at a low ebb. General practitioners had little representation in the training of medical students and a low social and professional standing in comparison with the glamorous specialists. MMS paid general practitioners only seventy-five percent of the fee that a specialist would receive for the same procedure. There were reasons for this; the specialists had through the Royal College

Medicine after the Second World War

of Physicians of Canada a national system for certification and later for training.The general practitioner learned on the job; the opportunities for keeping up to date were limited, particularly for the practitioner in small country places. The first step in the revival of general practice arose out of the deliberations of a Canadian Medical Association committee in 1947.The College of Family Physicians was founded in 1954 and had a Manitoba chapter. The rose by another name would smell sweeter. General practice became family medicine. Residency training positions in family practice were set up elsewhere in Canada in 1962 and a certifying examination in 1969. By 1974, there was residency training in Manitoba at St. Boniface Hospital, and in 1977 the University of Manitoba Department of Family Medicine was established. Family practice was on the way to becoming academic and being accepted as the professional equal of the specialties.The Department of Family Medicine developed a strong influence on undergraduate medical education and a firm hand on the postgraduate training of family physicians. Dr. Gary Beazley first Department head, was responsible for this important development. The exemplar of family medicine in the province is the University of Manitoba's Family Medicine Centre at St. Boniface Hospital. With access to all the facilities of a teaching hospital, it trains residents in family medicine, does research, and tries to be everything family medicine should be. It usually succeeds. The nature of family practice changed during the years after 1945. Advances in medicine, particularly the discovery of antibiotics, made it more often possible for the family doctor to cure. Advances in diagnostic techniques made it more desirable for the patient to see the doctor in an office or clinic with good adjacent radiologic and diagnostic facilities.The home visit by 1983 was uncommon, almost a thing of the past. As referral to specialists became usual in serious disease, family physicians developed a new role, as patient advocate, to advise their patients on making appropriate choices and occasionally to protect them against the specialists. During these years, family practices evolved from one-doctor practices to health centres with several physicians sharing responsibility for emergency calls. For instance, after graduating from Laval University in 1948, Dr. P.P. Doyle started to practise in 1949 in the small town of St. Anne, Manitoba. He started in a small way with a space sixteen by eleven feet; this space served as office, examining room, change room, and pharmacy. Several years afterwards, he moved into a larger office attached to his house. He often practised under difficult conditions; on at least one occasion he delivered a baby in his

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140 Chapters office with his wife pouring the anaesthetic. On many occasions he delivered babies in their mothers' own homes, often after long journeys over dirt roads, drifted high in winter with snow. He would stay overnight when necessary. In the early days, the distant trips might be caused by need to inject penicillin. He provided the first response to road and agricultural accidents, often gruesome in character. The blades of a threshing machine could do terrible things. His, too, was the responsibility to help the mentally ill. There was no drug treatment for schizophrenia, and community arrangements for managing the mentally ill were sadly deficient. For Doyle, the early days were hard. However, time brought not only growing reputation but also association with colleagues and the opportunity to form a clinic. Like many of his colleagues, he spent many hours of unpaid administrative work in the service of his hospital, in this case St. Boniface. Doyle's professional and personal life were sustained by a deep Catholic faith, often applied pragmatically. He tried to help sterile women by artificial insemination with the husband's sperm. On abortion he noted: "In all of my experience over 45 years, I had only one case where a mother's life was truly threatened." This was the touchstone that justified abortion in the law of the time. Some might doubt his conclusion; none would question his honesty. Another practice in Morden had been going by 1983 for three generations. Dr.A.F. Menzies started it in 1920, and in 1950 he was joined by his son, Dr. J.C Menzies, as his assistant for the eight years until the elder Menzies's death. The son remembered the time when his father did all the x-ray and laboratory work, the thrill of developing an x-ray plate from fluid bath to fluid bath, until the ghostly shadow emerged, or of looking at blood slides down an old brass microscope. Patients used to come to the house for penicillin injections.The doctor was an important figure in the community, working all hours. At the weekend, the family would go off to the lake for a picnic, and the doctor would go back to work afterward. All the doctors had station wagons big enough to hold a stretcher; there were no other ambulances. As the years went by, things improved. The new hospital in Morden in 1952 had an x-ray and laboratory technician. An autopsy room was provided so that it was no longer necessary to carry out forensic autopsies in the mortuary. In the 1950s and 1960s, with suitable refresher courses, the second Dr. Menzies continued to do middle-level surgical operations: hernia repairs, hysterectomies, and intestinal surgery. An anaesthetic machine was purchased in 1960, which allowed the use of pentothal, muscle relax-

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ants, and closed-circuit anaesthetic gases. Menzies made a trip to Britain to study geriatrics and soon developed an extended-care program, with physiotherapy and occupational therapy available. Continuing medical education was now formal and organized, and Dr. Menzies played a part in its extension. By 1975, the medical group in Morden had expanded to eight physicians and was joined by the third-generation Dr. RJ. Menzies, after a residency in family medicine in St. Boniface Hospital. Outreach programs, developed with the aid of specialists from Winnipeg, provided dialysis for patients with renal failure and chemotherapy for cancer patients.The third Dr. Menzies in 1995 still performed significant surgical operations: hernias, appendicectomies, caesarean sections, and tubal ligations. Similarly, in Hamiota, Dr. E.D. Hudson served the district from 1908 to 1946, when he was joined by his son, Dr. J. Edward Hudson, who was still in office practice until 1995. A group practice developed with up to eight doctors working under a municipal contract scheme. A qualified surgeon was attracted to provide surgical care, a twenty-five-bed acute-care hospital developed in 1950, and in 1974 a district health centre was set up incorporating a community clinic with salaried physicians, public-health nurses, a mental-health worker, and a dental clinic. In 1981, thirty personal-care beds and fifteen housing units for the elderly were added. In 1987, the centre comprised the medical clinic, twenty-one acute-care beds, thirty personal-care beds, fifteen housing units for the elderly, and outreach and social services. The centre served a population of about 4,200, about a fifth of whom were sixty-five or older. There were other types of general medical practice. In Winnipeg, Mount Carmel Clinic had long provided health care for poor people in the core area. The most prominent figure in the 1950s and later was a nurse, Mrs. Anne Ross, who became a familiar public champion of free health care and family-planning services, particularly for women. Similar care was provided by Klinic, which was set up on Broadway in 1973. It provided an informal alternative for those to whom the doctor was a formidable establishment figure. Not only general medical advice was provided, but also dental care, counselling, advice on drug abuse, addiction, contraception and abortion, as well as crisis intervention. It was staffed by doctors, medical students, nurses, social workers, and trained volunteers and had a strong populist and feminist attitude. It served poor people and street people. It did and does much good and has a permanent influence, not only on the patients, but also on the staff, by focussing the social conscience of young physicians in particular.

142 Chapters Rehabilitation, the Aged, Home Care, the Dying As infectious disease was controlled and people lived longer, a new group of problems emerged. People recovered from acute illnesses and injuries and needed help to re-establish themselves in normal life; they needed rehabilitation. They lived to old age and needed more and more care as they declined. As the evening came and shadows lengthened, they needed help in the home so that they might stay as long as possible in familiar surroundings. The need for rehabilitation from acute disease is relatively new. As survival from tuberculosis improved with sanatorium care, there was a need to help patients back on their feet after recovery. In the Winnipeg General Hospital, the Department of Massage and Corrective Exercises started in 1921, efflorescing into the Department of Physiotherapy two years later. The Second World War gave further impetus, as did the poliomyelitis epidemics. Artificial respiratory support allowed survival of poliomyelitis sufferers who would otherwise have died; they needed physiotherapy and occupational therapy. When improved coronary care allowed patients to recover from what would previously have been fatal heart attacks, they needed graded and supervised exercise and physiotherapy to permit not merely survival but a higher quality of life. The discipline evolved in 1960 into the School of Medical Rehabilitation. The Rehabilitation Hospital opened in 1962. The expectation of life in Canada in 1920 was fifty-nine years, and forty years later it was seventy-one years; expectation of life in Manitoba was at least as good as the national average. Aged veterans were cared for at Deer Lodge Hospital in a unit run by Dr. Jack McDonnell; at St. Boniface Hospital the influence of the Grey Nuns promoted interest in the care of the elderly. The Faculty of Medicine in 1973 invited an expert in the new discipline of geriatrics to spend some time in the province and report on his findings at a symposium in the medical school. The subsequent evolution and improvement in geriatric services was led by McDonnell. The fundamental process of aging was not, and is not, understood, nor are the effects of old age in many areas, such as endocrine and psychological function. Old people needed health care in many ways, for example in the treatment of acute disease to which they were more liable, and in acute and expensive treatment of chronic disorders that did not become manifest until old age, like cataract. As they entered extreme old age, people needed help with just the simple processes of living. There was a need for specialized housing for the elderly, nursing homes, day centres, and day hospitals.

Medicine after the Second World War

In 1950, Princess Elizabeth Hospital, a new part of the municipal hospital system, had opened as a geriatric facility, and over the years other municipal hospital beds had been committed to such care.Yet, in 1973, for the eleven percent of the provincial population over sixty-five, there were about 4,000 nursing-home beds and 750 hospital beds, but little sheltered housing. It was expected that by the end of the century fifteen percent or more of population would be over sixty-five. While individual components of the health and social services for the elderly were adequate, there was a lack of integrated forward planning. Medical students received grossly insufficient teaching in the care of the elderly. Until well past the first third of the twentieth century, home care was the norm. In the 1940s, escalating medical specialism and expansion of hospital facilities led to more hospitalization and less home care, encouraged by increased federal funding. The first organized home care in Manitoba followed the 1950s poliomyelitis epidemic: Manitoba Home Care Equipment Pool. Similar care was provided in the early 1950s by the Canadian Arthritis and Rheumatism Foundation. Occupational therapy and physiotherapy were prominent. Even before medicare, there was concern about escalating medical and hospital costs. The 1968 Federal Task Force on Cost of Health Services in Canada pointed out that cost of medical services was rising at a rate of over ten percent per year, and that of hospital services by about fourteen percent. The 1972 Manitoba White Paper on Health Policy called for better planning and integration of health care and for community health boards. There was a need for integration and control of home-care services and assessment of their effectiveness. An inventory in 1973 noted that fortyfive different agencies were involved in home care.The agencies concerned (provincial, municipal, voluntary, and commercial) ranged from the Victorian Order of Nurses to the Children's Aid Society and the Canadian Red Cross. A year later, in 1974, the province approved a universal home-care program, government funded and community based. Until 1973, the many personal-care homes were run by a variety of organizations, religious, cultural, ethnic, or fraternal, with variable government grant support. Application for admission was a purely private procedure. In July 1973, personal-care homes were incorporated into the universally insured benefits. The per-diem charge was affordable within the range of anyone receiving old age security and guaranteed income payments. At once there was a rush of applicants for admission.

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144 Chapters The Office of Continuing Care set up a bureaucracy to collect data in a central computerized registry and integrate continuing home-care and personal-care services with the hospital system.There were tiers of caregivers; family physicians and nurses would make home visits, and homemakers would assist with domestic chores. Considerable problems arose, in particular with the latter. Homemakers had little training, were given low wages, and did not stay long in their jobs.Volunteers would help by visiting people shut in their homes, by making telephone calls, or providing meals. As would be expected, more than three-quarters of the people receiving home care were over sixty-five. In the 1973-74 fiscal year, the comprehensive provincial plan cost $4.8 million, and in 1974-75, $5.5 million; the cost for home care expanded progressively but saved much larger hospital costs. Life ends. Our modern technology sometimes obscures the need to ask the question How long? How long can we patch the aging frame? How many more expensive drugs can we prescribe, with diminishing return? When does testing and treating become a fate worse than death? When does longer life become merely protracted dying? The two great prophets of the care of the dying were Elizabeth Kubler Ross, psychiatric counsellor and teacher, and Cicely Saunders, who founded a hospice reminiscent of the stopping places for mediaeval pilgrims who were sick or dying on their journeys. Dr. Paul Henteleff led the Palliative Care Unit at St. Boniface Hospital for many years, using the hospice model. Saunders's perception of pain and suffering informed the service; pain has physical, emotional, social, and spiritual (or existential) elements, which interact to augment or ameliorate suffering. This required alleviating pain by titrating drugs and determining a level neither sub-therapeutic nor toxic. It also meant listening and responding to the individual patient and family to determine interventions rather than giving primacy to biomedical objectives. Once it is accepted that death is inevitable and imminent, the urge for diagnostic precision for every change in condition and the urge to prolong life are suppressed. This approach differs from that used in other areas of health care; it requires an interdisciplinary, egalitarian team to coordinate the observations, interpretations, and actions of many people, each of whom is accustomed to dealing with patients within a different professional frame of reference with a different approach and different ideas as to what treatment might help the patients. The service, despite being hospital based, was structured to provide secure continuous care at home and guaranteed direct admission to the Palliative Care Unit for crises, bypassing the Emergency Unit. Home and

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out-patient visits were available the day of request or the next day, according to urgency. Visits were closely followed by telephone calls until the condition stabilized. Arrangements for death at home were put in place in advance. After death, follow-up continued for family support in bereavement. At the Municipal Hospital (now called Riverview), a similar palliative care unit developed. The Palliative Care Unit at St. Boniface was the site of an important study demonstrating that patients receiving adequate palliative care wanted life shortened only when they were clinically depressed. Not all physicians can do this work; some do not have an appropriate personality, and the stress can be great. Medical schools offer little training in symptomatic treatment, and the discipline of medicine is uncomfortable with accepting death, shifting from trying to cure to attempting only to relieve symptoms. Many physicians are not accustomed to interdisciplinary teamwork, with its implication of equality among caregivers; they do not grasp the idea that equality lies in the contribution each gives to the comprehensive care of the patient. The provincial medical profession rejects legalized euthanasia in favour of better terminal care. Palliative care is now regarded as an essential service to which all dying patients should have access. Henteleff himself had a significant effect on the development of the discipline across Canada, as founding president of the Canadian Palliative Care Association, in 1991.

Aboriginal Health In 1945, aboriginal people had a much lower standard of health, and poorer health care, than anyone else in the province. Medical services for both Inuit and Indians were transferred to the federal Department of Health and Welfare in 1945, and over the years the Department of Indian and Northern Health Services came to control a wide variety of health functions, including quarantine and public-health inspection. Dr. Percy Moore, who was in charge, was competent and well meaning. The task was enormous. In the Central Region alone (Manitoba and the adjacent areas of northwestern Ontario and Keewatin), there were reckoned to be about 45,000 Inuit and Indians in 1964. The birthrate in 1962 was high (47.6/1,000); it was double that of the population as a whole. The infant death rate (69/1,000 live births) was double that of the population as a whole and had been as high as 240/ 1,000; one in four of aboriginal infants died in the first year of life. The death rate from infection was high; twenty-six percent of all deaths were due to pneumonia, and gastroenteritis was prevalent. Eighteen percent of

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146 Chapters deaths were due to accidents and violence. As the medical authorities recognized, poor living conditions were the cause; aboriginal people lacked adequate food, clothing, and shelter. The medical authorities tried. Starting from the beginning, women were encouraged to have their children in hospital, baby clinics were set up, and school health services were provided to attempt to look after aboriginal children, who too often suffered from the minor diseases of poverty: scabies, lice, impetigo. Cases of infectious diseases were notified, and immunization programs were set up against diphtheria, pertussis, tetanus, poliomyelitis, and smallpox. Paediatricians, obstetricians, and other specialists flew in from Winnipeg. Attempts were made to control tuberculosis by x-ray screening programs and BCG vaccination.Yet, in one remote area in 1963, ninety of 400 people developed tuberculosis about nine months after the population had been screened. In the Central Region, there were hospitals in Norway House, Fisher River, and Sioux Lookout. In smaller, isolated communities, which could not support hospitals, there were nursing stations, which were usually staffed by two nurses, who provided advice on good health and administered minor medical care. Where a midwife was on staff, she dealt with uncomplicated obstetrical cases. Other patients were referred for medical care to the nearest hospital, and those requiring specialist care were sent to Winnipeg. Patients not admitted to Medical Services' hospitals were admitted to the nearest community hospital. All Indian people were covered by hospitalization insurance. Premiums on hospitalization or co-insurance were paid on their behalf by the federal government if they were unable to pay. Aboriginal people had to pay for medical services and hospitalization if they were gainfully employed or had established "residency" in a municipality away from the reserve. It was clear by the mid 1960s that health in the north was not improving. Infant mortality in some areas was as high as 250 per 1,000 live births, and there were regular and lethal epidemics of smallpox, measles, whooping cough, and tuberculosis. Up to half of all aboriginal children in some areas were said to sniff glue, often regularly. It was difficult to recruit and keep physicians for the north, but there was another national interest at stake in the north: defence.This led circuitously to improvements in health care for aboriginals. There had been intense strategic interest in northern Canada during the Second Wo rid War, and the Defence Research Board had funded the Arctic Medical Research Unit to work on adaptation to prolonged exposure to cold. Natives of arctic climates were found to sleep longer with less

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shivering, and coastal fishermen whose hands were exposed to near freezing temperatures were found to constrict their peripheral blood vessels less readily in response to cold than non-acclimatized individuals.The leader of this unit, Dr. J.A. Hildes, spent much time in the north as physician and research worker; the conundrum of how to provide adequate medical care was answered by calling in the university. In 1969, the University of Manitoba launched the Northern Medical Unit, led by Hildes; twenty years later it was successfully providing physician services to 25,000 people living in remote parts of Manitoba and the Northwest Territories.There had been an armed forces hospital in Churchill, which was replaced in 1970 by a brand-new health centre with thirty beds and modern surgical, laboratory, and x-ray facilities, as well as resident physicians. Smaller, sixteen-bed hospitals with resident physicians exist at Norway House and in Hodgson in the Interlake. Modern, well-equipped nursing stations east and northeast of Lake Winnipeg are visited weekly by fly-in physicians, as are stations in the Keewatin District of the Northwest Territories.The visiting physicians include paediatricians, obstetricians, otologists and other specialists from Winnipeg; the duty involves not only stress and inconvenience but also occasional severe hazard, and sometimes tragedy, in small planes in bad weather. The Northern Medical Unit has not only improved the health of northern residents greatly but has also engendered much good research. Social conditions are still not good by the standards of the non-aboriginal population but have improved; sadly, while health has improved, the old epidemics are being replaced by the new, in a pattern similar to that in Western societies in the past 100 years. Meningitis, severe respiratory infections, and otitis are common among aboriginal children, and the sequelae of streptococcal infections, rheumatic fever, and glomerulonephritis are much more common than in southern Canadian children. The diseases of civilization, cardiovascular and cerebrovascular disease, dental caries, alcoholism, drug abuse, and sexually transmitted disease, have increased dramatically. Diabetes mellitus is extremely common. The cancers that used to be common arose in the kidney and parotid. This pattern has changed; cervical and bronchial carcinoma are now common. So are child abuse, suicide, and violent death. However devoted the medical care, these problems will be resolved only by political and social change. The problems are compounded by the relatively high reproductive rate of aboriginal people, who now make up ten percent of the population of Manitoba.Whether or not modern Canadians of European origin feel guilt for the misdeeds of their ancestors in the past,

148 Chapters there can be no doubt about the need to generate equality for all in the present, and in particular for such a large, and increasingly vocal, minority. It is not clear that anyone knows how to do this. Phil Fontaine, grand chief of the Manitoba Assembly of Chiefs, put it well: "The Directors of the Northern Medical Unit understand that First Nations health care in the next decade will either be controlled by First Nations, or irrelevant to First Nations." Northern Manitoba was not the only place where Manitoba physicians served altruistically, often for long years. Elsewhere in Manitoba, hospitals in developing areas, as in Vita, originated as mission hospitals. For instance, Dr. Herman McLean (MD Manitoba, 1928) spent forty-two years in medical missionary work within Canada. After spending seven years in Bella Coola, B.C., he moved to Esperanza on the west coast of Vancouver Island where he lived for thirty-five years and organized the building of a mission hospital to serve the fishermen, miners, loggers, millmen, and aboriginal people. Dr. Isabel McTavish was one of the first to be led far afield by her beliefs to medical mission, in her case in China. There were others: not long after graduating in 1920, Dr. Jessie Findlay left for the mission hospital atVellore and was for thirty-three years professor of surgery and vice-principal in the medical school in Madras. More recently, a Winnipeg surgeon took his skills for a sabbatical year to Pakistan. These medical missions have been largely replaced by formal medical academic collaboration, particularly in the area of infectious disease, in many parts of the Third World. But the altruism is similar.

Flood and Plague In the early 1950s, two major natural emergencies threatened the public health and put to the test some of the skills developed in war time. The 1950 flood inundated most of the Red River Valley and came near to drowning Winnipeg. The winter of 1949-50 was colder and snowier than usual, and it was clear by early April that significant flooding was likely. Some flooding is usual in a flat land whose major rivers drain an area of heavy snowfall, but 1950 saw the worst flooding since 1861. Yet, as April passed, with more snow and then heavy rain, there was little sign of urgency as different levels of local government dithered as to which might pay. Some dykes were sandbagged, but it was not until early May that the floods to the south of Winnipeg compelled attention. On 6 May the water was high, a state of emergency was declared, and control was put into the hands of the army. A command medical officer called together the medical superintendents of all the hospitals and representatives of all the

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medical organizations. An appeal went out for all doctors to register; some were recalled to military service, and many others undertook emergency duties, whether visiting the housebound sick or running clinics to provide inoculation against typhoid. The areas threatened by flood had to be evacuated, and thousands of people had to leave their homes. Patients in the municipal hospitals were evacuated to higher ground locally, mainly to Deer Lodge and to a lesser extent to the Winnipeg General Hospital, using a fleet of army ambulances. Similar evacuation was carried out from St. Boniface Hospital and the Grace Hospital. Maternity patients were moved to the new Women's Hospital, by chance on the very day it opened.The heart of the medical system was cooled when eight feet of water turned off the furnaces in the medical school basement. Many patients had to be evacuated to rural Manitoba hospitals and even to Regina, Saskatoon, and Fort William (now Thunder Bay). A trainload of patients was evacuated to Regina on 13 May using a standard baggage car outfitted either with hospital beds in one end and double decker beds in the other to carry thirty patients, or with only hospital beds in either end to carry nineteen patients. In all, 659 patients were moved. The flood crested on 15 May and the cleanup started ten days later. Thousands of people had to leave their homes, and indeed a plan was made, and would have been carried out had the water risen a little further, to evacuate almost all Winnipeggers from their homes, leaving 75,000 fit people to fight floods. Fortunately the waters receded before this drastic emergency plan became necessary. Moving 400,000 people would have been no small task. The Manitoba climate posed problems other than flood. In 1955,Vita Hospital had served the community for over thirty years and had provided excellent experience for many medical students and young doctors.Then, one placid summer Sunday afternoon a tornado struck. As the local newspaper reported, there was an explosion. A nightmare of sound and motion. Windows shattered, roofs were wrenched off. Walls shivered and tottered and collapsed. Villagers watched in horror as tongues of flame slithered up walls. Vita's hospital was back at the beginning, about half a million dollars back. The main plague of the postwar period all over North America was poliomyelitis. The crippling disease had struck before, in the late summer, usually affecting children and young people, more often male than female. It was a disease that occurred in a paralytic form more frequently as the hygiene of communities improved because infants were less often exposed

150 Chapters to the virus. Manitoba had suffered severe epidemics in 1928, 1936, and 1941, and less severe outbreaks in 1947.The worst outbreaks occurred in 1952 and 1953, the latter one of the worst ever suffered by any city in North America.The community was not prepared.The Winnipeg Municipal Hospital was an old fever hospital encompassing a new extended-care hospital. Two cases of respiratory poliomyelitis admitted in 1951 had both died in the acute phase; despite attempts to improve preparedness, in 1952 there were only four tank respirators and four electrical circuits suitable to support them. The public not surprisingly was stricken by fear of the mysterious disease that disabled and killed their children, and willingly cooperated with any attempts at prevention. A clinic at Princess Elizabeth Hospital offered free gamma globulin to all between the ages of six months and thirty years, and to pregnant women who had been in contact with the disease. In 1953, 1,290 patients were admitted to the municipal hospitals between late June and late October. Many (207) of the patients sustained damage to the nervous centres controlling the muscles of breathing, swallowing, and speaking and leading to respiratory obstruction and aspiration of saliva into the lungs. At the peak of the outbreak there were 330 patients in hospital, ninety-two of whom were on respirators. Polio in pregnancy caused particular problems, especially in delivery. The sudden influx of so many acutely ill people in six months caused problems of organization, in terms of admission, acute care, rehabilitation, and aftercare. Poliomyelitis, a viral infection, could not be treated effectively, and all that could be done was to maintain life until infection passed.This meant artificial respiration. There was an acute shortage of respirators, both in the province and across Canada, and equipment was flown in from outside. In the oldfashioned tank respirators, positive/negative pressure changes in the tank were transmitted to the patient's body to simulate respiratory movements. These respirators were superseded in their turn by rocking beds that moved the abdominal contents up and down,thus producing passive movement of the diaphragm. The more recent respirators featured electrically operated positive pressure air pumps fitted to a tracheostomy tube. Such pumps could be attached to a wheel chair to allow the patient to move around. It was difficult to humidify the air properly, particularly in winter, and adequate alarms had to be fitted, to be used when the air got too dry. In one case, a twelve-inch fire bell powered by a separate battery was used.When the patient pressed the switch, the bell was heard a quarter of a mile away. In earlier epidemics, patients were kept immobile on a frame to allow the muscles to relax, but by the early 1950s patients were being managed more actively with heat,

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massage, and mobilization, a treatment popularized by Sister Kenny, an Australian nurse who became well known during the epidemics. There was a shortage of nurses at the Winnipeg municipal hospitals; nurses came from other hospitals, the Department of National Defence drafted nurses, and medical students served as nurses. Physiotherapists were in equally short supply. All the staff worked long, arduous hours. The hard work paid off; at one point over ninety-three patients were cared for in respirators, and the overall mortality rate was only 3.5 percent. The skill that physicians developed in caring for patients with respiratory failure led to the improvements in intensive-care medicine in Winnipeg in the next decade. There was widespread public admiration for the devotion of the hospital staff, and in particular for Dr. Hildes, who was voted Winnipeg Man of the Year. During the epidemic, recovering patients played their part in entertaining one another and in caring for those sicker than themselves.Their dance band, the Merry Menders, played for wheelchair square dances. Some patients have interesting stories of that time, some recorded in a symposium held in 1989. For once we know what the patients thought. Martha Smith wrote: It was a beautiful summer. I was in the prime of life — I had a loving husband and a beautiful baby boy. . . . I contracted polio September 26. Three days later my physician sent me to King George Hospital, much against my wishes. I didn't know then that this machine would be with me for the rest of my life. After re-learning to breathe for about five months, I finally was able to breathe unassisted for ten hours a day, and then I was on my own.

A year later she could spend weekends at home, but her husband divorced her; they separated with little bitterness, and she spent the next twentyseven years as a polio patient living in hospital. She made the best of it and learned, for instance, to paint and type with her head stick."! have not been deprived of the beauties of life. I hope the next 27 years will be as good as the last." Paul Sigurdson, similarly disabled, was discharged home in 1955 and wrote of the problems of being dependent on others: "By the time the nurses have washed you and changed your diapers, and fed you and brushed your teeth and shaved you and combed your hair and literally gone over every inch of your body, you decide it is time to throw dignity into the basket and leave it there.You have been pretty well humbled." He had lost, as he said, "the preciousness of life."

152 Chapters David Steen was stricken at the age of six and remembered being rushed 320 miles to Winnipeg from Swan River. He was at once put into an iron lung and did not leave the hospital until 1957. He succeeded in enrolling at the University of Winnipeg and, despite his handicaps, had a successful career, latterly as director of Public Library Services for Manitoba. It was a hard row to hoe, and many years later, as executive director of the Society for Manitobans with Disabilities, he spoke out for better public acceptance of the disabled, better use of technology, better home care, and better employment facilities. The epidemic had significant economic implications. Care cost money, and medicare had not yet arrived. Although many people had private insurance for acute illness, few had private insurance against long-term medical calamities. In 1952, many took out specific insurance policies against polio to cover the cost of hospitalization and such equipment as wheelchairs, and the province provided considerable financial suport. It became clear to the public and the politicians how much proper and permanent public funding of medical care was needed. Moreover, the skills and techniques acquired in keeping acutely ill people alive stimulated the development of intensive-care units, and the level of organization required to deal with the crisis helped the public to understand that health care must be planned. Clearly, prophylaxis had to improve. Earlier attempts, in the 1920s and 1930s, at treatment with convalescent serum met 'with little success, and prophylactic nasal spraying had a transient vogue in the late 1930s. Effective prophylaxis came only in 1955 with the Salk killed vaccine given by injection. In 1958, it was combined into a polyvalent vaccine against diphtheria, tetanus, and poliomyelitis; it was succeeded by the Sabin live attenuated oral vaccine in 1962. The two catastrophes, the flood and poliomyelitis, left no doubt that integrated planning and public funding of health services was essential.

Since the Wars: Ivory Towers

9 In 1945, change was needed in the Manitoba medical world; the engine that drove change in the profession, the motive force of progress, was the medical school, the place where a medical life begins. Change was especially needed in the medical school itself: in clinical practice, in faculty, in attitudes toward research, but most of all in the manner of selecting medical students. The medical school was controlled by an "old boys'" network, which limited the entry of women, Jews, and Eastern Europeans. The problem over the selection of medical students had been brewing since about 1922. Twenty years later, towards the end of a war that was ostensibly fought for freedom and equality, it came to be thought that young people were being selected unfairly for the coveted privilege of training to be a physician. It had happened gradually. In July 1924, the Manitoba Medical Association recommended that the medical school review the moral, physical, and social attributes of applicants and refuse admission to those deemed unworthy, and it noted at its annual meeting in 1925 that there was an overproduction of doctors. In the 1920s, Jewish students were very successful in gaining entry to the medical school; this did not please the racist Anglo-Scottish establishment. There was a high failure rate; a third of each first-year class was eliminated before reaching fourth year. Mathers wanted to limit the firstyear class to fifty-five or sixty students. The faculty felt it appropriate to have a mix of medical students similar to the ethnic mix in the province. Such a policy seems to have come into effect in 1933; on 7 April 1935, faculty executive minutes show the motion, "Five students of the Jewish race be admitted to the first year next

154 Chapter 9 session. Carried." No one on faculty stood firmly against such racist decisions; the Scots came from a society where discrimination against Jews was common. Those who made or assented to the decisions cannot escape censure for their complicity; their attitudes, while now unacceptable, were those of many educated people of the time. Similar attitudes elsewhere had horrific consequences. By 1940, the quota system was firmly established. Eligible applicants were divided into four lists: a preferred list of Anglo-Saxon, French Canadian, and Icelandic male applicants; one "male Jewish"; one "male miscellaneous"; and one for women.The dean told the admissions committee how many places to fill from the non-preferred lists. Usually about a dozen of the fifty or sixty places were filled from the non-preferred lists.There is no documentary evidence as to how many qualified women were rejected in this way, but one woman doctor who graduated in the early 1940s recollected that, of thirty women who applied for entry, only three were accepted.This pattern had the support of the then University president, Sydney Smith. A similar pattern existed in many medical schools across North America; it had to change. In March 1944, a complaint by a representative of a Jewish organization to the education committee of the Manitoba legislature caused considerable public hullabaloo. Mr. Justice Dysart, chair of the Board of Governors of the University of Manitoba, announced that the policy would change. It did, within a few weeks, despite objections from members of the Faculty of Medicine. The new policy stated: "The selection shall be made without regard to the racial origin or religion of the applicant."There was no mention of gender. To ensure change, the new president, Albert Trueman, became chair of the admissions committee.This policy applied to classes starting in the fall of 1945, of whom thirty-six percent were Jewish; fifty-seven percent of the women were Jewish. The prejudice against women in medicine took a long time to fade, yet most of the few early women graduates recollected their medical-student days with affection. Their training was only a little different from that of the men; they were not taught about male urology but did receive instruction in contraception, from Dr. Elinor Black. When they graduated, there was no room for them in the interns' quarters, and for many years women physicians found it difficult to obtain training in some traditionally male medical specialties, notably surgery.The prejudice died down somewhat in the 1950s, and as social attitudes changed and feminist attitudes evolved, more young women applied to enter medical school.

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In 1949 there was a new dean of the Faculty of Medicine, Lennox Bell. Bell was a skilled general physician, dedicated to the future of his institution, and drove change. He sought, by the nature of the appointments he made and by his influence on national medical committees, to foster the research that changed medicine. Bell graduated MD (Manitoba) in 1928 and trained in clinical medicine in London, at the National Heart Hospital and the National Hospital for Nervous Diseases, Queens Square. He acquired the certificate of higher clinical competence, the London MRCP, in 1930.Thereafter, he spent his life as a physician at the Winnipeg General Hospital, apart from two years' leave (1943-1945) for military service. Lennox Bell was an excellent clinician who was instrumental in imbuing students with a sense of professionalism and meticulous attention to detail. His ward rounds and out-patient sessions were models of clinical instruction. Not himself a basic research worker, he did see the part that basic research had to play in the development of the new medicine. He did not always foster so well the development of sub-specialty medicine. Bell's power derived partly from his own competence and partly from his connections. As the son of Gordon Bell, he was a trusted member of the closely knit Manitoba establishment and in the 1920s and 1930s had been friendly with most of the important local figures. He was the paterfamilias of the faculty medical establishment, a group of men who controlled things but not always themselves. Alcoholism, cigarette addiction, and broken families were sadly common among them. Bell was a rather shy bachelor whose private hours were spent listening to classical music on the new long-playing records; he influenced the school partly by his choice of colleagues and partly by involvement in national medical activities. His push for increased medical research funding in 1957 led to the improved funding of the succeeding decade. The Royal Commission on Health Services stated the urgent need to expand Canada's output of physicians and set out preliminary plans to double the size of the twelve existing medical schools by 1970. By that time, there were two more new Canadian schools in operation. As a result, more students were admitted to the Manitoba Faculty of Medicine; the number of graduates peaked at about 100 in 1978. The students were not the conformists of older days; it was the time of flower power, and many strange flowers bloomed; it had not been necessary previously in Manitoba to insist that students be clean and neat to meet patients, but now it was. Change did occur, however, led by Dr. Arnold Naimark, as dean. Admission procedures changed: as far as we know, until about 1970, admission

156 Chapter 9 depended at first only on passing certain examinations and on the possession of a pair of testicles, not necessarily descended. There had been one woman graduate in 1894, another in 1906, five by 1915, and relatively few by 1970. It also helped to have a medical father, or even, rare phenomenon, a medical mother. The disgrace of racial quotas had disappeared, but there was still bias. Progressively after 1973, there was an increasing attempt to place more reliance on candidates' human qualities through interview and to reduce bias due to gender, or racial or social origin. Yet, not until the 1990s did medical classes contain as many women as men; by 1982, only one aboriginal had graduated MD, and, despite special pre-medical programs, only six by 1992. The teaching program changed. The undergraduate medical course in 1970 was calcified. It lasted four years during the period between 1883 and 1905, five years between 1905 and 1956, and returned to four years in 1957 after introduction of a compulsory graduate intern year. It followed the traditional Scottish pattern. Students had to have a smattering of Latin and had taken two years of prior university science, including physics, chemistry, botany, zoology, and biochemistry. In medical school they studied anatomy in infinite and infinitesimal detail, and physiology/bio chemistry. Then they proceeded to study pathology and pharmacology, at the same time starting in the wards to study clinical medicine and surgery. Thereafter, they studied public health and forensic medicine. The last year was spent in the intensive study of medicine and surgery, with added obstetrics, gynaecology, and paediatrics. After due deliberation, a new curriculum was put into place in 1973 under the influence of specialists in medical education. Undergraduate education gradually came under central control, headed by an associate dean, vulgarly known as an ass-dean, and was subject to increasingly effective review, notably student review. The students were believed to know best, and sometimes did. It was a hybrid systems/departmental curriculum. The first year taught normal structure and function and the second introduced diseases of systems. The third year consisted of lectures, seminars and case presentations in clinical departments.The fourth year was clerkship with some responsibility for patients. Physiology was taught not departmentally but largely by clinicians with a training in clinical physiology. Practical physiology laboratories were abolished. Lectures began to dominate, but family medicine started to challenge the dominance of the clinical specialists. In 1983, the third year involved the clerkship on the wards, and a service-dominated education was provided for third and fourth years.

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There was less rote learning and more small-group teaching, and a pass/fail system was introduced, placing more emphasis on student collaboration rather than competition, and less on memorizing facts.There was a greater attempt to care for students as people, with provision of health care and counselling services. Tutorials were the thing, and computer-based education, led by Dr. Marcel Blanchaer, in biochemistry. Formally organized teaching units were developed in the teaching hospitals, and academic family physicians had greater input into medical education as a result of establishment of the University Department of Family Practice and Family Practice units at St. Boniface and Seven Oaks Hospitals. The expansion of the rural elective program provided students with experience of medicine outside cities, and it was hoped that this would encourage young doctors to practice in rural areas.This was not entirely successful. The development of the Northern Medical Unit improved medicine in the north and provided experience there for students and young doctors. A special access program was set up to encourage aboriginal students to train in medicine. The examinations changed. They, too, had calcified. From 1883, examinations were written, practical, and oral, and examined largely regurgitative knowledge, with the exception of the clinical examinations. The results were expressed in various grades of honours or distinction, with numerous medals and prizes. The University examinations were reinforced by those of the Medical Council of Canada in 1915, leading to the licentiate diploma of the Council, LMCC; the written examinations were set and marked centrally, the clinical examination for Manitoba students set in Winnipeg by local clinicians with national inspection. Anatomy and physiology were left out of the national system from 1918, and pathology from 1954. In the 1960s there was increasing scepticism about the examination system, and from 1967 to 1978, multiple choice objective examination gradually took over, replacing essay examination by 1973.The new dogma was not accompanied by a new scepticism, and its results were examined only by performance in the national MCO examination. During the 1970s the Manitoba performance was usually above the national mean in the LMCC and by 1983 had fallen just below. The honours system was abandoned for a pass/fail system in 1972. Literacy was no longer required, excellence at least at rote learning was no longer stimulated, and the candidate was immersed in a hell of biting ticks. The intentions were excellent, but no one measured to what extent the changes in education affected the quality of the physicians produced. Science had not yet come to medical education. In 1983, first-year medical

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158 Chapter 9 students still had more than five hours of formal lectures per day. Broad bottoms and flapping ears were still needed. Medical training no longer ended with the first degree. A royal commission mandated that all residency programs come under the formal control and supervision of university faculties of medicine. The standards for the training of medical specialists were now set by the Royal College of Physicians and Surgeons of Canada. Founded in 1929, the Royal College had by 1942 set up certifying examinations for specialist recognition in general surgery, internal medicine, paediatrics, ophthalmology, ear, nose, and throat surgery, and urology. By the 1970s, several more specialties were recognized, and specialist qualification was marked by Fellowship in the College. These changes caused the University of Manitoba Faculty of Medicine to take a progressively greater part in postgraduate education. At first, in 1958, the University actually gave postgraduate diplomas, for instance in anaesthesiology, general surgery, and orthopaedic surgery. Led by the Department of Surgery, organized training for residents in nearly every specialty had become available by the later 1970s. Before 1965, postgraduate clinical education consisted of separate apprentice-style internships in the Winnipeg hospitals: Winnipeg General, Children's, St. Boniface, Deer Lodge,Victoria, and Misericordia. The residency programs operated separately but under the overall control of the Faculty of Medicine and depended on the passive support of the administration at Winnipeg General and St. Boniface Hospitals. In 1965, the Canadian Medical Association intern accreditation program noted many deficiencies in the internships, including excessive workloads and absence of consistent teaching policies. The programs were put on probation, with the threat of withdrawal of accreditation. By 1969, the programs at St. Boniface Hospital, the Winnipeg General Hospital, and the Children's Hospital were centrally administered.The Division of Postgraduate Clinical Studies became in 1972 the central University focus for postgraduate clinical education. This body engaged in collective bargaining with the newly established Intern Resident Association and provided support service for the residencies, call rooms, and interns' and residents' lounges. By 1975, the programs at the other hospitals had been discontinued. The centralized training programs met with approval from the Canadian Medical Association and the Royal College. Continuing medical education, too, became more formal; since the 1920s, regular update sessions had been run for doctors under the auspices of the Manitoba Medical Association. From 1962, under the guidance of Dr. Dan

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Snidal, the Division (later the Department) of Continuing Medical Education provided extensive programs in Winnipeg and sent speakers to smaller centres around the province. Most, though not all, physicians took advantage of this and travelled to medical meetings elsewhere in Canada or in the United States to keep up to date. As the years passed, the public became more demanding and litigious, and regular update became more necessary. Updating meant, among other things, reading books and journals, and the Medical Library developed to meet the need.

The Medical School and Research It was now more necessary than ever that medical students be trained in institutions where research was active; they had to learn to live with constant change. Medical research in Winnipeg in 1939 had been at a low ebb and in 1955 was carried out by single workers assisted by a technician or two. As time passed, a single physician with a technician could no longer do effective research. By 1983, research was an elaborate business carried out by multidisciplinary teams and involving many non-medical PhD scientists. Competition for funding was intense. The tradition of research hearkened back to the start of the century and to Swale Vincent. The doyen of local research 'workers was A.T. Cameron, professor of biochemistry, who had over the years kept up a continuous output in biochemistry and on the side contributed to fishery research. But the candle of research guttered, not only in Winnipeg, but also across the country; medical research was under-planned, under-coordinated, and under-funded. The national body for scientific research was the National Research Council, which in 1945 supported some work on tuberculosis, radiology, radiotherapy, and parasitology; its offshoot, the Associate Committeee on Medical Research, surveyed medical research across the country and noted as outstanding workers in Winnipeg Dr. P. McDonald at the Cancer Institute, Dr. A.T. Cameron, Department of Biochemistry, Dr. I.M.Thompson, Department of Anatomy, Dr. J.D. Adamson, St. Boniface Hospital, and Professor Frank Allen, Department of Physics, a few tall poppies in a barren field. There were then few posts available in western Canada for a young graduate interested in research. The Associate Committee evolved in 1946 into the Division of Medical Research of the National Research Council and ultimately into the Medical Research Council, which was formed in 1960 and became a crown corporation in 1968. Lennox Bell, Joe Doupe, and their Winnipeg colleagues had their share in its development. The Medical Research Council

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160 Chapter 9 today points with pride to the research done under its auspices and with its funding; its training schemes have supported the careers of many young scientists. The possession of a Medical Research Council grant became a major lever of academic political power in the medical schools of the 1970s and 1980s; most of the money for medical research in medical schools came from Ottawa, and a significant amount of the real power in these institutions moved to Ottawa. The other major national research institution, the National Cancer Institute of Canada, founded in 1947, has worked in a more precise field, has had influence only less than that of the Medical Research Council, and is similarly proud of that influence. Within Manitoba itself, smaller research foundations have grown up in attempts to keep research dollars within the province. For instance, the Manitoba Heart Foundation, founded in 1957, in its first year allocated $52,988 to heart research in Manitoba and forty years later was contributing over four million dollars to various programs, including a million and a half to research. In those forty years it supported over a thousand research workers, with awards totalling $28.5 million. This transformed cardiovascular research and, as a result, the teaching and practice of cardiology, and indeed of medicine. During that same period across Canada, the proportion of deaths due to cardiovascular disease fell from fifty percent to thirtyseven percent of all deaths, a saving of over 35,000 lives a year. As the years passed, many other research organizations developed, devoted to numerous individual diseases, or as individual hospital foundations at the Childrens' Hospital, St. Boniface General Hospital, the Health Sciences Centre, and the other smaller hospitals.This trend had two effects, one positive and one negative. Funding improved for several sectional interests; but coordinated planning of the raising and spending of health research and health-care money was inadequate, and the distribution of the funds was not always appropriate for the health needs of the community. However, the money available for medical research did increase progressively, from a few thousand dollars in 1938 to many millions in 1983. Need increased even faster. In February 1965, the University formally opened the five-storey Chown Building on the Medical College grounds; it was used for administration and research.The new Basic Medical Sciences Building followed in 1973. These buildings were the indication of federal government support for the development of medical schools across the country. The local faculty of medicine had lobbied hard for them. Postgraduate students came in increasing numbers from all over the world, seeking opportunities for study and research. As time passed, the requirement for money

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increased logarithmically. It was clear by 1977 that a major change had taken place in the Faculty of Medicine; an account of the research activities of the faculty members, published in its medical journal, occupied over eighty pages. By 1983, laboratories were crowded, and more research space was needed.The medical school was now the provincial centre not only of medical teaching but also of medical research. As clinical medical teaching became more complex, and as clinical research developed, the question arose as to which people should do it and how should they be paid; increasingly, from the middle 1960s, the solution of the geographically full-time clinical professor, clinician scientist, developed. Typically, such doctors would teach, do research, and treat patients, deriving large parts of their income by billing for patient care through medicare, and passing a tithe of this income to medical school funds. Such an individual might have a small, twenty percent or less, University salary, and be expected to do a great deal for it. The formula for many years provided academic doctors with good incomes and opportunities to teach and do research. They had to work long hours to be successful, but many were. The scheme led to clashes between the clinics' interest and those of the medical school. Increasing numbers of physicians recruited to the medical school were geographical full-time and were required to staff the hospital units and programs requiring full-time, on-site involvement of specialists. Many of these recruits had academic and research responsibilities much greater than those carried by part-time visiting clinicians whose practices were based outside the hospitals. The clashes came largely from competition for resources: beds and operating-room time, and partly from the question of control of access to hospital appointments. It has become increasingly difficult for geographically full-time physicians to be competitive in obtaining research funds, although many still do.

The Power House: Physiology The advances in medicine grew out of advances in basic science. Anatomy maintained its position as the cornerstone of medicine, stately if sometimes a little petrous. Winnipeg anatomists did what anatomists always do, and did it well, following faithfully the major advance in their field, the development of electron microscopy. The inside of a cell became familiar, and their concentration on embryology led to distinguished work on the development of abnormal embryos (teratology). This became important for the obstetricians and was later the basis of a moral dilemma.Was it justifiable

162 Chapter 9 to abort an abnormal fetus? Dr. Keith Moore, head of the Department of Anatomy from 1966 to 1976, wrote important textbooks on embryology, and his successors carried out significant research on abnormal development. The powerhouse of change was elsewhere, in the Department of Physiology and its offshoots. The main initiator of change was a clinical physiologist, Dr. Joe Doupe, who worked hand-in-hand with Lennox Bell. Doupe returned to Winnipeg from war service in 1946 with a guarantee of adequate support from Thorlakson. Doupe was an unusual man, well trained in research, and with a significant body of good experimental work to his name. His creditable war record made him acceptable in an environment controlled by veterans. He aimed to integrate experimental physiology with clinical medicine and taught socratically rather than by lecture. He taught by stirring; his manner with students was abrupt, and sometimes sarcastic and downright rude. Many of his pupils revered him, a few disliked him. After his early death from poorly controlled diabetes, he was locally canonized: stir stick become saint. He would have been amused. Doupe's first task was to build the Department of Medical Research, a central source of innovation closely tied to clinical medicine. The laboratory and the ward were intertwined. There were initially eleven research beds in the Winnipeg General Hospital; the laboratories were equipped to study such parameters of health as skin temperature, heart rate, finger volume, rate and depth of respiration, body volume as an index of adiposity, hormone levels in biological fluids, the effect of various diseases on the needs of the body for vitamins, and the relationship of blood pressure as measured in the clinic to the actual pressure as measured directly in the artery. Little that was highly important and new was discovered, but young physician-scientists were trained to obtain new knowledge and to practise medicine in its light. One result was the development of the Clinical Investigation Unit, directed by Dr. John P. Gemmell. From this unit came research on a variety of topics, covering most of clinical medicine, and several men who eventually controlled Winnipeg medicine. Gemmell himself became head of the University Department of Medicine. The graduates attached for research training included Dr. Arnold Naimark and Dr. Henry Friesen. Twenty years later these men, neither of Anglo ancestry, dominated the Winnipeg medical world. Naimark, who succeeded Doupe as head of the Department of Physiology, was a man with a magic touch with words, spoken or written, and the rare ability to wave, Circelike, a wand over a committee so that, whatever its members thought when they entered the room, they came to the right conclusion (his conclusion)

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by the end of an hour. He later became dean of Medicine and subsequently president of the University of Manitoba and a respected academic statesman. Naimark was the son of eastern European Jewish immigrant parents and had grown up in north Winnipeg. He had a good eye for academic talent and early recognized the need for funding molecular biology. His appointees came to be the leaders of the next generation and to direct such enterprises as the Institute of Cardiovascular Sciences at St. Boniface Hospital. Henry Friesen made his way differently, by making an important scientific advance. He had chosen, after graduating in medicine, to go to Boston for research training and learned there the latest biochemical techniques in protein separation. In 1970, endocrinologists doubted the existence of prolactin as a separate human hormone. Chance favoured Friesen's prepared mind; a colony of pregnant monkeys became available for study, and at the same time a local surgeon was removing pituitaries from women with acromegaly and those with excess milk flow (galactorrhoea). Friesen and his colleagues identified human prolactin, which makes the breast of the nursing woman secrete milk. Women who secreted too much of this hormone could not conceive. One practical end result of the discovery was the drug bromocryptine, which lowers prolactin levels and allows conception. When Friesen returned to Winnipeg he single-mindedly drove the Department of Physiology to do research as the main function of a university department; the same single-minded impetus led him to take charge of the country's main research-funding institution as president of the Medical Research Council. The ghost of Swale Vincent would have approved. By 1970, research, and the promotion and organization of research, was now the Manitoba medical school way of life. One wag saw Naimark and Friesen walking across the campus, along with Dr. John Wade, Naimark's successor as dean of Medicine, and quipped, "There go three men with but a single mind." Another of Doupe's recruits, Dr. Jack Hildes, had a different career with a different effect. A graduate of the University of Toronto, he had met Doupe in Burma and subsequently been attracted to Winnipeg.The Canadian Defence Research Board created the Arctic Medical Research Unit, which studied prolonged exposure to cold; Hildes was appointed to lead it. His focus changed from defence to the needs of the people of the north and led to the development of the Northern Medical Unit. There had been a training program in medical research for medical students that led to a BSc Med. Doupe revitalized it into a potent educational tool. Its graduates were later shown to have more chance of academic

164 Chapter 9 careers, specialist qualification, and successful research careers than comparable MDs who did not undertake this training; it was never quite clear whether this was due to the excellence of their training, to their own brightness, or to the medico-political advantage conferred by the BSc Med degree. One way or another, Doupe's Department, first of Medical Research and then of Physiology, was a seed bed in which talent flowered. The physiologists spun off new disciplines centrifugally. Long years previously, the Department of Biochemistry had been the first to leave. In the decades from the 1940s on, the biochemists, led by Dr. Frank White, went from the analysis of proteins and the definition of enzyme pathways to the elucidation of the mechanism of inheritance and the analysis of DNA. Their techniques soon became essential in any serious medical research. Their techniques were, moreover, applied daily in practical diagnosis by clinical biochemists. Clinical biochemistry, at first a side branch of pathology, became an independent profession, staffed by PhDs with special hospital training and experience. The pharmacologists spun off next; by 1950, the study of the action of drugs was a separate field. In 1954, Dr. Mark Nickerson was appointed to the Department of Physiology, in charge of the teaching of pharmacology and therapeutics, and in 1956 the Department of Pharmacology and Therapeutics was established, comprising by 1959 eleven teaching faculty members, many of them refugees from the McCarthy political witch hunts in the United States. Graduate students appeared, often from afar, funded by research foundations, the federal government, and drug-firm money. The pharmacologists were ensconced in the new Chown Building and were highly successful in research. Clinicians of the time were beset by the problem of shock, which often set in after a successful surgical operation and resulted in a white, pulseless patient, too often dead. The pharmacologists, often themselves physicians, driven at once by clinical need and by newly available funding, concentrated on the functions of the autonomic nervous system and how they were modified by drugs. They studied neurogenic, traumatic, and haemorrhagic shock; they also studied hypertension and its lethal end results, stroke and heart attack. Drugs were now more numerous and more effective, and new ones were appearing weekly. Medical students a generation before had learned to recognize the plants whence remedies came, pharmacognosy.They now had to know the empirical use of drugs and had to grapple with complex organic chemical formulae, from dicotyledons to double bonds, in a decade.

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Laboratory Physicians Two groups of applied medical scientists had been useful in the development of medicine and surgery up to 1945: the pathologists (or laboratory physicians as they came to be called) and the radiologists. After 1945, they soon became became essential. As a corollary, those who studied applied, non-clinical medical science became increasingly separated from clinical practitioners, and many were not medically qualified. Pathology early split into pathology and microbiology. Gordon Bell, first professor of microbiology and pathology, had sloughed responsibility for pathology to William Boyd in 1915. The Department of Medical Microbiology evolved in close collaboration with the Provincial Laboratory and with the Departments of Public Health of the Province of Manitoba and the City of Winnipeg. Dr. Fred Cadham had led the discipline. A small, energetic man, Cadham had been deeply involved in the immunization programs that reduced infectious disease; after his death and a brief interregnal period, Cadham was succeeded by Dr. Jack Wilt. Dean Bell had not been entirely happy with bacteriology in the city. One day he walked into the autopsy room as Wilt was doing an autopsy. "Wilt, I would like you to be our Head of Microbiology." Selection of staff was then simpler; after a little further training he was duly appointed. Infectious disease was still the main killer in the 1940s; there were dramatic advances in treatment with the development of antibiotics: penicillin, tetracycline, chloramphenicol, and a host of others. Not only could pneumonia be effectively treated, but, as well, gonorrhoea and syphilis lost some of their terrors.This permitted the sexual revolution and the permissive society of the 1960s. It also stopped cardiovascular syphilis and neurosyphilis in their tracks.These had been major causes of cardiovascular disease and dementia. The task of moral monitor was taken over by new organisms, the chlamydia and the herpes viruses.The new antibiotics were overprescribed, and bacteria soon developed resistance. Microbiology was developing rapidly. Techniques of bacterial culture and identification were improving by leaps and bounds. As each new antibiotic came in, it was necessary to identify in the laboratory which bacteria were sensitive to it. Culture of fluid from the site of an infection allowed determination of which antibiotic was most likely to be effective. Blood culture helped in prescription of the right antibiotics for septicaemia, which before that time was usually lethal. As bacterial infections were controlled, at least for the time being, the identification of viruses became more important,

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166 Chapter 9 using culture on such living cells as egg or the allantoic membrane of the chick. The nature of infectious disease changed regularly. The viral epidemics of the 1940s and 1950s emphasized the need for a strong diagnostic service closely tied to research. Diagnosis affected many aspects of life; for example, for many years there was compulsory premarital serological testing for syphilis. New antibiotics followed one another, and for a while antibiotics suppressed bacterial disease. Attention shifted to viruses, now readily grown in cell cultures and seen with electron microscopes. Their research ranged widely, emphasizing viral diseases such as western equine encephalitis and the then major problem of poliomyelitis. It led to such practical results as monitoring the presence of encephalitis arbor virus in mosquitoes and mosquito-eradication campaigns. A great interest in sexually transmitted disease, particularly chlamydia, developed in the 1970s. By the middle of the 1980s, the many aspects of AIDS, though still a relatively rare disease in Canada, came to occupy medical minds. Medical microbiology thrived, partly because of the genial personality of Dr. Jack Wilt, who as professor and head of the Department of Medical Microbiology, persuaded and enforced close collaboration among the Provincial Laboratory and the Departments of Bacteriology of the University of Manitoba, the Winnipeg General Hospital, and Children's Hospital.The microbiologists kept their feet firmly in the centre of medicine by continuing to practise as infectious-disease physicians. They formed a potent specialty in which the skills of the physician were allied to those of the laboratory microbiologist. Wilt was revered for his own high ability and incisive mind and because he trained his juniors well; they were a powerful force in the years after his death. The Department of Medical Microbiology remained one of the strongest in the medical school, and the infectious-disease physicians dominated the internists. The Provincial Laboratory had its fingers in many pies. It was the reference centre for the province in any matter related to infectious disease, running such diverse enterprises as serological checks on young lovers for syphilis before they approached the altar, immunizing against rubella and hepatitis, monitoring the sterility of intravenous fluids, and checking that the summer infestation of mosquitoes did not carry arbor virus, the cause of Red River encephalitis. Gordon Bell must have smiled benignly in his quiet corner of Elysium. From microbiology, with the help of the biochemists, arose the science of immunology. The microbiologists had long measured the serum levels of

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antibodies against various bacteria. Diphtheria antiserum was first used in the province in the 1890s, and immunization of children against one infection after another had played a major part in the control of infectious disease.This was all "humoral" immunology, characterized by the presence of a circulating antibody; the need to treat burned pilots in the Second World War with skin grafts had led to a second major division, cellular immunology, in which the response was conveyed by lymphocytes. As kidney transplantation became the preferred treatment for kidney failure, the need for immunological research, both theoretical and clinical, burgeoned. This was symbolized by the creation of the separate University Department of Immunology in 1969, headed by a distinguished import, Dr. Alec Sehon. In William Boyd's day, the Department of Pathology had a predominant influence in the medical school; its teaching was the foundation of the study of disease. When Boyd walked along a corridor in the Winnipeg General Hospital, the clinicians heard and attended the sound of his steps. In later years his successors did not always receive the same respect. When he left Winnipeg in 1937, he left a competent hospital anatomic pathology department, where pathologic diagnosis was as accurate as in most places. The high-water mark had been reached. Boyd was followed by two of his pupils, both of whom were less charismatic than he. Dr. Daniel Nicholson wrote an excellent practical laboratory manual and established a blood-transfusion laboratory in the Department of Pathology. Dr. John Lederman was also a competent teacher and an adequate diagnostician. Boyd's followers taught in the Boyd museum, but the touch of the master had gone. Boyd had invested much time and ability in building up his own reputation while leaning considerably on others and had spent less time in cultivating research than in teaching. The Department of Pathology at the Winnipeg General Hospital remained the core of pathology in the province. Dr. Daniel Nicholson, with the financial assistance of the Rotary organization, opened a bloodtransfusion laboratory. A medical student, Donald Penner, helped to start the blood-transfusion services. It was difficult to find donors in the early days, but he persuaded the convicts at Stony Mountain penitentiary to give blood by assuring them of a square meal afterwards. They lined up, and he collected their blood and would drive back to Winnipeg, laden with bottles of blood. One dark night, there was a collision at an unlit corner, with a truck. When the police appeared, a huge pool of blood spread over the road. The circumstances looked suspicious but Penner, renowned as a talker, talked his way out of it. Medical students as far back as 1943 were paid donors ($25 for a private patient and $10 for a public-ward

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168 Chapter 9 patient), and patriotic citizens would regard it as their duty to give blood for the armed forces. As early as 1945, the Pathology Department was able to send ninety-five flasks of plasma to a disastrous hotel fire at Red Lake in northwestern Ontario. By 1949, the responsibility for blood-transfusion services had passed to the Canadian Red Cross Society. The society had conducted a successful campaign to collect supplies of fresh serum during the war. It now had a permanent centre in Winnipeg and sent out mobile units to collect blood. The blood was stored in the centre, grouped ABO and Rh, and tested serologically for syphilis. Blood not used was converted into dried, irradiated plasma. A national blood transfusion service did not develop as it did in Britain, nor did blood transfusion become a separate medical sub-specialty. This failure in vision came to matter later on. Other aspects of haematology were divided between a subgroup of pathologists, the laboratory haematologists, and the group of clinical haemato-oncologists, led by Dr. Lyonel Israels; considerable new work on bilirubin metabolism, the breakdown of blood pigment, came from the latter. Penner, by now a pathologist, also introduced cervical cytologic examination to the province, in collaboration with the gynaecologists, notably Dr. Alex Goodwin. Women with precancerous conditions of the uterine cervix were diagnosed early, allowing effective treatment. Later, as radiologists with long needles probed deep and produced minute biopsies, the pathologists became adept at interpreting disease from tiny tissue fragments. Pathologists retained responsibility in subsequent years for the investigation of deaths in suspicious circumstances.Their job has been become more systematic and detailed, and the screening of bodies for alcohol and drugs has become ever more complex, under the control since 1972 of a chief medical examiner. Successive generations of hospital pathologists have shouldered the tasks of forensic pathology as a time-consuming and often unpleasant addition to their hospital duties; more recently, hospital biochemists have sub-specialized in forensic biochemistry. The indications for medicolegal inquiry have become numerous and complex. In Manitoba as elsewhere, it is becoming increasingly more difficult to die in an unregimented manner. Pulmonary medicine was important in Winnipeg in the early 1960s and, when Dr. John Wyatt was appointed head of Pathology in 1964, he and his colleagues successfully developed experimental research in pulmonary biology. Boyd's pathology museum shrank into a single room to make space for experimental laboratories, whereas in Toronto andVancouver other pathology museums created by Boyd remained as teaching tools. In Winnipeg,

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the days when students gathered in the pathology museum to learn about medicine were gone. In the peripheral hospitals, pathologists were paid rather low salaries as hospital employees and increasingly offset this by setting up profitable private laboratories, where they provided services not only in anatomic pathology but also in biochemistry and haematology, and where technicians could run the automatic machines that now did analyses. Biochemistry was evolving from analysis of proteins and enzymes to the elucidation of the mechanism of inheritance and the analysis of DNA. Such techniques were soon applied daily in practical diagnosis. In the 1940s it would be usual to measure such chemical constituents of the blood as the plasma urea, glucose and uric acid, and the urinary protein and sugar. The measurement would often be made by an intern in a side room. As the decades marched by, biochemical analysis became at once more complex, more automated, and more rapid so that, twenty-four hours after withdrawal of a blood sample, estimations of forty or fifty biochemical components would be available.

The Image Makers: Radiology Another basic science, not chemical but physical, increasingly dominated medicine in the 1940s and subsequent decades: radiology. By the 1930s, xray diagnosis had become a mainstay of medicine, and radiologic empires had appeared in which doctors could make not only large contributions to diagnosis but also large incomes. The best known of these was that of Dr. Digby Wheeler, who became head of the University department. Wheeler had a prodigious appetite for work, and for money, and built up a large radiologic firm that served several clinics and provided services to urban and rural hospitals. He was a conspicuous figure, driving a Rolls Royce, accompanied by a bulldog. His shadows gave him an opulent substance. The plain x-ray was only the beginning. In the 1920s, barium had been introduced as a contrast medium for the visualization of alimentary lesions. This was followed in the 1950s by basic angiography: a needle would be introduced into a superficial vessel; down it, a wire was passed; the needle was withdrawn and a fine catheter passed into the vessel.The infusion of an iodinated contrast medium allowed visualization of a venous or arterial tree in many sites. From this followed stereoscopic angiography, the examination of the vascular tree in three dimensions. Air was used as a contrast medium in investigating the central nervous system. As the techniques proliferated, the radiologists became expert in one or another of the new artifices and also sub-specialized and developed particular

170 Chapter 9 expertise in an individual body system; Dr. Arthur Childe, for instance, had been trained in the Montreal Children's Hospital and Neurological Institute and was a particular expert on radiology of the central nervous system. Without his expert services, the neurosurgery unit of the 1950s and 1960s could not have developed. The new radiology was a very academic subject, and in 1966 Dr. Douglas MacEwen became head of the new University Department of Radiology, which was exceedingly successful over the next twenty years. Radiologists were well placed not only to make valuable diagnostic contributions but also to venture into treatment. Their close collaboration with clinicians ensured the success of developing radiology. By the early 1980s, interventional radiology was established. The radiologist could introduce a needle and watch where it went, could suck back tiny portions of tissue for diagnosis, could introduce a little balloon to stretch narrowed arteries, or particles, to embolize the vessels in a neoplasm and perhaps destroy it. Any hollow tube was fair game: bile duct, ureter, bronchus. Radiology could determine the precise site for injections to relieve pain or determine where the needle should be inserted to dissolve an intervertebral disc that was causing sciatica. Developments in ultrasound allowed good localization for biopsies. Radiology spawned like the frogs in the spring. In 1964, Dr. Michael Saunders introduced the first ultrasound machine to the Winnipeg General Hospital. It was used first for examination of the brain and the heart, and later the abdomen and pelvis, and was of particular value in examination of pregnant women because it provided an image of the fetus without damaging fetal tissues.The first computerized tomographic (CT) scanner came in 1976, giving a new accuracy by providing an image of a simulated slice of the body. Magnetic resonance imaging developed in the 1980s: a computerized image was constructed from the emitted energy after a radio pulse. Efficient computers facilitated most of these developments, and fine catheters made from new synthetic materials allowed the eyes of the radiologist to peer into the uttermost crevices. The allied discipline of nuclear medicine developed at the same time. It had started with the use of gamma cameras to make an image of such organs as the thyroid after injection of radioactive iodine, which was taken up by the thyroid. The variety of radiopharmaceuticals became wider, and it became possible to examine the breakdown of bone in bone cancer using such isotopes as technetium, treated by the body as if it were calcium.

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As radiology became more complex, a highly organized training program for their residents developed with a mandatory year away. Radiologists planned the financial side of their specialty well, on an item-for-service basis. Dollars sprouted like beans from their ever more complex tests, and were planted to defray the cost of the next generation of equipment. Radiology cost money and implied expensive heavy equipment and expensive buildings with high ceilings, rock-steady floors, and heavily shielded walls. Planning and purchasing the next generation of equipment, installing, testing, and maintaining the present generation, and servicing the last generation, took physicists and technologists much time. The ability to plan for the province led to economical use of machinery; by 1988, the two CT scanners were among the most heavily used in North America. And the newer, less invasive gadgetry allowed older, more invasive techniques to go out of use. More invasive techniques such as the pneumoencephalogram, the ventriculogram, and the cerebral angiogram fell into disuse; less invasive techniques gave more information and distressed the patient less.The contribution to medicine made by the radiologists was enormous.

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Since the Wars: The Specialists

10 Progress in basic science, and the applied sciences of laboratory medicine, led to better medicine; the new medicine was the world of the specialist. Specialized internists appeared. They were physicians who specialized in medicine, practised in hospitals, and had access to sophisticated investigative apparatus. Such physicians were at first general internists who would regard themselves as capable of looking after serious, non-surgical disease of any organ.The specialized internist was able to make a living by treating diseases too difficult for the general practitioner, or at least by trying to. The general internist soon specialized further; knowledge advanced so rapidly that it became impossible for one internist to be competent to treat more than one kind of disease, or one organ system.This sub-specialization was resisted by some physicians and promoted by others; after considerable discussion, the Royal College of Physicians and Surgeons of Canada fostered it by setting up sub-specialist examinations. By 1942, there were separate examinations in general surgery, general internal medicine, paediatrics, ophthalmology, ear, nose, and throat surgery, and urology, and these multiplied. Infectious disease was still the main killer in the late 1930s. By 1953, the picture had improved: diphtheria was much less common due to immunization; scarlet fever and its complications less common due to sulphonamides and antibiotics; whooping cough rather less common, perhaps due to immunization. Poliomyelitis was a major problem until effective immunization developed, encephalitis was now recognized to be of viral origin, transmitted by mosquitoes from such animals as horses, and mosquitoeradication campaigns were carried out. There were dramatic advances in treatment of such diseases as pneumonia with the development of antibiotics,

174 Chapter 10 penicillin, the tetracyclines, chloramphenicol, and many more. As treatment of cancer improved, it was more often necessary to treat infections in patients whose immune systems had been suppressed.The infectious-disease physicians, who bestrode clinic and laboratory, formed a powerful specialty in which the skills of the physician were allied to those of the laboratory microbiologist. The skill lay increasingly in finding the right antibiotic or combination of antibiotics to treat resistant infections. Effective antiviral agents were in the future. Heart disease and stroke were next on the list of killers, and so arose cardiology. Cancer was the next greatest problem, handled by physician, radiotherapist, and surgeon. In due course, there was to be a specialist for every organ system: heart, lungs, kidney, intestines, endocrine, skin, nervous system, bones, and joints. As the specialist physicians sub-specialized, the future of the general internist became less clear. Could an internist be sufficiently expert in so many things? The heart attack was the terror of the time; the chest pain passing down the left arm often summoned to eternity. Many Manitobans now lived affluent but physically idle lives, able to afford an expensive, high-fat, highprotein diet and its resultant obesity, and dealing with its tensions in a wreath of cigarette smoke. Cardiologists separated with some difficulty from the main body of general physicians, stimulated by the failure to treat effectively the two main problems, hypertension and coronary artery disease. Doctors talked of joining the coronary club. Manitoba physicians kept up with the world; cardiology, a new specialty, separated off, its tools the sphygmonianometer and the anticoagulant. The realization that hypertension caused cardiac disease triggered research from many angles by many specialists, cardiac, renal, and endocrine alike.The pharmacologists urgently investigated the manipulation of blood pressure by drugs.The early antihypertensive drugs were ineffective or toxic or both. Surgical attempts to reduce blood pressure by removing the adrenal glands or the sympathetic nervous chain were only partly successful; pharmacologic attempts to block the ganglia were only a little more effective. The ganglion-blocking agents such as hexamethonium, which became available in the late 1940s, had severe side effects. It was only in 1953 with the introduction of thiazide diuretics that effective and acceptable control of blood pressure began to be feasible. These were followed soon afterwards by the beta blockers and a range of other drugs.The end mechanism of tissue damage in hypertension was often blood clotting (thrombosis) in one vessel or several.This became controllable with the development of anticoagulants, notably heparin.

Since the Wars: The Specialists

Thus, a serious disease, malignant hypertension, was suppressed, if not cured, and the life expectancy of most hypertensive patients began to approach normal.This advance was one of the most important of the postwar era and occurred so gradually that neither the public nor the medical profession completely recognized its substantial benefit. Those who travelled brought back new ideas and techniques. Dr. Robert Beamish returned from training at the National Heart Hospital in London in 1948 to establish a clinic devoted to hypertension and a sub-specialist Department of Cardiology in the Manitoba Clinic. Here anticoagulants were used in impending heart attacks (unstable angina).Beamish also brought back the technique of heart catheterization and carried out, with Dr. Jack Hildes, the first heart catheterization in Winnipeg. An electrocardiograph department developed in the Winnipeg General Hospital, organized by Dr. F.A.L. Mathewson from 1934 to 1967.The technique became more complex, and other methods of analyzing cardiac action developed, specifically the analysis of heart sounds: first phonocardiography, then echocardiography By 1958, radiologists were injecting contrast media to image the coronary arteries (coronary angiography).These techniques led to the introduction of little balloons to stretch narrowed coronary arteries (percutaneous transluminal coronary angioplasty), or more recently to stretch narrowed valves (balloon valvuloplasty). Defibrillators were introduced in a similar way to return cardiac contraction rhythms to normal and pacemakers to maintain regular cardiac rhythm. The immediate cause of a myocardial infarction was usually thrombosis in the coronary arteries. In the 1940s the complex mechanisms whereby clots formed in blood vessels were being elucidated. It became clear that stopping thrombosis with anticoagulant substances like heparin could halt the disease process. Anticoagulant treatment was very effective in reducing the death rate in patients with heart attacks. It was important to understand the progression of cardiovascular disease over the long term. Dr. Mathewson served as a medical officer in the Royal Canadian Air Force during the Second World War and was responsible for the physical examination of aircrew recruits. These examinations included measurement of height, body weight, and a resting electrocardiogram. Mathewson organized a long-term follow-up starting in 1948 of 3,983 of these men. Subjects in the Manitoba follow-up study maintained annual contact with their personal physicians, who examined them annually. The study continues still, even after Mathewson's death in 1994; the participants, a group of elderly men, undertook the responsibility of funding the continuation of the study when conventional funding sources dried up.

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176 Chapter 10 One of the most dramatic advances of the 1950s lay in the treatment of chronic renal failure. First, the new advances in membrane technology allowed science to simulate the kidney glomerular membrane and to develop extracorporeal membrane perfusion systems that worked. Useful artificial kidneys first appeared in 1951. Again, physicians in Winnipeg followed world trends actively, and by 1961 at Deer Lodge Hospital a disposable coil kidney was in use, under the supervision of Dr. Ashley Thomson. It was used to treat acute renal failure, barbiturate intoxication, and anaesthetic coma. In an early series of twenty-one patients, eight, who would otherwise have died, were saved. As hypertension was sometimes of renal origin and often had renal effects, the border between the cardiologist and the renal physician was often blurred. Artificial kidneys became more complex and successful, but the patient had to spend long hours attached to the kidney machine. Renal transplantation, introduced in 1954 and available in Manitoba in 1969, was preferable but was at first unsuccessful, unless the kidney of a twin was used.The immune response that led to kidney rejection was as time passed suppressed by drugs such as imuran and cyclosporine. A tissue-typing laboratory and a complex national communication network had to be set up to obtain optimal matching of donor and host. The new medicine saved many lives and cost many dollars. Respiratory medicine (respirology) originated largely from the success of the treatment of tuberculosis. The sanatorium movement had led to the formation of such hospitals as that at Ninette. Treatment was at first rest, good food, and fresh air, supplemented later by collapse of the lung and surgery. In 1948, streptomycin arrived; it took some time for its use to be publicly funded, but by 1949 there were enough hospital beds in the province for tuberculous patients. Para-aminosalicylic acid (PAS) and isonicotinic acid hydrazide (INH), and later rifampin, followed. The sanatoria emptied, and the tuberculosis problem was alleviated; young physicians and surgeons whose main interest had been pulmonary tuberculosis sought fresh diseases to conquer. In 1973, the sanatorium at Ninette was shut down, but the problem of tuberculosis in aboriginal patients remained. There was pneumonia; it had always been a killer, but the chest pain and shortness of breath that had led to the ten-day march to death or recovery was first interrupted by the sulphonamides in the mid-1930s, and then by penicillin and the tetracyclines. The scientific interest lay elsewhere. By 1955, a cohort of men had been smoking machine-made cigarettes for half a lifetime. Now these men came to see their doctors, blue and puffing due to chronic bronchitis and emphysema. Or they spat blood and died sooner of carcinoma of lung. Cigarette smoking and urban pollution drove new,

Since the Wars: The Specialists

slow epidemics. Women started to smoke in droves years later, and the epidemic struck them correspondingly later. The lethal nature of the cigarette was first identified in the late 1950s. The young physicians were drawn to the new epidemic; Dr. Reuben Cherniack attracted and trained a cohort of people who in their turn attracted ancillary specialists, such as pathologists.The respiratory physicians depended heavily on measurement of volumes of air breathed in and out (spirometry) and on radiology. Like many other Winnipeg physicians of the time, they travelled widely and came back with new ideas and new treatments. They were preoccupied with asthma and with chronic bronchitis, and emphysema, chronic obstructive pulmonary disease in the fashionable new terminology. Treating these diseases involved investigation of the allergens involved, and a new subgroup, the clinical allergists, emerged.Treatment of patients with advanced emphysema required administration of oxygen. The provision of home-care oxygen was necessary, and the new breed of respiratory physicians spent time both investigating respiratory function in the laboratory and visiting the patients at home, to be sure that the home-care oxygen system was working. They discovered little that was fundamentally new but had a local influence disproportionate to their numbers over the next forty years.The simple monitors that had originally been improvised, from space-flight equipment, became more complex.The lessons learned were important in the development of intensive-care medicine and paediatrics. Advances in other sub-specialties of internal medicine were less spectacular but significant; the Manitoba sub-specialists kept up with those elsewhere. The physiological and biochemical study of the endocrine organs led to rational treatment of endocrine disorders. New drugs became available to block the action of thyroid hormones, and radioactive iodine was used to destroy over-active thyroid tissue. The adrenal steroid hormones were used to treat a variety of inflammatory diseases, notably arthritis. As years passed, more and more hormone deficiency or excess states were identified and regulated by treatment with hormones or by reducing hormone production. The specialty of clinical endocrinology was born. The local interest in prolactin led to effective treatment of prolactin deficiency states. A local interest in cell receptors for oestrogen and progesterone led the physiologists to offer an effective service whereby the sensitivity of breast cancer to treatment by hormone manipulation might be determined. Some particularly effective health education was carried out on diabetes. A group of internists defined themselves by their specific interest in the nervous system; the neurologists, led for some years by Dr. Robert Ross,

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178 Chapter W derived great benefit from developments in scanning techniques in identifying intracranial lesions, and the menace of meningitis was reduced by antibiotic therapy; such advances were important in the development of improved neurosurgery. The ravages of arthritis have always been difficult to treat, so the specialty of rheumatology separated off in a rheumatic disease unit. The rheumatologists allied themselves to specialists in the rehabilitation of injury and to the paramedical physiotherapists. Patients' aches were reduced by administration of cortisone and non-steroidal anti-inflammatory drugs and by improved and extended physiotherapy. Diseases of the alimentary tract remained for a long time the purview of the general internist, but a subgroup of gastro-enterologists separated out, at first dependent heavily on radiologic techniques, outlining ulcers and tumours by means of negative images after the patient had swallowed a radio-opaque medium.They then learned to pass fine fibre-optic endoscopes, both down and up, so that only parts of the small intestine escaped their notice. As the endoscopes improved, the specialists became able to snip off biopsies (tiny pieces of tissue) that the tissue pathologist would strive to interpret. In the early days of the medical school, diseases of the skin had been closely related to venereology, since the protean manifestations of syphilis were often evident on the skin. In the 1950s and subsequently, treatment of skin diseases underwent a revolution. The antibiotics cured many serious skin infections, and the steroids suppressed, at least partly, many noninfectious inflammations. Most skin neoplasms were readily and effectively treated by surgical excision and by radiotherapy, and the plastic surgeons became more and more effective at complete excisions and repair of open skin wounds. Dermatology in Winnipeg flourished after the war, under the aegis of Dr. Arthur Birt. Birt trained in Winnipeg with Dr. Andrew Davidson and studied ringworm, then a major problem, particularly in children, treating it with an ultraviolet lamp. Birt contributed to the treatment of childhood eczema by devising appropriate dietary regimes and described polymorphous skin eruption, a rare light-sensitivity dermatitis in aboriginal people.

The Cancer Doctors After cardiovascular disease, the next major killer was cancer.The doctors who looked after cancer patients included radiotherapists, clinical oncologists, a brand of internist, and surgeons.There were major developments in treatment in the 1960s and 1970s: improved radiotherapy, chemotherapy, and to

Since the Wars: The Specialists

a lesser extent surgical techniques. Survival was better and there was hope for the future. The peak of belief that the new medicine could abolish cancer was reached when in the United States President Nixon naively dedicated a national plan to conquer cancer in the 1970s. This has not yet happened; we should be a little sceptical in regard to more recent similar claims. The problem was being recognized in the 1930s: Dr. M.R. MacCharles, a leading cancer surgeon at that time, had realized the need for a systematic attack. A central provincial cancer registry was set up in 1937 and a tumour service in the Winnipeg General Hospital in 1940. In 1944, the Manitoba Cancer Treatment and Relief Institute became the sole provider of radiotherapy in Manitoba; systematic follow-up programs were set up, a new 250-kilovolt radiotherapy machine and a plant for making radon seeds were installed.The more powerful the radiotherapy machine, the better the chance of eradicating the tumour with minimal damage to the patient's own tissues. In 1953, one of the new cobalt "bombs" was installed. This allowed more effective treatment of pelvic malignancies with relative sparing of skin.There was a shortage of properly trained medical radiotherapists; in 1953, two radiotherapists, Doctors James Bennett and James Gillies, were imported from Glasgow, and in 1954 Dr. Richard Walton, a New Zealander trained in England, was appointed as medical director. In the same year, St. Boniface Hospital installed a radiotherapy unit. The organization of cancer care was improved when in 1957 the Manitoba Cancer Treatment and Research Foundation was set up to provide comprehensive treatment, care, and education, and to foster research; a purpose-built cancer centre followed, full of the latest expensive gadgets. The basement radiotherapy floor housed a thirty-eight-megavolt betatron, its twelve tons suspended from the ceiling on a massive yoke, allowing it to move up and down and rotate through 180 degrees. It was fitted with a closed-circuit television, two-way voice intercommunication, and a fluoroscopy unit. An early research project investigated the use of hyperbaric oxygen as an adjunct to radiotherapy, an avenue that turned out to be of little value. As the years passed, new equipment was acquired regularly: in 1972 a simulator to aid in planning treatment; in 1973 a linear accelerator. A further building expansion in 1980 provided more research space.The microcomputer revolution of the 1980s was of particular use to the radiotherapists. The progressively more powerful radiotherapy equipment always had the aim of greater destruction of tumour tissue, with less effect on the adjacent normal tissues.

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180 Chapter 10 The most striking progress in treating neoplasms between 1945 and 1985 was due to the development of chemotherapeutic agents that interfered with the proliferation of cancer cells, and also of other dividing cells; their side effects were dire: baldness, diarrhoea, failure of the bone marrow, and overwhelming infections. The chemotherapeutic drugs initially used were mainly effective for leukemia, particularly childhood leukemia, and for neoplasms of the lymphoid system. The leader in developing this area, and cancer services in general, was Dr. Lyonel Israels, known initially for his work on bilirubin metabolism and on leukemia. He developed a medical field new to the province, haemato-oncology, or, as chemotherapy for most cancers became possible, just oncology. The use of such toxic drugs demanded close medical supervision and also a careful analysis of how large a dose was needed to kill all the cancer cells, without killing the patient as well. The clinical trial was born. Many of the curable cancers were haematological; some previously fatal childhood leukemias had by the mid-1980s a fifty-percent cure rate, Hodgkin's disease, previously always fatal, had an eighty-percent cure rate; many testicular cancers were curable. The tumours of trophoblast, the tissue of the embryo responsible for obtaining nutrition from the uterus, were in 1955 100-percent fatal and had by 1985 an eighty-percent cure rate. Survival improved at least somewhat in many others.There was a price to pay: after most cancer chemotherapy, patients vomited distressingly and, because of damage to marrow cells, often became very susceptible to infections. The new sub-specialists, the clinical oncologists, had to be particularly expert in the use of the increasingly effective but toxic anti-cancer drugs and skilled at treating the infections common in cancer patients treated with these drugs. As more new drugs appeared, it became increasingly important to measure objectively how effective they were. Selection of patients for different treatments had to be random. Such a randomized clinical trial held in Manitoba in 1981 examined the effects of chemotherapy on breast cancer. As chemotherapy for cancer developed, it became apparent that patients who lived in rural areas were subjected to unnecessary inconvenience because they had to come into Winnipeg for treatment.This was significantly alleviated by coordination between Winnipeg oncologists and rural physicians to provide specialized treatment of cancer in rural hospitals, an outreach program. Israels led the development not only of the necessary clinical skills and clinical research but also of basic research into the underlying cellular problems of cancer and its cure and, in due course, the foundation of the Manitoba

Since the Wars: The Specialists

Institute of Cell Biology. The students had to be taught the new field, and so over the years there was a gradually successful pressure for teaching time in the medical undergraduate curriculum. Yet, many cancers could still only be palliated. It was realized that doctors were not good enough at alleviating the suffering of the dying; better terminal care was needed.

The Sleep Doctors: Anaesthesiology Anaesthesia has become progressively safer and more effective since 1945, due to improvements in anaesthetic machines, better anaesthetic agents, and better understanding of their pharmacology. In 1945, anaesthetists were rudely nicknamed "gas passers"; their status and skill have since risen greatly. By 1945, the open-ether "rag-and-bottle" had long given way in major hospitals to closed-circuit positive pressure machines that administered one or another anaesthetic gas: nitrous oxide, ether, chloroform, or halothane, along with oxygen. Respiration was maintained artificially after paralysis by curare, or succinyl choline; the manual inflation of the anaesthetic bag was replaced by a machine that artificially maintained breathing. The patient's respiration and metabolism were increasingly closely monitored. As variants, intravenous barbiturates had been in use since the early 1930s to induce anaesthesia, and spinal anaesthesia had been in use since the early 1900s. In the latter technique, drugs were injected into the spinal canal. In 1945, Winnipeg anaesthetists were salaried hospital employees with heavy workloads due to increasing and more complex surgery and with relatively low incomes; they were assisted by general practitioners and even medical students. Things changed in the late 1940s, and by 1953 most Winnipeg anaesthetists were practising on a fee-for-service basis and were significantly better off. Anaesthetists had correspondingly little academic influence in Winnipeg in 1945. They gave a few lectures to fourth-year students just prior to their final examinations.The fourth-year student was still expected to give a few open-drop ether anaesthetics under supervision and the intern to spend a month on the anaesthetic service. As an academic subject, anaesthesia remained a sub-department of surgery. As surgery became more complex, the contribution and skill of the anaesthetists enlarged. Surgeons expected them not merely to send the patient to sleep but also to maintain suspended animation, with artificial circulation.The increased sub-specialization among surgeons led to corresponding sub-specialization among anaesthetists. Moreover, their skills were needed in areas outside the operating theatre: management of severe chronic

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182 Chapter W pain, intensive care of patients with acute cardiac or respiratory problems, the provision of oxygen therapy. Highly competent anaesthetists were among the postwar wave of emigrant physicians from Great Britain, Ireland, and Continental Europe, and in time a new generation of anaesthetists appeared who were not only well trained in formal postgraduate programs in clinical use of anaesthetics but trained also in experimental physiology.They were bright, articulate, and active in research. Dr. Colin Ferguson, appointed head of the Department of Surgery in 1954, recognized the need for better training of anaesthetists and their deeper involvement in academic life; Dr. James Parkhouse was appointed full-time professor of anaesthesiology in 1966, and in 1969 a separate University department, Anaesthesiology, was instituted. Anaesthetists were now the equals of surgeons. Their specialty, now one of the most complex and challenging in medicine, combined a knowledge of the subtleties of physiology and pharmacology with an onerous and often urgent responsibility for life. Their help in maintaining life was needed in many emergencies as was their knowledge of local anaesthesia in treatment of chronic pain. Dr. John Wade, first head of the independent University Department of Anaesthesiology, symbolized the change. He had been well trained in cardiorespiratory medicine and in experimental physiology as part of his preparation for academic anaesthesiology. From the Department of Anaesthesiology flowed research on such topics as oxygen saturation in the brain, the control of pressure and ionic concentration in the blood, and the effects of various anaesthetic agents on brain blood flow, matters vital to sophisticated modern anaesthesia. Equally important was a series of epidemiological enquiries into illness and death after an anaesthetic; death due to the anaesthetic itself was now rare but morbidity still not uncommon. Such research forms the basis of increasing the safety of anaesthesia by routine monitoring of results in any hospital. The practice of clinical anaesthesia underwent a major transformation between 1945 and 1985. No more struggling as ether anaesthesia was induced; much less vomiting during recovery. Omnopon and scopolamine gave way to other pre-medications.The old practice was deep general anaesthesia with relatively toxic inhalation anaesthetic agents, administered to a spontaneously breathing patient. During the operation, the anaesthetist would do little more to monitor anaesthesia than put a finger on the pulse. As the years went by, anaesthetic agents became less toxic and anaesthesia lighter but were supplemented by such receptor-focussed agents as narcotics and muscle relaxants, often with controlled, artificial ventilation.

Since the Wars: The Specialists

Anaesthetic machines became more sophisticated, with multi-faceted clinical monitoring devices providing information heartbeat by heartbeat and breath by breath. Oxygen and carbon dioxide levels were monitored, as well as blood pressure, heart action, and much more. The rate of unpleasant complication during and after anaesthesia fell markedly, and it became possible to operate on patients previously too old or too sick for surgery. And it became possible to carry out much more extensive and complicated surgery than before. Manitoba anaesthetists knew they had arrived when in 1982 Wade became dean of Medicine. It was a far cry from "passing gas."

Surgeons on the Wings of the Morning Surgery by 1945 had become safer, but death from haemorrhage, from pulmonary embolism and from infection was still lamentably common. Radical mastectomy was the treatment of choice for breast cancer, and gastrectomy (or gastrojejunostomy a bypass operation) for peptic ulcer. Hernias were treated with relative safety, and inflamed gall bladders and appendices were removed with only an occasional tragedy. While the abdomen was well explored and the thorax known territory, the central nervous system was seldom invaded and the heart and blood vessels were still unknown country. The bones and joints increasingly belonged to orthopaedic specialists. Many, but not all, doctors performing surgical operations had advanced postgraduate training and were Fellows of the Royal College of Surgeons. The further from the centre of Winnipeg, the less was this true. Over the years, the relative number of surgical specialists increased. In 1955, of 1,560 registered physicians in the province, 103 were surgical specialists, not all yet College Fellows; by 1993, of 2,382 physicians, 282 were surgical specialists, all College Fellows. Their surgery was not yet protected by antibiotics and especially outside Winnipeg their anaesthetists were not always fully trained in their specialty. Patients did not yet have the benefit of detailed control of the chemistry of their body fluids and of blood clotting during and after the operation. Preconditions for further surgical advance included better anaesthesia, better pre-operative examination, and post-operative care and haematologic control of blood clotting, blood transfusion. The changes between 1945 and 1983 were great: blood clotting was controlled, infection was treatable, blood electrolytes were monitored, radiologists imaged every cranny and nook, anaesthesia was safe and effective. With all these supports, surgeons of one brand or another were ready to take the wings of the morning and dwell in the uttermost parts of the

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184 Chapter 10 human frame. Whatever the assistance from others, the manual dexterity, the credit for the clinical skill, the intellectual resolve, and the moral courage would be theirs alone. Further advance in surgery implied effective leadership, which should have come from the University Department of Surgery. In 1945, its affairs were not at their highest point. While the scalpels were sharp and the surgeons competent, there was a lack of overall direction. Dr. Oliver Waugh, then head, was by 1945 ailing and elderly. A younger man was required as head of Surgery. There were several active and influential surgeons at the Winnipeg General Hospital: Thorlakson, MacCharles, Fahrni, and Burns. The Winnipeg General group all agreed to support whichever one of them was chosen, but the Faculty of Medicine recommended the appointment of Dr. C.E. Corrigan, the able chief of Surgery at St. Boniface General Hospital. Corrigan was well trained and, unlike most Winnipeg surgeons of the time, a Fellow of the Royal College of Surgeons of England, the best diploma in the business. He had written a good teaching book and had a distinguished war record, about which he later wrote well but anonymously. He was a modest man and did not want to move from St. Boniface Hospital, where he was content. It was not felt that the University head should be seated at the "lesser" hospital, so, without appropriate consultation with the dean of the Faculty of Medicine, the authorities of the University of Manitoba and the Winnipeg General Hospital appointed Thorlakson, who was a surgeon at the Winnipeg General. The dean saw this as an infraction of academic rights.He did not cooperate and made Thorlakson's position untenable; after less than a year of turmoil Thorlakson resigned, to be succeeded by the safe but less adventurous Dr. Charles Burns. It was a storm in an academic teacup, in the worst traditions of universities and teacups. Thorlakson and Corrigan came out of it with dignity, Dean Mathers less so. His time, too, was passing. The local surgical world changed when in 1954 Dean Bell appointed Dr. Colin Ferguson as head of the Department of Surgery; Ferguson had graduated MD (Manitoba) in 1945, having served in the Canadian Navy in the Second World War; he was well trained, notably in Boston in the new field of paediatric cardiac surgery. The appointment of a sub-specialist to such an academic post indicated the dawn of a new surgical day, but many surgeons, conservative folk, came to scoff and remained to obstruct. Sub-specialization threatened incomes; the resultant political schisms in the Winnipeg surgical world for long denied

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Ferguson access to the adult surgical wards at the Winnipeg General Hospital and reduced his influence. Family doctors without a postgraduate surgical diploma still practised major surgery; it added interest and financial profit to rural practice.There were a few whose surgical training and standards were lower than their aspirations, to the peril of their patients, but most were at least competent, some excellent. In rural areas, the general practitioner surgeon was what was available; many such practitioners assiduously obtained specific postgraduate instruction in the areas of surgery in which they actually practised and kept it up with refresher courses. Minneapolis and the Mayo Clinic were favourite training centres. Such doctors gave sterling service to their communities over many years. Their efforts were supplemented by visiting surgeons travelling by car or later by plane from Winnipeg. There were difficulties: sometimes the visiting surgeon did not see the patient before the day of operation. This was declared unethical by the Royal College of Physicians and Surgeons and was finally legitimized by a set of guidelines issued by the provincial College of Physicians and Surgeons. The newly powerful Royal College of Physicians and Surgeons was aware of problems in rural surgery and also may have wished to emulate the monopoly position of the older British Royal Colleges.The Royal College claimed that only its surgical Fellows should operate, but it took over thirty years to enforce this.The general surgeons were similarly reluctant to give up parts of their practice to younger sub-specialist colleagues. Family doctors earned fees by assisting in the operating theatre and at times received a fee without actually being there. Some family doctors would not refer a patient to a surgeon who would not split the fees.This fee-splitting caused much dispute. Sub-specialties apart, the general surgeons remained in charge of the abdominal cavity; the mortality and morbidity rates following such common procedures as appendicectomy, cholecystectomy, and hernia repair fell progressively and the methods of coping with common causes of postoperative mortality improved.Antibiotics treated the infections, and early postoperative mobilization reduced the leg-vein thromboses that had so often led to lethal pulmonary embolism. In the 1980s, the general surgeons were converted from the stem-to-stern incision; improvements in fibre-optic technology and smaller cameras allowed them to insufflate the abdomen with gas and carry out first appendicectomies and then cholecystectomies through tiny laparoscopic incisions. The improvements in technology and financial pressures led to great reductions in hospital stays. Repair of a

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186 Chapter 10 hernia, once entailing up to three weeks in hospital, came to be done as an out-patient procedure.

Subspecialist Surgery In the early 1950s, Winnipeg needed cardiac surgery. It seemed ridiculous that an otherwise perfect child should die because of a congenital mechanical anomaly in the heart, or that an adult should die because of mechanical defects in the heart valves, often caused by rheumatic heart disease or because occlusion of a small, narrow segment of a coronary artery caused a heart attack. Advance was occurring elsewhere, and Winnipeg was not far behind. In 1953 and 1954, surgeons who were experienced in chest surgery carried out numerous mitral valve operations on patients with rheumatic mitral stenosis at several Winnipeg hospitals. For further advance, it was necessary to cool the patient to reduce oxygen consumption (hypothermia) and to raise the blood oxygen level artificially by means of a pump replacing the heart (the pump oxygenator). Further advances in Winnipeg were led by two remarkable men. Operating on the tiny hearts of small children was a daunting task. Dr. Colin Ferguson recruited a team of physicians and anaesthesiologists and collected equipment including a pump oxygenator. The new Children's Hospital, opened in 1956, provided good conditions for clinical work, and in the experimental surgical laboratories a variety of problems mainly related to cardiac surgery were studied. Ferguson had, in addition to technical expertise, a great concern and love for children. At his Saturday morning rounds, children slated for elective surgery were prepared psychologically for surgery by letting them see the operating rooms and masked-and-gowned personnel. At St. Boniface General Hospital, another young surgeon, Dr. Morley Cohen, developed adult cardiac surgery. Cohen graduated MD (Manitoba) in 1948 and trained in Minneapolis, where he was involved in the development of open-heart surgery. On return to Winnipeg, he built up a successful cardiac surgical team at St. Boniface Hospital, backed by a productive experimental surgical laboratory. Cohen himself was deeply dedicated to the welfare of his patients, staying in the hospital until all hours to monitor their post-operative progress. The St. Boniface team carried out its first open-heart operation in 1959, only a little ahead of the team on the other side of the city. Thus, by the middle 1960s, it was useful to operate on such congenital heart defects as patent ductus arteriosus and coarctation of the aorta in

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Winnipeg as elsewhere, and attempts were being made to correct more complex disorders. In adults, mitral valve operations for rheumatic heart disease were similarly commonplace, and mitral and then aortic valves were being replaced in 1962. By 1961, the coronary arteries were being imaged by injecting radioopaque media, and x-raying the patient's heart (coronary arteriography). This led to the repair of coronary arteries, at first by patching and then by bypassing the narrowed coronary artery with a graft. In 1970 the first triple coronary bypass was performed. By the early 1980s, attention was fixed on the more complex cardiac anomalies and on the late complications of valvular disorders, the surgical treatment of ischaemic heart disease was expanding, and permanent pacemakers were being implanted. Cardiac surgery demanded good biochemical and haematological support and careful postoperative care and follow-up. Its success sparked off research into a wide variety of allied problems and rigorous training of young surgeons to the requirements of the Royal College of Physicians and Surgeons of Canada. As the years went by, techniques improved, more complex cardiac problems were tackled, and better and more complex valve prostheses were introduced. The early operations had been nerve-wracking, demanding of the surgeon firm resolution as well as delicate fingers.The costs were high, and lack of resources became a problem. Surgery for ischemic heart disorders was expanding, but not fast enough. During the spring of 1980, the mortality on the long surgical waiting list was higher than the surgical operative mortality. The surgery of blood vessels was not neglected. Dr. Alan Klass had treated intestinal ischaemia by removing an embolus from a mesenteric artery in the early 1950s; thereafter, a new sub-specialty of vascular surgery grew up, led by Dr. Allan Downs, later head of the Department of Surgery. Surgeons now had new and effective operating microscopes and could suture tiny vessels. The rupture of a stretched section of the abdominal aorta, aortic aneurysm, had in the past caused sudden death; modern anaesthetic and bypass techniques now allowed the abnormal segment of aorta to be excised and replaced by a dacron graft. Constrictions of peripheral limb vessels had long caused gangrene. The constricted segment could now be bypassed and clots in the vessels removed as an emergency surgical procedure. There had been some neurosurgery services in Winnipeg before 1950. Dr. Oliver Waugh and Dr. Hugh Cameron provided neurosurgical service at the Deer Lodge Veterans' Hospital and in 1947 were removing parts of

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188 Chapter W the cerebral cortex (lobotomy) from psychiatric patients profoundly ill with schizophrenia or deep depression. Lobotomies were also being done in Brandon. The operation was abandoned in the early 1950s as ineffective and sometimes harmful. In 1950, the time was ripe for advance in neurosurgery; there were already several specialists in essential neurological techniques in the Winnipeg General Hospital. Dr. Michael Saunders was a clinical neurophysiologist trained in Manchester, Dr. Harold Rice had developed an electroencephalogram for measuring brain waves as a way of detecting neurological abnormalities, and Dr. A.E. Childe had extensive experience in neuroradiology. Dr. Dwight Parkinson, a McGill graduate, trained at the Mayo Clinic, was appointed in 1950 as head of Neurosurgery and over the next few years built up a widely known and successful neurosurgical unit in liaison with neurologist Dr. R.T. Ross.The major technical advance in the 1960s was an effective operating microscope, with co-axial illumination, which gave the surgeon an excellent view into a narrow opening. Parkinson latterly became a world leader in the difficult area of caroticocavernous fistula, a lesion of the cavernous sinus, inaccessible, and deep within the head. He developed multi-disciplinary teaching rounds and a successful training program. The development of a successful neurosurgical service was impaired by the parochial opposition of hospital administrations to centralization of actual neurosurgical operations. Even in the Winnipeg General Hospital, there was often a cheese-paring attitude to the provision of such simple aids as secretarial help.The group attracted other neurosurgeons, including an expert in transphenoidal surgery in 1973. By 1984, there was an integrated organization of neuroscientists, physicians, surgeons, laboratory physicians, and basic scientists.This was the necessary organization for successful treatment of brain tumours and other local brain lesions. Urologic surgery continued on its separate channel. Dr. C.B. Stewart trained in Winnipeg and Edinburgh, became FRCS Ed in 1932, and subsequently worked in St. Peters Hospital for Stone in London and the Berlin Charite. Treatment of benign prostatic enlargement improved, but prostate cancer continued to be a significant cause of death; there was no effective cure, but surgical and later chemical castration came into vogue as palliatives, to retard progress of the disease. The vascular surgeons, with the aid of the urologists, successfully developed renal transplantation. The first, unsuccessful, attempts at relief of renal failure by transplantation of cadaver kidneys were made elsewhere in the early 1950s, but the kidneys were usually rejected. Only the kidneys of identical twins were accepted. In 1969, the first successful kidney transplant

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in Manitoba was carried out at the Winnipeg General Hospital by Dr. Allan Downs. Drugs became available to suppress the immune response and rejection of the grafted kidney (steroids, azothioprine, and later cyclosporine), and adequate techniques of tissue typing were developed. Renal transplantation became routinely successful. By 1983,150 renal transplants had been performed. The urologists were successful in adapting to the new techniques of passing fine catheters into unlikely places. They passed catheters through a small flank incision into the renal pelvis, or up the urethra and into the ureter, and were able to grasp and break up urinary stones, previously a cause of severe pain. By 1988, they could set up electrical shock waves to break up such stones (lithotripsy). The orthopaedic surgeons split off from the general surgeons after the First World War. From dealing with fractures, their interests had widened to include a wide variety of skeletal deformities, and in particular the replacement of painful, severely damaged joints. New diagnostic methods such as scanning bone with radioactive tracer and CAT scanning allowed more precise diagnosis. The introduction of effective antibiotics revolutionized the treatment of infections of bone and joint, including tuberculosis, and allowed safe operation on bone: fractures could be pinned with metal pins with little risk of infection, and severe deformities of the spine (scoliosis) could be corrected surgically. Diseased joints could be examined by the introduction of devices to view the interior of the joint (arthroscopy), and painful chronically osteoarthritic joints could be replaced by artificial prostheses; this became widespread, as did the replacement of the head of the femur in elderly people with fractures. The best known of these protheses was the successful artificial knee developed by Dr. Frank Gunston, later of Brandon. The rising toll of road accidents led to an increasing need for surgical repair and rehabilitation. As more people participated in sports, the sub-specialty of sports medicine arose.

Squint and SnifF: Eye, Ear, Nose, and Throat The diseases of eye, ear, nose, and throat are common and troublesome. By 1945, the specialists were segregating, eye one way, ear, nose, and throat the other. One private practice group of eye doctors served the community with distinction for sixty-three years, the partnership of Doctors N.L. Elvin, W.C. Guest, and DR. Magee, all trained in Winnipeg and qualified in ophthalmology with the Royal College of Physicians of Canada. Elvin was head of the University Department of Ophthalmology between 1949 and 1963. New ideas came with an incomer.

190 Chapter 10 Dr. Howard Reed, trained in London, arrived in 1953 and started to perform corneal grafting; the Lions Club set up the necessary Winnipeg Eye bank to supply donor corneas. In the following year thirty-two corneal transplants were done, and the procedure thereafter became commonplace. Reed also improved the traditional procedure of extraction of cataracts, first by extracting the cataractous lens in its capsule using a small plastic cup, then some years later by freezing the lens to make it easy to remove. Lens implantation was introduced in the mid-1970s, and, about 1984, eye surgeons began to emulsify the lens, extract the lens material, and replace it with a plastic lens in the lens capsule. In 1964, a specialist retina clinic was set up to deal with retinal detachment and glaucoma. Modern equipment was obtained: successively a ruby laser, a photocoagulator, and equipment for displaying the retinal vessels using fluorescein and for removing the vitreous humour (vitrectomy).Their success brought light back into many darkened lives. The ear, nose, and throat specialists became distinct around 1945.Their specialty had encompassed such conditions as chronic sinusitis and nasal polyps, chronic tonsillitis and adenoids, occasional neoplasms of the nasopharynx, laryngeal inflammation and laryngeal cancer, and common important and lethal mastoiditis arising from middle-ear disease. Dr. E.J. Washington, head of the Department of Otorhinolaryngology from 1938 to 1947, became expert in the surgical drainage of mastoiditis, a forerunner of the sophisticated modern operations on the small bones of the middle ear. The treatment of laryngeal cancer improved greatly when effective radiotherapy of the larynx became available. Otologists became interested in the detection of hearing loss in children and set up programs to detect it, and in the late 1970s in the mechanisms and treatment of dizziness and vertigo.

Women's Health: Obstetrics and Gynaecology There had been serious concern about maternal mortality just before the Second World War. A survey by the Division of Maternal and Child Hygiene of the provincial Department of Health and Public Welfare found that in the period between 1 May 1938 and 30 April 1940, of 27,965 births, 23,422 were attended by a doctor. One hundred and twenty-two mothers died, that is, 3.26 per 1,000 live births. This rate fell until 1952, when there were 0.5 maternal deaths per 1,000 live births; by comparison with elsewhere, it was still not good enough. The maternal mortality per 1,000 live births between 1911 and 1915 was 6.6 in Winnipeg only. It fell

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thereafter progressively, consistently below the rates for the rest of the province. In 1945, the obstetricians and gynaecologists, firmly set apart as a specialty, were led by Doctors J.D. McQueen and EG. McGuiness. McQueen, a Scot by birth, had graduated from the University of Manitoba in 1909 and then trained in the United States. He had a distinguished war record. McGuiness was born in Ottawa, graduated in medicine from the University of Manitoba in 1917, and trained thereafter in the Dublin Rotunda and Glasgow Royal Maternity Hospital. Obstetrics was still a very clinical subject; the patient would usually be delivered on her back, legs in the air, in the "lithotomy" position. Before the development of adequate blood-transfusion service, forceps delivery was thought safer than Caesarean section, despite risks to the baby.The best obstetricians were expert at turning a baby presenting backside foremost, the breech presentation. Many male obstetricians would incise the mother's perineum to facilitate delivery but not always take care in surgical repair, leaving the woman with persistent pain. Antenatal care had become much more careful, but toxaemia of pregnancy would be treated by coIonic irrigation, a common resort at that time for any baffling disease, equally ineffective for any. As time passed, obstetricians were becoming increasingly less inclined to meddle, for instance to use forceps in difficult circumstances, and their task was being made easier by the increasing availability of laboratory investigations. Ultrasound, in particular, introduced in the 1960s, made it possible to produce an image of the pregnant abdomen without harm to the fetus. Blood transfusion and the use of the pituitary hormone oxytocin made treatment of severe obstetric haemorrhage possible. After the war, the Caesarean section was changing; the baby was often being extracted through the lower segment of the uterus (lower-segment section). The best obstetrical care was good, but specialists were available only in the city, and there were significant problems in rural areas. Obstetricians, like many other doctors, were overworked during the war, and after the war their lives became almost intolerable due to the baby boom.The load on the maternity hospitals was heavy. A doctor might have to call around to every hospital in the city for a bed for a woman in labour and finish by pleading that yet another bed be set up in a corridor. In 1946, McGuiness began to work behind the scenes to arrange for a new Maternity Hospital; the old and overcrowded wards in the Winnipeg General were fertile ground for infection and the lethal puerperal fever.

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192 Chapter 10 The outbreak in 1936, which had cost several lives, was not forgotten. Earlier plans had been shelved because of the war, and there was still considerable resistance to the idea of a separate women's hospital; a major driving force behind the idea was a woman obstetrician, Dr. Elinor Black. Finally, in February 1950, the new Maternity Hospital opened. Three months later, as the patients were moving in, came the flood. As the water rose, maternity patients from other hospitals threatened by the flood had to be moved in from St. Boniface Hospital and the Grace. The confusions of a new building were further confounded by the overcrowding. Babies came in incubators whose plugs did not fit; garbage and linen chutes were mixed, so that the bed linen went to the incinerator and the placentas to the laundry. McGuiness, shaken by Parkinson's disease, was succeeded as professor and head of the Department of Obstetrics and Gynaecology by Dr. Elinor Black, a local graduate. Elinor Black was a formidable woman. She was an excellent obstetrician and educator, interested in the basic science behind her specialty. It was not easy for her as the first woman in Canada to head an academic medical department, but she won the grudging respect of her male colleagues. She kept students in order and would dismiss a student from her clinic for unprofessional appearance; young men with long hair, jeans, and sandals were not welcome. A good administrator, when necessary she kept her male colleagues in order as well. Outside Winnipeg she was widely respected and played a leading part in major professional organizations. The other great influence in obstetrics and gynaecology in this period was Dr. Rosslyn Mitchell, a highly competent surgeon who was one of the first to perform the new lower-segment Caesarean sections and removal of the uterus by the vaginal route. Mitchell had a second reputation as a medical historian. Obstetrics improved during this era; as fetal monitoring became more careful and Caesarean section safer, section would be carried out at signs of fetal distress. Maternal mortality remained a worrisome problem. In 1925 and 1926, the maternal death rate for Canada as a whole was 6.4 per 1,000 live births, and for Manitoba it was slightly higher at 7.7. By 1938 and 1940, the Manitoba rate had fallen to 3.26 and by 1948 to 1.4; in 1952, it was 0.5,but over the next decade it hovered around the same figure.Whereas elsewhere it was lower, in some parts of the United States as low as 0.1, at least among white populations. Over the period between 1952 and 1960, twenty-seven percent of maternal deaths were due to toxaemia, a complex kidney failure in pregnancy, which went undetected when prenatal care was lacking, and thirty-one

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percent to haemorrhage, attributable to distance from or lack of hospital facilities, notably blood transfusion. The improvements in maternal health and survival were attributable to general improvements in medicine: blood transfusion, antibiotics, ultrasound (a safe way of imaging the fetus), and the use of the pituitary hormone oxytocin, which helped to control severe post-partum haemorrhage. The picture was marred by the thalidomide disaster of the early 1960s when pregnant women were given thalidomide to treat severe vomiting; the result was severe fetal deformity. Seven such babies were born in Manitoba. In 1961, death review procedures were tightened up by the Maternal Welfare Committee, which emphasized that nearly all maternal deaths could be prevented and that, when a death did occur, responsibility had to be allocated: to doctor failure or lack of facilities, equipment, or personnel. A standard letter went to the physicians who had attended women who died between the ages of fifteen and fifty years to ask whether the patient had been pregnant in the year prior to death. This investigative function was taken over by the College of Physicians and Surgeons of Manitoba in 1975. More changes came with Black's successor, Dr. Mervyn Roulston, a genial Ulsterman. Roulston was a competent obstetrician, committed to medical education and to training his young colleagues, many of whom were sent off for sub-specialist training elsewhere, in such diverse areas as fetal maternal medicine, gynaecologic oncology, female endocrinology, infertility, family planning, gynaecologic urology, and adolescent gynaecology. Like other medical specialties, gynaecology had to splinter to keep up. Roulston had a profound interest in family planning and world population problems. Locally, in Winnipeg, his influence promulgated better family planning and safer abortion. In Winnipeg, obstetricians had incurred controversy by providing contraceptive advice, some as early as the 1940s, and many with increasing enthusiasm from the mid-1960s, although artificial contraceptive devices remained technically illegal in Canada until 1967. Contraception became easier with the introduction of the hormone contraceptive, "the pill," in the mid-1960s. In 1974, before an abortion could be legally performed, the written approval of two doctors and an approved hospital committee was needed; such approval was initially given only where the continuation of the pregnancy would be likely to endanger the mother's life or health. This review became nominal in many non-Catholic hospitals. Abortions were rarely performed in Catholic hospitals. The abortion rate in Canada in 1974 was 10.1 per 100 live births and in Manitoba 6.3. Most of the 1,261 abortions were carried out in the Women's

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194 Chapter 10 Hospital (Health Sciences Centre) (601) or the Victoria Hospital (556). Twenty-eight were performed in the Grace Hospital and the rest elsewhere. Of the 601 women aborted in the Women's Hospital, fifty-eight percent were single and forty percent were between the ages of fifteen and twenty years. Because of the relatively high number of abortions, there was a shortage of doctors willing to perform them, and many hospitals would not allow abortion for ethical reasons. Even hospitals that permitted abortion had to restrict their services for fear of being swamped; at least two clinics would typically advise a woman that she needed abortion but could give her little help to find a physician to perform it. When Dr. Henry Morgentaler opened a clinic in Winnipeg in 1983, it was raided by the police and closed down.When the national abortion law was struck down in 1988, the clinic was found not to conform to the bylaws of the College of Physicians and Surgeons and closed down again. After compliance with the bylaws, the clinic reopened and still functions. The drive for availability of abortion came partly from the physicians who saw the circle of poverty, repeated pregnancy, and deprivation on women and on their children. It came also from women themselves and the new and vocal women's movement. Women for the first time could control their own fertility by the use of the steroid pill and became more conscious that they need no longer accept unwanted pregnancy and its frequent concomitants, violence and second-rate status in society. There was an increasingly strong backlash by those who believed in the "right to life" of the fetus. The number of abortions rose to over 3,000 in 1990, and public dispute on the matter became violent.The gynaecologists in the Health Sciences Centre stated clearly in 1990 that they would provide safe, prompt abortion services with the utmost respect for the needs and wishes of Manitoba women. They could not accept the devastating toll of young women's lives caused by illegal abortion and the consequent sepsis. A big series of changes came with the appointment of Dr. John Tyson as head of the Department of Obstetrics and Gynaecology in 1978. He was a breath of fresh air from outside. Trained in Baltimore, he introduced the concept of reproductive sciences. Maternal mortality had fallen, but all was not entirely well. In 1982, the perinatal mortality rate remained unacceptably high. The attitude to the fetus changed from regarding the fetus as a passive parasite on the mother to considering it a patient. When at risk, fetal health needed elaborate assessment. A "fetal biophysical profile" introduced by Dr. Frank Manning in 1983 comprised congenital anomaly screening, alpha-fetoprotein screening, genetic amniocentesis, prenatal detection

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of Down's syndrome, and screening for Rh isoimmunization. Better ultrasound produced a clear image of the fetus. The assessment of movement, tone, breathing, heart rate, and amniotic fluid volume became routine.The techniques of molecular genetics were applied to predict fetal abnormality. It became possible to detect fetal asphyxia at an early stage and by implication to improve the chances that a fetus would survive unharmed. Over forty fetal transfusions were being carried out per year. It even became possible to carry out limited intra-uterine surgery to correct fetal defects. The incubators used for premature infants became ever more complex, and it became possible to maintain tinier and tinier newborns to the threshold of independent life.Yet, there were worries; this unnatural selection of the less fit led to the survival of children less able to withstand the changes and chances of mortality. The physiology of the fetus was increasingly explored; much experimental work was being carried out in Winnipeg on the mechanisms whereby the lung became aerated when the fetus took its first breath.The complex natural substance that lines the interior of the lung, surfactant, became available as a therapeutic agent; in adequate quantities to treat newborn, particularly premature, infants with respiratory distress, leading to a remarkable fall in perinatal mortality. There was considerable research on reproductive endocrinology, much of it related to the pituitary hormone prolactin and to the hormone beta HCG (human chorionic gonadotrophin), derived from the placenta and present in the blood of pregnant women; its presence in large amounts in the blood of women with tubal pregnancy became a rapid diagnostic test for this abdominal catastrophe. The gynaecologists had to deal with the problem of infertility; they could now often use microsurgical techniques to clear blocked fallopian tubes to allow natural fertilization. An artificial insemination program, using donor semen, was started in 1979, and in vitro fertilization was practised for a year (1986-87) but discontinued because of cost. It was blocked at one hospital for religious reasons. Prenatal sex selection remained a dream of some reproductive biologists and a nightmare for conservative ethicists. The teaching-hospital obstetricians attempted to improve services outside their immediate ambit by educating family practitioners in better obstetrics, whether in Winnipeg, where specialist advice was easily and quickly available, or in rural areas, where it was not. Outreach specialized services such as ultrasound were provided, and obstetrics improved province-wide. The treatment of cancer of the female reproductive tract became a subspecialty. Early detection of cervical cancer improved because of cervical

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196 Chapter 10 cytologic screening for all sexually active women, and early treatment improved as gynaecologists used direct vision (colposcopy) to inspect the cervix and treat early lesions of the cervix by freezing, laser, or curette. Cancer of the ovary in the later stages was increasingly treated by chemotherapy. As public knowledge and exploitation of sex increased, and as the sexual revolution revised traditional moral attitudes, there was increasing concern about adolescent women, pregnant outside marriage or at least a stable partnership, often infected sexually and sometimes raped. Providing care for them became an important part of gynaecology. Tyson, like many breaths of fresh air, caused an occasional cough; he was not universally popular and moved off after six years, but the changes he effected were permanent. Modern obstetrics saved mothers and saved babies; yet there was a price. Many mothers saw the labour ward as an inhumane place and yearned for an experience of childbirth like that of their grandmothers; often they did not reckon that women of their grandmothers' generation did not always survive to tell the tale.Their influence led to the fortunate result that many obstetricians tried to humanize the labour room, turning it into what was fashionably called a "birthing" room. It led also to increasing pressure by women for the legalization of midwifery; trained midwives were giving excellent care in the British National Health Service. Physicians were resistant to the idea, but midwifery became established practice by the late 1990s. More than most parts of medicine, reproductive medicine has always raised ethical problems, hedged around with religious prejudice and irreligious desires. Artificial insemination and fertilization, contraception, and abortion made priests don their chasubles, women state their putative ownership of their own bodies, and libertarians and ethicists call on the Bill of Pvights.

The Health of Children By 1945, in most major centres, the care of children had become a separate medical and surgical specialty. In Winnipeg, the University Department of Paediatrics was created in 1946. The needs of children drove much basic research into the causes of disease. Paediatrics became one of the most distinguished parts of the Manitoba medical school for several reasons, due mainly to two remarkable men. The first full-time head of Paediatrics, Dr. Bruce Chown, scion of a well-known Winnipeg medical family, was a brilliant research worker and an excellent teacher and paediatrician. Dr. Harry Medovy, appointed head of the Department of Paediatrics in 1954, was

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unusually competent, with a wide spectrum of interest and ability and a knack of finding and appointing able people. Medovy had been born in Russia in 1904 and moved to Winnipeg as a small child. Locally trained, he saw the passing of many of the lethal infectious diseases of childhood. The pneumonias, ear infections, and the cases of mastoiditis and meningitis that led to the death of many children were treated with increasing effect first with sulphonamides and then with antibiotics. Mastoiditis no longer required complicated surgery, and osteomyelitis, which had held children in bed for long months and required extensive surgery, became uncommon. Primary pneumococcal peritonitis all but disappeared.The diseases of malnutrition, such as rickets, became rare because of better diets. Acrodynia ("pink disease"), a wasting disease of small children, disappeared after 1950, when it was found to be due to poisoning by mercury in teething powders. Even tuberculosis yielded to streptomycin, and the once rapidly lethal tuberculous meningitis became treatable with intrathecal streptomycin. The Children's Hospital shared fully in the management of the poliomyelitis epidemics, particularly that of 1947, when at one time 200 children with polio were being cared for. In 1956, a new children's hospital opened adjacent to the Winnipeg General. Here the needs changed; the paediatricians had to deal with the results of major traffic accidents, provide surgery for congenital defects, particularly cardiac defects, and provide treatment of childhood cancer and leukemia. Medovy had a particular interest in prevention. He advocated such sensible measures as immunization against infectious diseases like measles, diphtheria, pertussis, and polio, and immunization of adolescent females against rubella, and promoted the provision of nutritious diets with the necessary vitamin supplement to prevent scurvy and rickets. He was ahead of his time in his outspoken opposition to cigarette smoking and persuaded the provincial Department of Health to provide prophylactic penicillin free of charge to anyone with a documented history of rheumatic fever. Prevention was better for the patient than cardiac surgery, and cheaper. Babies in rural areas were being brought to the doctor because they were a dusky blue in colour; the paediatricians identified the cause as nitrates in well water from areas saturated with nitrogenous fertilizers. Medovy fostered improvements in the care of the newborn, particularly the premature newborn, initially with better incubators and later with improved means of lung ventilation and the use of surfactant to help the lungs expand. Paediatric research moved in many directions. Dr.Victor Chernick carried out significant work on the lung of the fetal sheep, measuring the

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198 Chapter 10 blood gases of the fetal sheep and analyzing its respiratory movements and the effects of drugs on them. Pulmonary surfactant, a lipid derived from the lung, was shown to have an effect on hyaline membrane disease, a lethal respiratory ailment of the newborn. Basic research on blood platelets was carried out, and paediatricians were deeply involved in the development of human genetics, and screening programs for congenital metabolic abnormalities that could cause mental defect. Paediatricians attacked child abuse and neglect, developed a poison-referral centre, and started outreach programs to help the aboriginal children of the north. The development of the Children's Hospital was greatly advanced by successful women's guilds; the Children's Hospital Research Foundation, started in 1959, was one of the first such foundations in the province and provided a means of attracting and keeping talented research workers. Rh Haemolytic Disease Pathology in the Children's Hospital flowered ultimately into that rare bloom, a major discovery. Rh haemolytic disease of the newborn in 1944 caused ten percent of the fetal and neonatal deaths in Canada. It is now known to be due to immunization of the mother against the Rh blood group antigens, identified in 1935, elsewhere. An Rh negative woman impregnated by an Rh positive man develops antibodies against the Rh antigen; these cross the placental barrier and attach to the fetal red blood cells. The first time this happens there is little effect, but in second and later pregnancies there is progressive destruction of the fetal red blood cells. The fetus becomes hydropic, or waterlogged, and dies. Dr. Bruce Chown, a man with a distinguished war record, long established as pathologist to the Children's Hospital, saw this sad sequence again and again. With superb tancity he followed the problem to its solution. A modest man, he gained fame and local veneration. In 1944, Chown set out with one technologist, Marion Lewis, to determine the mechanism of Rh haemolytic disease, its management and its ultimate prevention. In 1944, he offered free Rh testing for all mothers. It had been determined elsewhere that prompt transfusion of compatible blood could save the newborn. The first such exchange transfusion in Winnipeg was carried out under Chown's supervision in the summer of 1945.The death rate fell at first to twenty-five percent and by 1955 to ten to fifteen percent. Up to 1992, more than 2,500 exchange transfusions have been carried out in Winnipeg. Next it was shown, in 1953, in Winnipeg, that fetal red cells cross over into the maternal circulation; it subsequently became apparent that an Rh negative mother exposed to Rh positive fetal red cells produces an Rh

Since the Wars: The Specialists

antibody (anti-D), which traverses the placenta, coats the Rh positive fetal red cells and causes haemolysis, often fatal to the fetus. It was next shown that premature delivery would save more neonatal lives. In 1961, to predict how severe the hemolytic disease would be, amniotic fluid was obtained by puncturing the mother's abdominal wall and the amniotic fluid examined by spectrophotometry. By 1964, perinatal mortality from erythroblastosis in Manitoba had been reduced to thirteen percent. Fetal ultrasound assessment was added in 1978. About half of all fetuses doomed to become hydropic become so too early in pregnancy to benefit by early delivery. The risks of death from prematurity before thirty weeks' gestation in a sick infant are prohibitive. The next advance came elsewhere in November 1963, when Dr. William Liley, a New Zealander, reported the first example of fetal surgery and the survival of a fetus following intraperitoneal transfusions in utero, begun at thirty-two weeks' gestation. The first fetal transfusion in North America was carried out by Dr. Rhinehardt Friesen and the Rh Laboratory on 2 January 1964. Under ultrasound visualization, the fetal peritoneal cavity was catheterized. Successful catheterization was proven by injection of radiopaque contrast down the catheter; x-ray revealed the contrast medium in the peritoneal cavity. Rh negative red cells were then injected. It was subsequently shown that the disease could be prevented by administering Rh immune globulin to an Rh negative woman pregnant with an Rh positive fetus. The Winnipeg laboratory produces much of the Canadian supply of this. By 1983, Manitoba was one of the safest places on earth for an Rh postive baby to be born to an Rh negative mother. As in most biomedical discoveries, the end success was attributable to many people in several centres. Much of it belonged to Chown and his colleagues in Winnipeg.

Human Genetics One of Medovy's greatest achievements was encouraging the development of the study of human genetics. It is a short step from the health of children to the consideration of congenital disease and the genetic mechanisms involved in its cause. In Manitoba, as elsewhere, paediatrics and the study of Rh incompatibility spawned a study of genetics. A relatively young science, it was given a fillip by the fame of the Dionne multiple birth in 1934 and by the discovery of sex chromatin by Murray Barr in London, Ontario, in 1949. The widespread adoption of a new biochemical technique, starch gel electrophoresis, in 1955 was the first of many technologic advances. By the late 1950s, the importance of the new cytogenetic techniques was widely recognized, and Chown and Medovy wished to advance the

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200 Chapter 10 field. They imported new talent. A well-trained cytogeneticist, Dr. Irene Uchida, arrived from Toronto. She started to examine cells cultured from blood and soon published a study of patients with congenital abnormalities due to tri-somy eighteen. She later showed that Down's syndrome occurred more frequently in the children of women who had received irradiation than in those who didn't. Then Dr. John Hamerton was recruited from Guys Hospital Paediatric Research Unit in London, England. He had made his name by defining how many chromosomes human cells had, an important discovery. It was an exciting time. New techniques abounded; chromosome banding, cell hybridization, and new syndromes were being described every week. Prenatal diagnosis was developing and in 1969 a genetics clinic opened, run by Hamerton and Dr. William McDiarmid. The group carried out a major survey of the births in the province to determine chromosomal abnormalities and did basic studies of somatic cell genetics and cell hybridization, and on gene mapping. In time, the University Department of Human Genetics developed. Accommodation was difficult to find; the expanding group outgrew its space in the Children's Hospital and, after an intermediate stay in an old house, was settled in space in the Pathology Building.Their experience "was typical of many clashes between new-style scientists and the old-style administrators of service-based hospitals. Hamerton wrote of the "total lack of planning as to the future of the genetics group— This lack of planning was not atypical of the Health Sciences Centre administration at that time." Here, as elsewhere, administrators, formerly the assistants of physicians, now increasingly controlled them, making physician or scientist dance like a puppet at the end of a purse string. Administrators sometimes failed to cooperate with research-based clinicians and even obstructed them.

Psychiatry The most powerful medical figure in Manitoba in 1945 was a psychiatrist, Dr. Alvin T. Mathers, dean of the Faculty of Medicine; he had stepped down as provincial psychiatrist in 1945 and was succeeded by Dr. T.A. Pincock. There had been perturbations about psychiatric management in the late 1930s, but change had to wait until after the war. Care of the mentally ill in Manitoba was probably no worse than it was elsewhere in Canada. There were not enough beds, children and adults were not adequately segregated, tuberculous patients were not adequately isolated, and little consideration was given to mental hygiene and the prevention of severe psychiatric illness.

Since the Wars:The Specialists

Before the war, most psychiatric activity was carried out in "mental hospitals": purpose-built, stand-alone, provincial institutions.Therapy was non-specific and not very effective; occupational therapy was prominent, stays long, and cure uncommon. Conditions were inadequate and at the •worst very unpleasant. While care was better in Winnipeg, a summerstudent clerk in Brandon Mental Hospital in 1952 saw very similar conditions: an old, 1,600-bed mental hospital with mostly locked wards; regressed, poorly dressed or undressed patients wandering around aimlessly or completely self-absorbed. Electroconvulsive therapy was given freely mainly to keep patients tractable. This clerk witnessed the last insulin deep shock therapies given in Brandon. He assisted in lobotomies, done twice a week by a Brandon surgeon on two or three patients each time. The techniques used were primitive. In 1955, when he became a psychiatry resident, things had changed. Patients were treated more humanely and were properly dressed, insulin coma had gone, and psychosurgery was done much less often. The change was led from the University Department of Psychiatry, headed from 1955 to 1975 by Dr. George Sisler and the next twelve years by Dr. Harry Prosen. It was a change that brought psychiatry back into the fold of general medicine. Postgraduate training improved; the residency training curriculum of the University of Chicago was imported, and formal training courses were initiated, to meet the requirements of the Royal College of Physicians. As well-trained residents emerged from the program, some staffed Manitoba hospitals; too many left for better opportunities. First of all, in Deer Lodge, the veterans' hospital, and then elsewhere, psychiatric wards were developed in general hospitals, until by the mid1960s there were psychiatric wards in most Winnipeg hospitals.These wards were open, and, as had happened in the mental hospitals, the patient would be involved in an active treatment program, with increasing community integration.Volunteers would come in from outside to break the isolation often perceived by the mentally ill. Moreover, patients in such wards would help in teaching medical students, yet another welcome breach of isolation. Increasingly, psychiatry was being re-integrated into general medicine. During the twentieth century, there was a change in the causation of mental illness. At the turn of the century, ten percent of patients in mental hospitals had suffered from general paralysis of the insane due to neurosyphilis. The advent of organic arsenicals and then penicillin rendered this rare. People lived longer, and the percentage of patients with arteriosclerotic psychosis increased; Alzheimer's disease became recognized as a cause of dementia.

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202 Chapter 10 The discharge rate in manic-depressive illness increased somewhat, and in schizophrenia significantly.The discharge rates from Selkirk Mental Hospital over the years between 1932 and 1957 are a good example of the effect of changes in treatment. In 1932, before insulin shock therapy was used, there were 164 admissions, of whom forty percent were discharged. In 1947, before tranquilizers were introduced, there were 181 admissions, of whom sixty-three percent were discharged. In 1957, after the introduction of antipsychotic such as chlorpromazine in 1953 and diazepam (Valium) a little later, there were 360 admissions, of whom seventy-two percent were discharged. Mental diseases were intractable, but there was improvement in response to treatment. There was greater consideration for children; child guidance clinics opened, a sub-specialist child psychiatrist was appointed, and special consideration was given to the physically and mentally handicapped; special classes had existed for many years, but these were expanded. Alcoholics began to receive more sympathetic treatment; an alcoholism foundation was the basis for attempts at rehabilitation. A psychiatrist was appointed in 1957 to look after the needs of inmates in correctional institutions. Treatment improved when the major and minor psychotropic medications chlorpromazine and diazepam appeared, and intensive psychotherapy became possible more often.The patients who had been long-stay patients in the old mental hospitals were now looked after in the community as out-patients. For many, this was a marvellous release, for not a few it led to destitution and misery. The care of those who are mentally handicapped for genetic reasons or because of birth trauma now falls to psychiatrists. It has in Manitoba, as in most other places, been a sad story. In 1890, the Home for Incurables was opened in Portage la Prairie, serving a wide variety of patients; this evolved in 1932 into the Manitoba School for Defectives and, after several name changes, into the Manitoba Developmental Centre in 1984. Despite the devotion and concern of the responsible physicians, the institution was often overcrowded and tended often to become custodial rather than therapeutic. Many of the patients were moved in 1973 to the now disused sanatorium at Ninette. Prior to the 1950s, there was no systematic provision for the care of such children, and only after the age of six could they be admitted to the Portage la Prairie Institute. In 1939, Beatrice St. Amant, a widow with an epileptic child, set up a home to look after such children. With the support of the Grey Nuns, this was in 1956 housed in a ward in the St. Boniface

Since the Wars: The Specialists

Home for the Aged and ultimately, as the need for sanatorium care of tuberculosis fell off in the St. Boniface tuberculosis sanatorium, renamed the St.Amant Centre. Many of the more recent changes in psychiatry reflect changes in medicine as a 'whole. Fewer psychiatrists practise general psychiatry, and fewer practise privately. Sub-specialties have proliferated. Not only are there children's psychiatrists and child-guidance clinics, but there are also psychiatrists who treat adolescents and psychiatrists who specialize in the ravages of age. Psychiatric services are now almost always provided in general hospitals, usually in out-patient clinics, and are commonly available in emergency rooms. Financial exigencies have affected psychiatric services as they have other medical services, although the specialty now rejoices in a new psychiatric health centre, whose cavernous halls seem a fit temple for the sick soul. Yet, standards of diagnosis sometimes seem less rigorous than in physical disease. The search for new drugs has led to more effective treatments for schizophrenia and depression, but cure is as elusive as ever. Psychiatrists have had to contend with changes in social mores, partly due to the decline in religious observance, partly due to the different social attitudes of immigrants. Our community attitudes on alcohol and drugs, abortion, contraception, and homosexuality have changed radically. Family breakdown is more common, and more children are brought up by foster parents. More recently, patients have asserted their rights in medical decisions, notably on involuntary hospital admission. The task of the psychiatrist has changed, often becoming more difficult, but the mentally ill are now regarded as sick, not mad.

Trouble at the Mill: Occupational and Environmental Health Medical specialties are occasionally defined not by a bodily organ system or physiological function but by social need. The specialty of occupational and environmental health has grown in this way. Workers in Manitoba as elsewhere in Canada have had a constant struggle to obtain fair compensation for injury at work. Early in the century, fifty or so workers a year would die in Manitoba in industrial accidents; compensation was rare. It was not until 1916 that a worker had a good chance of reasonable compensation with reference to a quasi-judicial body in disputed cases. Major employers developed a conscience and engaged physicians to advise on better health practices. Dr. Emmett Dwyer was the first Manitoba physician specialist in occupational medicine, being regional medical officer of

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204 Chapter 10 the Western Region Canadian National Railways and later working for Trans-Canada Airlines. As the years passed, the range of recognized occupational disorders became wider: accidents, poisons, infections, deafness, skin rashes, stress neurosis, lung diseases. Farm workers were prone to most of these.The Manitoba Federation of Labour in 1984 finally opened its own occupational health centre. The Faculty of Medicine followed suit in recognizing the importance of this discipline. Curiously, hospitals are among the employers who until recently often failed to protect their workers against occupational hazards. It has sometimes been difficult even in a teaching hospital to persuade administrators to provide safe environmental standards in laboratories.

Intensive Care and Emergency Medicine The tale so far has been of splintering, of physicians who knew more and more about less and less. But the splinters came together in a curious way. During the poliomyelitis epidemic of the early 1950s, it became clear that, if patients could just be kept alive through the acute phase of the illness, the residual damage might not be life-threatening and might even be slight. Artificial respiration might be needed only temporarily, or the patient might be left dependent on it for the remaining years of a life whose quality was in other ways high.The respiratory physicians became good at maintaining respiration, often with the assistance of the anaesthetists. The renal physicians became able to keep patients alive by dialysis during acute renal failure and to dialyse out drugs in patients who had taken an overdose. The cardiologists developed better ways of monitoring and treating otherwise fatal arrhythmias. And so it went on. The individual branches of medicine and surgery came together to form a new kind of general medicine, called under different circumstances acute-care, intensive-care, or emergency medicine, immensely effective in saving life, very expensive, and highly stressful for the nurses and physicians involved. Emergency departments (and morgues) saw more and more of a strange disorder, drug addiction. Drunks were always a familiar sight; alcohol had been bad enough, but this was worse. The sad condition afflicted all segments of society and destroyed lives slowly, sometimes suddenly. The drugs, cocaine, heroin, and the like, were smuggled in; their cost on the street led the addict to violent crime, and the sharing of syringes spread infections. Addictions clinics attempted to remove the addiction, with little success. The intensive-care unit illustrates the outstanding difference between medicine in 1945 and 1983. In 1945, the doctor, a beloved figure, visited

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the patient with a heart attack in the home, gave morphia and tincture of bedside manner. The patient sometimes survived to thank the doctor for his kindness. The patient in 1983 was whisked to hospital, hooked up to complex machinery, terrified by the impersonal surroundings, prodded, poked and needled, but much more often survived, sometimes to complain about the harsh impersonality of modern medicine.

Medical Progress: 1945 to 1983 The overall progress in medicine in the years between 1945 and 1983 was remarkable in the organization of health care, in basic science, in family medicine, and in the medical specialties. Before 1945, while most physicians in the province were products of the local medical school, many of the new advances had been led by doctors or scientists imported from elsewhere. After 1945, progress accelerated, and remarkably, while a healthy exchange of doctors took place with other centres, most advances came from local graduates, and the medical school exported at least its share of medical leaders to advance medicine elsewhere. Local medical chauvinists would have larger claims; the dispassionate observer might say that in the thirty-eight years from 1945, the Manitoba medical school developed into a modern biomedical institution at least as good as, and perhaps a little better than, could be expected in a province of a million people, a little far from metropolitan centres, and of less than average Canadian wealth.

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Organized Medicine

11 Medical doctors, like many other groups in society, are drawn to organize like iron filings around a magnet. The "organization doctor," like other forms of the "organization man" is easily caricatured: the blue suit, the firm stance and confident gaze into a middle distance, which holds both sense and dollars, the ritual trouping to other, preferably climatically more favourable, corners of the globe to exchange information, learn new techniques, impart new discoveries, and enlarge one's reputation in an atmosphere of back-slapping and good food.Yet, such human organization is an essential part of advance in any field, medicine no less than any other. Physicians organize for several reasons: to maintain and improve standards, to defend their interests, and to train the next generation of physicians. There are some other public purposes or organizations that have a significant organized medical component, such as the insurance industry. The development of the medical school in Manitoba is the backbone of the medical history of the province. From the College of Physicians and Surgeons, and from the College of Medicine, arose the medical library facilities of the province. Throughout the century, with only a few years' interruption, medical journals have been published in Winnipeg.

The College of Physicians and Surgeons of Manitoba Since the earliest days, the control of medical standards has been important; quacks posed a major problem. Doctors always like a closed shop; it may help the patients and certainly helps the doctors. The College of Physicians and Surgeons of Manitoba and the Province of Manitoba itself were born only a year apart, the Province in 1870 and the College in 1871.The College was the first of its kind west of Ontario and had its beginning when the first legislature of Manitoba enacted a statute on 3 May 1871

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(the first medical act) to incorporate the medical profession under the name of the Provincial Medical Health Board of Manitoba. Provision was made for the election of a board of governors and other officers to set examinations for licence to practise and to provide courses of instruction and study. Registration with the Board became compulsory for all practitioners; the penalty for non-compliance was twenty dollars for each day of practice without a licence. The first president was Dr. John Harrison O'Donnell, aged thirty-three, born in Ontario. He arrived in Manitoba just in time for the first Riel uprising in 1869. He joined Dr. John Christian Schulz in defence of the latter s warehouse against the Metis and was taken prisoner but later released. As a justice of the peace, he made out the warrant for Kiel's arrest when theWolseley expedition arrived in 1870. He was a member of the Legislative Assembly from 1871 to 1876 and later Speaker of the Upper House. The other officers were Dr. Curtis J. Bird as secretary and Dr.J.C. Schulz as treasurer; other members were Dr. H.S.Beddome and Dr.J.B. Campbell. Former registrar Dr.J.B. Morison writes: In the archives there is a type-written list of doctors in Manitoba up to December 1899, prepared by my pre-decessor, Dr Max McFarland. It lists 390 physicians, 29 before the first Medical Act, and 361 licensed between May 3, 1871 and December 12,1899.The five original members named in the Act are listed as registering on May 3,1871. Only three others were registered in that year: Drs Roy, Pare andTurver are listed as registered in 1871.There was one registered in each of 1872 and 1873, none in 1874, and one in 1875, a total of 15 during the five years of the Manitoba Medical Board. The Henderson street directory states that the population of Winnipeg in 1876 was 4,000.

The Manitoba Medical Act of 1877 changed the name of the corporation to the College of Physicians and Surgeons of Manitoba, enlarging its powers. It retained the Medical Board as the body to carry on its affairs. Dr. J.H. O'Donnell remained president until he was replaced by Dr. J.S. Lynch in 1882. Again, little is known of the activities of this board. The first register contained forty-six doctors: nineteen educated at Toronto, ten at McGill, seven at Queen's, two at Edinburgh, two at Glasgow, two at English schools, and two at schools in the United States.The standard was fairly high. The College had the power to admit, censure, and dismiss.The doctors on the first register were all male, and all were general practitioners. In 1882, a second five-year board was elected under the 1877 act. Dr.J.S. Lynch was president, Dr. David Young was vice-president, Dr. A. Codd was

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treasurer, and Dr. A.H. Ferguson was registrar. Ferguson registered on 13 May 1882; his hand may have been responsible for the great increase in activity, or at least recording of activity. From 1875 until 1882, there were few registrations, usually fewer than ten per year and sometimes only one or two. In 1882, there were forty-four registrations, a level not again achieved in the nineteenth century. As there was no corresponding population boom, there may have been a vigorous sweep by the new broom. During this period, many doctors probably drifted further west in search of more remunerative practice, or south to the United States. During the period from 1882 to 1886, six separate examinations were set up for graduates of United States schools, including one in September 1882 for the first woman registrant, Lillian Yeomans, twenty-one, a graduate of Michigan. It appears that the five members of the Board formed the examining committee and were paid twenty-five dollars each for every examination. All six candidates passed, although two required a supplemental examination, given a few days after the first examination, before they eventually passed. A resolution of the Board on 13 December 1883 recognized the proposed medical school as a private enterprise but stated that the Board's responsibility was "to guard carefully the curriculum of studies to be taught by it." The third medical act (1886) replaced the Medical Board with a council of members chosen for two-year terms, three chosen by the Manitoba Medical College, three from the licensed practitioners in Winnipeg, three from each of the electoral districts of Selkirk and Marquette, and one from each of the electoral districts of Provencher and Lisgar. Dr. Lynch, the only holdover from the previous medical board, became the first president under this new act. Dr. J.S. Gray, thirty-seven, was one of the Manitoba Medical College representatives on council and then became registrar, a post he held for thirty years. Dr. Gray taught gynaecology at the Medical College and also operated a private women's hospital on Hargrave Street in Winnipeg. He was one of the original members of the Medical Council of Canada in 1912. For many years, a major activity of the College was tracing doctors to persuade them to register. There were also actions against advertising by doctors, and against irregular practitioners.Thus, at the outset, the College functioned mainly as a licensing body empowered under the Manitoba Medical Act to protect the public.

210 Chapter 11 In 1952, only thirty years after Dr. Jasper Halpenny's pleas for specialization in surgery, the College, in line with national developments, opened a register of specialists.This register was open to Fellows or certificants of the Royal College of Physicians and Surgeons of Canada, or to others at the discretion of the College, notably those with foreign specialist qualifications. There was a significant economic implication in being a recognized specialist: a larger income. Initially, many senior doctors were admitted to the register who did not have a formal specialist qualification. Thirty years later this was rare. The College also acted as the gatekeeper in admitting foreign doctors. This function not only maintained standards but also controlled the number of doctors allowed to practise. Until 1983, those registered with the British General Medical Council were admitted automatically if they were of good repute. Manitoba was the last Canadian province to withdraw this automatic recognition. Since the early 1970s, the College has expanded its role in promoting high standards of medical practice, by education and by discipline. It invited physicians to record their compliance with continuing medical education standards in 1983; fifty percent recorded that they did so, a percentage that rose significantly thereafter. The provincial Ministry of Health funds activities related to standards, such as perinatal and maternal health, paediatric death reviews, quality assurance, prescribing practices, hospital review, and most recently clinical guidelines. Professional discipline has become more open in response to increasing public consciousness that professional discipline must not only be fair but also be seen to be fair, lest there be public and external regulation of an ancient and proud profession.

The Manitoba Medical Association The organization of a medical association was initially halting and episodic. The first abortive attempt is recorded in the Manitoba Free Press of 12 February 1883."In response to a circular issued by Dr.Whiteford, a number of medical men met at the Potter House on Saturday evening for the purpose of forming a medical association in this city." The names of the twentythree doctors were listed: Codd,Thibodeau, Patterson, Munro, McAdam, Blanchard, Minaker, Sutherland, Jackes, Brett, Seyman, Covernton, Turnbull, Jones, Kerr, Greyjamieson, McEachran, Mewburn, Phillips, A.H. Ferguson, McDiarmid, and Whiteford. Dr. Codd occupied the chair and Dr. Mewburn acted as secretary. The record then falls silent, perhaps because of the public alarm and confusion arising from the second Riel rebellion between March and May 1885.

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The second fruitless effort occurred in 1890, as recorded by Dr. Ross Mitchell. The Manitoba Free Press of May 20,1890 has an account of a meeting in City Hall, Winnipeg of over forty medical men, the largest gathering of doctors in the province to that date, to form a medical association. Several doctors were present from outside points. It was resolved to form a Manitoba Medical Association, and the following office bearers were elected: Dr. M Macklin, President, Portage la Prairie, Dr.J.H. O'Donnell, 1st Vice-President, Winnipeg, Dr. J.W Good, 2nd Vice President Winnipeg, Dr. J.R.Jones, Secretary Treasurer Winnipeg.

There are no records of further meetings of this body, which presumably also died. By 1907, there were two medical societies in Winnipeg: the Winnipeg Medico-Chirurgical Society, founded in the 1890s, and the Winnipeg Clinical Society, founded about 1905 by a group of recently arrived doctors. The two societies suggested that a provincial medical association be formed, and a meeting was called by the president of the College of Physicians and Surgeons. Over 100 doctors attended the meeting, and in the evening, 200 members attended a dinner in the banquet hall of the Royal Alexandra Hotel. Several members sang songs, and Dr. Good gave a witty talk. Dr. Gordon Bell and Dr. Harry Chown both spoke strongly in favour of the construction of a tuberculosis sanatorium without delay; there had been undue delay in building one because some members wished to have it closer to Winnipeg than the designated site at Ninette. The Manitoba Free Press of the next day carried the headline "Manitoba Medical Men Organize and Entertain." This time, auspices were good, and the organization endured. In those days, rural physicians often went straight into practice from medical school without intervening intern training; they were isolated, and their medical knowledge soon became out of date. In 1923, the association decided to set up a scheme to form local medical societies that could obtain speakers and support largely from Winnipeg. The Winnipeg Medical Society, the Brandon Medical Society, and four rural district medical societies were federated as the Manitoba Medical Association. This was the province's earliest form of continuing medical education. Many years later, Dr. G.S. Fahrni recalled: The first meeting was in Dauphin, and Routley (Dr.T.C. Routley, newly appointed Secretary of the Canadian Medical Association) and I started out in my old reliable car for the 195 mile drive. The roads in those days were not paved — a gravel road was a luxury — and the autumn rains

212 Chapter 11 created havoc with the earthen grades, causing mud and slippery surfaces. Our meeting in Dauphin was a great success and, in this happy atmosphere, our first rural district medical society was born.... The next morning when we left Dauphin for Russell, there was a cold north wind with snow flurries. During the ninety mile drive to Neepawa, the snow had grown to about 4 [inches] on the road. We put on chains and turned west for the long drive in the storm to Russell. We got stuck several times and Routley and I renewed our acquaintance with the snow shovel. We skidded into a ditch, from which we were assisted by a friendly truck driver. We arrived in Russell about one hour late.

Some ten years later, in about 1933, each provincial medical association in Canada became a division of the Canadian Medical Association. Thus, each District society member was a member of the Manitoba Medical Association and, through it, of the Canadian Medical Association. The Association thus launched in 1908 since then has usually held its annual meeting in Winnipeg, but sometimes in Brandon or Portage la Prairie. For many years, the meeting lasted several days and had a major educational component, including scientific lectures and hospital demonstrations. However, as the profession became fragmented into specialist and family practice groups, the meeting has been reduced to a single day, which is devoted to socio-economic and medico-political issues. Over the years, the Association has examined most aspects of health care. The economics of medicine have always been considered important. During the Great Depression of the 1930s, doctors suffered along with the rest of the population, and the idea of a better payment system was born. The Association was a prime mover in the establishment in 1943 of the prepaid medical scheme known as Manitoba Medical Services, which operated until 1969, when a government-run medicare program was established in Manitoba. At that time, the Association covered eighty-five percent of the population, most of the subscribers and the doctors were satisfied, and all the government had to do was pay the premiums for the remaining fifteen percent of the population. This the government decided not to do. Despite the resistance put up by the Association to medicare, most doctors are better off financially now than they were before medicare. The Association has had significant input into development of the Manitoba Health Services Insurance Act and has submitted numerous briefs, reports, and recommendations to various provincial and national bodies on almost every aspect of health care, including such subjects as health services,

Organized Medicine 213

medical education, taxation, ambulance services, emergency services, the non-medical use of drugs, hospital admissions, and central drug purchasing. Over the years the Association has worked assiduously in advocating the interests of its members, and often of their patients. For many years, it resisted adoption of the principles and tactics of the labour unions, and doctors resented any reference to their organization as a trade union. Since the establishment of government-controlled medicine in 1969, the Association has increasingly resorted to union behaviour, including the threat to strike or withdraw services, and on occasion actually going on strike. This behaviour, while economically at times effective, has not endeared the profession to the public. Membership is now compulsory for all registered physicians, at least a few of whom do not support trade union behaviour by a medical association. The College of Physicians, the Manitoba Medical Association, and the Faculty of Medicine have all been involved in the maintenance of medical ethical standards, by enforcing, by setting, and by teaching those standards. These functions have never been entirely separate. The College of Physicians has enforced the standards of the day, reprimanding those found guilty of infraction or striking them off the register. In recent years, in an endeavour to demonstrate public accountability, disciplinary proceedings have been increasingly open to the public. Both the College of Physicians and the Manitoba Medical Association have been involved in reviewing traditional standards. The ethical code in force in the nineteenth century purported to derive from the Hippocratic oath. Physicians were concerned that their actions be in the best interests of the patient, and in particular that there be no sexual interaction between doctor and patient. Poaching another doctor's patients, advertising, and association with unregistered practitioners were frowned upon. In the 1930s, Dr. David Stewart chaired a Manitoba Medical Association committee that oversaw the revision of the national Canadian medical ethical code. The traditional code was reinforced, and such activities as radio broadcasting were allowed, providing that there was no attempt at self-advertisement. Endorsement of proprietary remedies was frowned on. The Nuremberg trials led to the Declaration of Geneva in 1948, codifying the world-wide horror at the unethical practices of the Nazi medical profession. Over the years, standards on advertising have relaxed somewhat, and interest has moved to euthanasia, abortion, and the need for patients to make active and informed decisions on their own treatment and on involvement as subjects in research.

214 Chapter 11

Insurance Medicine As Manitoba grew, and as the medical profession grew, there was a parallel growth in the insurance industry. The Great-West Life Assurance Company began in Winnipeg in 1891 and the Wawanesa Mutual Insurance Company in rural Manitoba in 1896. Both have been successful, and both have owed some of their success to the contributions of physicians. The Great-West Life Assurance Company started in a rented office costing thirty dollars a month with a staff of five, and in 100 years the staff has grown to 2,200 in Canada and 1,500 in the United States. It carries over $165 billion of life insurance and protects about six million people with health and dental insurance. This success depended on correct assessment of medical risks. The foundation was laid in 1892 when two well-known Winnipeg surgeons were appointed as joint medical referees. Dr. H.H. Chown served for fifty years, dying two years later, and Dr. R.J. Blanchard served for thirty-six years, dying two hours after suffering a heart attack in the company's office. Thereafter, Dr. WL. Mann, a chest surgeon, became medical director, followed by Dr. B.H. Olson, also a chest surgeon.The first four chief medical officers were surgeons; this reflected the dominant part played in the profession at that time by surgeons; asepsis and anaesthesia had made them effective, and, until the late 1940s, chest surgeons played a significant part in the treatment of tuberculosis, a major killer. Cardiovascular disease was by the 1930s a major killer, and it is not surprising that the next three medical directors of the Great-West Life Assurance Company were cardiologists: Dr. F.A.L. Mathewson, Dr. R.E. Beamish, and Dr. G. Gumming. All of these men played significant roles in the medical profession outside the insurance industry. The success of the Wawanesa Mutual Insurance Company also owed much to a physician. Dr. C.M.Vanstone entered practice in the village of Wawanesa shortly after graduating. He opened a drugstore, above which the insurance company rented a room, and began business in 1896.Vanstone was a popular and hard-working doctor in Wawanesa until 1912, when he moved to North Battleford, Saskatchewan. Always with a canny head for business, he had a profitable sideline in importing large draught horses. When the founding president of the Wawanesa Mutual Insurance Company resigned in 1922,Vanstone was invited back to Wawanesa to head the company. The tall, balding, sharp-faced Vanstone pinched the pennies and guided the company to prosperity until he retired in 1943; he died ten years later. Alone among the doctors involved in insurance, he made a major contribution to the business side.

Organized Medicine 215

Charts for the Voyage: Medical Libraries The present Health Sciences Library of the University of Manitoba has a complex ancestry. One strand goes back to the College of Physicians and Surgeons of Manitoba, which in 1895 passed a resolution appropriating $800 for a library for members of the College. It took three years to have the Manitoba Medical Act amended to allow this, and soon thereafter the library opened in the Enderton Building, moving in 1899 to rooms at 220 McDermot Street. The librarian, Miss Olive Stewart, was paid twelve dollars per month, and in the first year $500 was provided for books. The other strand is the Medical College Library, which seems to have started about 1899; in 1907, the new medical school had two large reading rooms on the first floor and a stack area in the basement. Dr. Swale Vincent noted that the lack of good library facilities held up his work; he was, however, a little critical about many things in Winnipeg. At that time Winnipeg was connected to the rest of the medical world only by the slow, silver link of the railway. It was a long way to a major medical library. In 1918, the Manitoba Medical College turned over its assets to the University of Manitoba, and in 1920 the College of Physicians and Surgeons signed an agreement to house its library at the medical school; there was now functionally one medical library. Out-of-town members of the medical profession were to continue receiving books by post. The role of the library in continuing medical education goes back a long way. In the mid-1930s, the library at the rear of the Manitoba Medical College was hardly a luxurious place; there were no easy chairs, and students had to sit up straight to study. The librarians, little Miss Sydney Mclntyre (librarian between 1931 and 1941) and big Miss Ruth Monk (librarian between 1941 and 1957) were known to students disrespectfully as "Atrophy" and "Hypertrophy." But the library sustained a scholarship that produced many noteworthy books and was clearly adequate for its time. The library stayed in its original, cramped space until 1956, when it moved to what seemed palatial new quarters. A collection of old and rare books was in 1965 housed separately in a room named after the first Manitoba historian of medicine, obstetrician Dr. Ross Mitchell. Soon afterwards, a collection of the works of students and faculty was established, the Manitoba Authors' Collection. As the record of medicine shifted from books to computers, the library kept up, establishing a facility for students to learn by computer: the R.T. Ross Learning Resource Centre. Generations of medical students and faculty remember the library with pleasure, as a place whose cramped quarters gave it a charming untidiness; old books would

216 Chapter 11 occasionally fall on one's head to announce their presence. It was a place where the personal touch and helpfulness of the librarians more than compensated for lack of space; Professor Audrey Kerr, a scholarly librarian, was the spirit of the place. Although financial restrictions limited its expansion, the library was soon connected by computer to world-wide medical library resources and because of that link became a major medical library.

Records of Voyages: The Journals The first of the medical journals in Manitoba was the Manitoba North West and British Columbia Lancet (1887-1899), edited probably by John Pyne Pennefather. It appeared with interruptions over ten years. It is not clear who published it initially, but latterly it was supported by the Winnipeg and Manitoba Medical Associations. The slim leather-bound volumes in the University of Manitoba Medical Library are apparently the only complete residual set; they give a picture of another world. In 1887, many of Winnipeg's doctors were picturesque, but the man who probably edited the Manitoba North West and British Columbia Lancet was as picturesque as any. He was an Anglo-Indian of Irish ancestry who trained at Trinity College Dublin in 1854 and became a Member of the Royal College of Physicians in 1859. He specialized in ear, nose, and throat disease and had been associated in Harley Street with Morell MacKenzie, the most distinguished ear, nose, and throat specialist of his day in England. Pennefather came to Manitoba in 1880 and moved to Winnipeg in 1885. It is clear from his polemical editorials that he loved nothing more than a windmill. The Winnipeg Medico-Chirurgical Society was founded in 1889 (with Dr. Pennefather as secretary) and in 1904 started to produce its transactions as the Annals of the Winnipeg Medico-Chirurgical Society (1904-1909). This was a purely Winnipeg journal, and its discussions, while of high standard, were local.The last issue of this journal appeared in 1909, perhaps because of schism in the medical community. A newly founded Winnipeg Clinical Society, composed largely of incomers, was at odds with the MedicoChirurgical Society, although the two societies fused in 1913. The next journal, the Western Canadian Medical Journal (1909-1915), was a more ambitious venture.The editor, Dr. George Osborne Hughes, a dermatologist, appointed local editors in towns from Thunder Bay to Victoria and received from them reports of medically related events ranging from epidemics to medical meetings. The first article in each issue was usually

Organized Medicine 217 invited; in the first issue the Regius Professor of Medicine at Oxford, Sir William Osier, wrote of the need for medical journals. It ceased publication in 1915 because of the war. The Annual Reports of the Winnipeg City Health Departments started in 1909. While not formally a journal, they are important records of the period, describing the Winnipeg slums, among the worst in North America; in the early years of the century it was recognized that they had to be cleansed before the community could be healthy. The next attempt at a formal medical journal occurred in 1922, when the Manitoba Medical Association introduced a short bulletin that later became the Manitoba Medical Review.The small bulletin gradually changed its title and expanded until 1934, when it was a significant medical journal, publishing a range of material from original medical articles to reviews, historical articles, and news about the Manitoba Medical Association and its members. The editor of the Manitoba Medical Review in the early years was Dr. T. Glen Hamilton; thereafter, notable editors included Dr. Ross Mitchell, Dr. J.C. Hossack, and Dr. Solomon Vaisrub.The Review was well funded, well edited, and well supplied with good local material and was the most effective medical journal ever produced in the province. The major figures in the medical school and the provincial profession wrote in it, and the standard of articles and of production was high. It died in 1971, mainly for financial reasons. Meanwhile, in 1929, the students had set up their own journal, the University of Manitoba Medical Journal.This was student edited and student produced; the first editor was Dr. F. A.L. Mathewson, and it contained a mixture of review material by students, invited articles by staff, and news about the medical school and the profession at large. The student journal fell into doldrums in the late 1960s. No volume appeared for 1973. A new dean in 1973 handed it over to a faculty member, Dr. Marion Ferguson, to run. The standard of production rose, and the range of articles became wider. In 1986, the editors changed again and the title was changed to Manitoba Medicine and subsequently to the Prairie Medical Journal. Money ran out and the last issue appeared in 1997. Another journal came from a poly clinic. The Winnipeg Clinic set up its own journal in 1948, the Winnipeg Clinic Quarterly (1948-1973).This journal had specific aims: to record the proceedings of the staff meetings of the Winnipeg Clinic and to publish accounts of interesting or unusual cases, as well as short practical articles on topics of common medical interest.

218 Chapter 11 Having blossomed and flourished, why did these journals wither and perish? The editors ran out of one of three things: material, money, and enthusiasm. As isolation was reduced, so authors tended more and more to write for national or international journals.

Epilogue

A hundred centuries ago, the glaciers left Manitoba; the history of effective medicine in Manitoba spans little more than one century. In that century, a European colony of a few thousand has grown into a modern society of a million, displacing and crushing the sparse pre-existing aboriginal society. By coincidence, in that century Western medicine has advanced dramatically, in anaesthesia, the germ theory, antiseptic surgery, x-rays, anti-toxins, immunization, vitamins, and antibiotics. As important, improved housing and hygiene and simple public health measures have prevented disease.The progress in medicine has happened throughout the Western world, and, as Manitoba society grew from wilderness to metropolis, Manitoba medicine has through its links with the rest of the world usually kept abreast of medicine elsewhere. The two world wars, and the subsequent Cold War, have spun off some benefits. The First World War led to improvements in surgical techniques, wound control, and fracture management and the Second World War to improvements in the treatment of burns and wounds, and great efforts in mass production of antibiotics and prophylaxis of, for instance, malaria. The experiences of the Great Depression and the two world wars changed how doctors thought. They became enthusiastic about group practice and reluctantly came to accept more government control.Veterans had received good free medical care during the wars and demanded similar treatment, free at the point of delivery. This favoured the development of medicare, which is expensive but here to stay. Medicine in Manitoba grew up around the medical school. For a century it trained doctors for the province and managed to keep many of them. Its faculty roamed the world, bringing home new ideas and improved techniques. Pivotal events in the life of the school affected health

220 Epilogue

care in the province. As the school was judged adequate in 1910 and firstclass in 1923, so provincial health care improved. The loss of Rockefeller money in 1933 slowed development until the tap of federal money was turned on in the 1960s, permitting medicare and allowing the appointment of new geographically full-time clinical faculty and new buildings to house them, their patients, and their research. Federal money became scarcer in the late 1970s, and growth slowed. By 1983, when the medical school celebrated its centennial, the medical system, too, was just over 100 years old. What was achieved? There were over 2,000 doctors. What were they all doing? How did the Manitoba system compare with systems elsewhere? In 1883, people often died young of infections; they were lucky to live much beyond fifty. The physician carried a little black bag and usually behaved to the fearful patient in a humane and sympathetic way. His image was beloved, his medical intervention usually ineffective. A century later, people were unlucky not to live to the early seventies and died of cardiovascular disease and cancer, though new infections were appearing. The physician peered into numerous scientific black boxes, sometimes was less than sympathetic towards the no-less fearful patient, and had sometimes an image of uncaring opulence. The medical intervention worked, but some patients were just as likely to sue physicians as to thank them. In recent years, society has changed in many ways, not always for the better, and doctors' roles have had to alter likewise. With increasing urbanization, growing affluence, and the declining influence of traditional family and religious values, there has been a growth of self-destructive disorders: smoking, alcoholism, illicit drugs, over-eating, promiscuous and unprotected sex, carelessness on the highways and on the water, and domestic violence.There has been an enlarging gap between the well-off and the poor. These trends have created new demands on the health-care system and on physicians. Patient care now involves a great deal of patient education; this is time-consuming and difficult to provide in a medical practice, where the doctor daily faces the demands of serious illness and injury. The face of disease has changed. With prevention of acute disease and prolongation of life has come an increase in chronic and degenerative disease such as arthritis, osteoporosis, emphysema and chronic cardiovascular disease, and some forms of cancer. The most extreme examples are the patients in prolonged vegetative states after severe strokes or cardiac arrest. In 1967, Dr. Paul Thorlakson mused on the changes in his lifetime: effective treatment of infections, better surgery, increased specialization, early diagnosis, and common survival into old age, and wrote of the latter :

Epilogue 221 Lobar pneumonia, formerly called the old man's friend — or kidney infections with terminal uremia, do not destroy the aged and infirm at their allotted time. Instead, these unfortunate souls now, by the tens of thousands, languish in beds in our chronic hospitals and nursing homes in a state of utter helplessness, forgetfulness and creeping senility, waiting and praying for that age-old privilege of dying without medical restraint, without repeated intravenous infusion, indwelling catheters, and recurrent faecal impaction of the rectum. Many of them pray fervently for the time when they will be allowed to pass into that happier land beyond the sunset.

We have not learned how and when to say enough. The Centennial Program of the Faculty of Medicine in 1983 showed what academic physicians thought important. The doctors had a grand junket.The president of the University, Dr. Naimark, described the medical faculty as one of the strongest and most dynamic within the University, and having fulfilled its historic mandate with brilliance and steadfastness. He had been dean of the Faculty of Medicine two years before. The Centennial Program meeting was addressed by almost everyone locally considered important; platitudes sprang lush like the prairie after the spring rain. Local graduates who had made good locally spoke their pieces, and those who had carried the message afar brought their offering to the shrine. There was much obeisance to the local pantheon, notably to Joe Doupe.The program depended largely on what the contributors submitted and thought important. Several themes stood out: obesity and diabetes, infectious disease and its control, cardiovascular disease and its prevention and treatment, treatment of the previously universally lethal leukemia, the assessment of the human fetus and in particular fetal respiration. Science was studied with devotion, backs were slapped with enthusiasm, dinners were eaten with a zeal amounting to abandon. Speakers came from all over Canada and from several distinguished schools in the United States. There was one paper specifically mentioning the problems of the aboriginal population by title. In the wide world outside, the great suicidal arms race was reaching its crescendo; its possible medical significance did not appear in the program. By 1983, the role of the physician in society had changed. Now the physician had to teach the patient how best to maintain health, had to act as an advocate for the patient in circumstances such as conflict with workers' compensation boards and had to persuade or sometimes bludgeon nonmedical administrators into the most favourable disposition of the health-care dollar. Nevertheless, the physician had to have some conscience as to the disposition of scarce resources.

222 Epilogue

Life expectancy, according to the World Bank, has risen more over the past forty years than in the previous 2,000. Over the past century in Manitoba, as in the rest of Canada, it has risen from forty-five to seventy-five years; Canadian life expectancy is second only to that of Japan, and only by a year. Smallpox and poliomyelitis have been eliminated; diphtheria, measles, and whooping cough have been greatly reduced; most infectious disease can be successfully treated. Hypertension is partly controlled, and mortality from cardiovascular disease has fallen by fifty percent. Advances in surgery have been breathtaking. Laparoscopic ("keyhole") surgery has reduced hospital stays for gall-bladder surgery from weeks to days to hours; artificial joints relieve arthritic patients from pain and confinement to bed or wheelchair. In Manitoba, corneal transplantation and kidney transplantation are common and successful, and even lungs are transplanted.There is no doubt that, within limits, modern western medicine works. There is, however, more objective evidence of the success of medicine. The re-invention of the discipline of public health into "community health sciences" led to the institution of a unit that analyzed the outcome of many medical procedures in terms of cost and effect on health. Many parameters were studied meticulously, from prostatectomy to influenza vaccination. The New England annual health costs per head were shown to be about $2,500 (U.S.) as opposed to about $1,500 (U.S.) in Canada, including Manitoba.Yet, when patients sought treatment for a range of conditions, in nine cases out often they fared better in Manitoba than in New England. In the tenth case, hip fracture, a major reason for the difference was related to geography: the need in Manitoba to transfer patients a long distance for care. The conclusion is inescapable that health care for much of the community in a small and rather poor Canadian province is about as good as in the Mecca of high technology medicine, New England. Manitoba physicians have done many things right. These are the successes. But there are still many unsolved problems. One great section of our community is underprivileged; aboriginal people in Manitoba have a much higher chance of being poor, ill-housed, addicted, diabetic, infected, assaulted, and short-lived. Not enough of our social and medical budget goes to alleviate the problems of the aboriginal community. Men still beat and kill women and children, and the drunk and the drugged add to the carnage on the roads. Terminally ill people lack adequate relief of pain and distress. The mentally ill, released from custodial homes, are all too often homeless. In a society where explicit sex cozens from cinema and television screens, we are unable to educate the young to avoid teenage pregnancy. We are

Epilogue 223

confused over the provision of abortion services. We are unable to decide how long and at what expense we can support the health of the elderly. Our medical technology often supplants rather than supplements kindly, humane care. Health-care resources are not always spent according to the community needs. Hospitals have constructed expensive bureaucracies, staffed by highsalaried administrators. Reductions in federal funding have led to closures, long waits, and overcrowding in hospital. Only very recently has there been an attempt to coordinate hospitals in Winnipeg, let alone Manitoba, under one health authority. We are unable to provide professional structures for doctors and nurses that will avoid the dangerous humiliation of strikes. Our medical associations are in fact, if not in name, trade unions. Worse possibilities loom. The AIDS epidemic has shown how new epidemics grow from changed social habits and faulty health precautions; how long will it be before an acutely lethal virus like the Ebola virus spreads in our mobile society? As each new and costly drug comes on the market, how long will it be before it bankrupts medicare systems? To give Viagra to all who ask might break the bank. For how long do we spend precious health dollars keeping ourselves alive in old age, perhaps as vegetables? "What is truth," said jesting Pilate, and would not wait for an answer. Has 100 years of medicine served Manitoba well? Emphatically, yes. Will it do better in the future? Current analysis of health-care outcomes suggests that we will learn from the past how better to direct our resources. Current advances in molecular biology and genetics promise new solutions, both in prevention and cure. However dazzling the future, most of us are mainly concerned with the quality of life here and now. Common medical complaints such as the misery of depression, shortness of breath, chest pain, creaky painful joints, headache, indigestion, toothache, faulty vision or hearing, broken bones, and unremitting pain would add up to a national crisis were it not for the day-to-day relief provided by modern medicine. Hippocrates lived twenty-five centuries ago. It took that long for science to replace superstition, as Hippocrates and Galen,Vesalius and Harvey, Morgagni and Hunter, Laennec,Virchow, and Lister laid the ground for the precise diagnosis and treatment that is usual today. In Manitoba, this progress was compressed into less than a century and a half. The men and women who shaped the progress of medicine in Manitoba were the product of their time and place. Often themselves at risk from infection, they brought comfort, relief, and latterly cure to those they served. They often had to improvise and were often unsuccessful. A few were heroic, most were just

224 Epilogue

plain folk who did their best. In this book we have tried to tell their story, set against their time. In her old age, Dr. Elizabeth Scott Matheson, as recorded by her biographer, Ruth Buck, was asked by a radio interviewer, "When you look back over all those years, what do you think?""Think," she replied,"! would go back and live them all over again — every one of them." In the latter pages of her diary, she quoted Shakespeare's Cymbeline:"Fear no more the heat o' the sun, Nor the furious winter's rages; Thou thy worldly task has done Home art gone and ta'en thy wages." The proudest part of the history of medicine is not recorded on memorial stones, prestigious lectures, or in famed professorships. It lies in the service of physicians. In the heat of the sun and the rage of winter, they have done their worldly task in medicine, gone home, and are at rest.

Appendix 1: Population and Disease Statistics

Year

Birth rates, death rates, infant mortality for Winnipeg, 1908 to 1959.

Years

Analysis of women medical graduates, University of Manitoba, in five-year periods between 1891 and 1970.The line indicates the percentage of graduates who were women, only marginally over ten percent. The vertical blocks indicate absolute five-year numbers of women graduates (Nitychoruk and Nicolle, 1994).

226 Appendix 1

YEAR Population of Winnipeg and Manitoba, 1871 to 1971 (after Artibise, 1977).

Incidence of typhoid in Winnipeg, 1909 to 1959.

Appendix 1 227

Incidence of diphtheria in Winnipeg, 1909 to 1959.

Incidence of pulmonary tuberculosis in Winnipeg, 1909 to 1959.

Appendix 2: Officials of Manitoba Medical Institutions

Admissions to the Order of Canada Robert Beamish Lennox Bell E. Harry Botterell John Bowman Naranjan Dhalla F. Patrick Doyle Joseph Du Gordon S. Fahrni Henry Friesen Frank Gunston John Hildes Stuart Houston Lyonel Israels

George Johnson Percival Johnson Francis Mathewson Harry Medovy Arnold Naimark Donald Penner Donald Rae Ian Reid Allan Ronald Robert Ross P.H.T. Thorlakson Robert Thorlakson Cornelius Wiebe

Recipients of Major Canadian Medical Association Awards The EN. G.Starr Award 1969 Bruce Chown 1995 Donald Penner 1996 John Bowman The CMA Medal of Service 1989 Paul Thorlakson 1992 Robert Beamish

Appendix 2 229 Special Medal for Outstanding Service to the Canadian Medical Association 1980 Gordon S. Fahrni Special Medal of Recognition 1987 Gordon S. Fahrni Deans of the Faculty of Medicine, University of Manitoba

1883 - 1887 J. Kerr

1949-1966 L.G. Bell

1887 - 1898 J. W. Good

1 - 1972 T. W. Fyles 1966

1898 - 1900 J. R. Jones (acting)

1972 - 1981 A. Naimark

1900 - 1917 H.H. Chown

1917 - 1931 S.W. Prowse 1931 - 1949 A.T. Mathers

1981 - 1982 T.W.Fyles (acting)

1982 - 1988 J.G Wade 1988 - 1999 N. Anthonisen

Registrars and Presidents of the College of Physicians and Surgeons of Manitoba Registrars

1871 - 1876 C.J. Bird 1876 - 1881 J.S. Lynch 1881 - 1886 A.H. Ferguson 1886 - 1916 J.S. Gray 1916 - 1929 J.E. Coulter

1929 - 1947 W.G. Campbell 1947 - 1972 M.T. MacFarland 1972 - 1989 J.B. Morison 1989 - 1999 K.R. Brown

Presidents 1871 - 76 J.H. O'Donnell (The Provincial Medical Board of Manitoba) 1877 - 81 J.H. O'Donnell 1882 - 87 J.S. Lynch 1888 J.A. MacDonald 1889 S.C. Corbett 1890 S.C. Corbett 1891 F.B. Lundy 1892 N.B. Gillies 1893 H.A. Husband

1894 J.R. Jones

1895 R.S. Thornton 1896 R.S. Thornton 1897 C. W. Clark 1898 B.J. McConnell 1899 W.H. Smith 1900 W.H. Smith 1901 J.R. Jones 1902 G. Riddell 1903 A.J. MacDonell 1904 R.P. Crookshank 1905 S.W. Prowse

1906 J. Hardie

230 Appendix 2 1907 Wm. Rogers 1908 M.C. O'Brien 1909 T.M. Milroy 1910JJ.McFadden 1911 I.E. Coulter 1912R.W.McCharles 1913 D.H. McCalman 1914 D.G.Ross 1915 W.G. Campbell 1916 W.J. Harrington 1917 T. Turnbull 1918 H.A. Wright 1919 J.R. Davidson 1920 W.H. Rennie 1921 R. Goodwin 1922 Wm. Rogers 1923 A.E. McGavin 1924 D.H. McCalman 1925 J.S. Poole 1926 R.J. Campbell 1927 J.R. Gunne 1928 W.H. Secord 1929 H. McGavin 1930 B.H.Olson 1931 J.H. Edmison 1932 J. Puller 1933 W.J. Harrington 1934 W. Turnbull 1935 H.O. McDiarmid 1936 C.W. Burns 1937 W.H. Rennie 1938 H.D. Kitchen 1939 C.C. Everson 1940 J.S. Mclnnes 1941 S. Bardal 1942 J. Prendergast 1943 A.A. Alford

1944 B. Chown 1945 C.W Wiebe 1946 B.D. Best 1947 W.F. Stevenson 1948 C.B. Stewart 1949 E. Johnson 19501. Pearlman 1951F.K.Purdie 1952 C.E. Corrigan 1953 T.W. Shaw 1954 C.H.A. Walton 1955 P. Johnson 1956 A.E. Childe 1957 R.E. Dicks 1958 A.R. Birt 1959 A.L. Paine 1960 R.E. Beamish 1961 G.H. Hamlin 1962 A.R Guttman 1963 W. Malyska 1964 D.J. Hastings 1965 G.N. Willson 1966 A.A. Klass 1967 F.J.E. Purdie 1968A.T. Gowron 1969 J.C. Rennie 1970 R.T. Ross 1971 J.E. Hudson 1972 W.J. Hart 1973 C.H. Opie 1974 A.R. Downs 1975 T.F. Beveridge 1976 D.P. Snidal 1977 F.W DuVal 1978 K.J. Collier 1979 R.G. Handford 1980 M.L. Weidman

Appendix 2 231 1981 R.O. Hinch 1982 M.J.D. Newman 1983 I.C. Peever 1984 P.P. Doyle 1985 E.J.S.N. Briggs 1986 D.M. Brodovsky 1987 G.O. Hansen 1988 W.B. Ewart 1989 C.H. Murphy 1990 A. W. AM

1991 P.G.W. Lommerse 1992W.G.Warrian 1993 H.A. Wiens 1994 O.K. Bristow 1995 C.M. McConnell 1996 L.A.S. Antonissen 1997 G.M. Lindsay 1998 RJ. Menzies 1999 M.W. Kepron

Presidents of the Manitoba Medical Association 1908 - 1909 J.R. Jones 1909-1910 H.W. Smith 1910 - 1911 F.S.Keele 1911 - 1912 H.P.H. Galloway 1912 - 1913 J.S. Matheson 1913-1914 J.Halpenny 1914-1915 H.A. Gordon 1915-1916 J.S. Poole 1916-1917 J.McKenty 1917-1918 D.G.Ross 1918 - 1919 G.D. Shortreed 1919 - 1920 J.A. Gunn 1920-1921 R.D.Fletcher 1921-1922T. G.Hamilton 1922-1923 S.J.S. Pierce 1923 - 1924 G.S. Fahrni 1924 - 1925 W.A. Gardner 1925 - 1926 D.A. Stewart 1926-1927 J.D. McQueen 1927 - 1928 H.W. Lewis 1928 - 1929 E.J. Boardman 1929 - 1930 C.A. MacKenzie 1930-1931 H.O. McDiarmid 1931-1932 R.B.Mitchell 1932 - 1933 A.F. Menzies

1933 - 1934 J.C. McMillan 1934 - 1935 G.W. Rogers 1935 - 1936 F.G. McGuinness 1936-1937 G.Clingan 1937 - 1938 C.W. Burns 1938-1939 W.S.Peters 1939-1940 WE. Campbell 1940-1941 E.L.Ross 1941-1942 H.D. Kitchen 1942-1943 F.K.Purdie 1943 - 1944 D.C. Aikenhead 1944 - 1945 S. Schultz 1945 - 1946 P.H. McNulty 1946-1947 J.R. Martin 1947 - 1948 R.W Richardson 1948 - 1949 H.S. Evans 1949-1950 D.L.Scott 1950-195 I E . Johnson 1951-1952 A.M. Goodwin 1952 - 1953 C.W. Wiebe 1953-1954 W.F.Tisdale 1954 - 1955 R. Lyons (acting) 1955 - 1956 R. Lyons 1956-1957 J.E.Hudson 1957 - 1958 C.B. Schoemperlen

232 Appendix 2

1958- 1959 E. Johnson 1959- 1960 F.G. Allison 1960- 1961 H.L. McNicol 1961- 1962 K.R. Trueman 1962- 1963 K.I. Johnson 1963- 1964 L.R. Rabson 1964- 1965 C.M. Thomas 1965- 1966 D.N.C. Mclntyre 1966- 1967 G.E. Mosher 1967- 1968 D.L. Kippen 1968- 1969 D.M. McPhail 1969- 1970 O.A. Schmidt 1970- 1971 R.E. Beamish 1971- 1972 L.J. Stephen 1972- 1973 P. Connelly 1973- 1974 K.O. Wylie 1974- 1975 P.G.W. Lommerse 1975- 1976 C.E. Abbott 1976- 1977 R.F. Myers 1977- 1978 J.H. Crust 1978- 1979 F. Khan

1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998

1980A.T.Laxdal 1981 J. Dyck 1982 F. Pearson 1983 I. Kowalchuk 1984 N. Hey wood 1985 D. Fewer 1986 R. Cantin 1987 J.B. Sutherland 1988 J.D. Armstrong 1989 M. Thornington 1990L.C.Bartlett 1991 W.T. Hoeppner 1992 J. Ross 1993 S. Cleghorn 19941. Goldstine 1995 N. Donen 1996 J. Patel 1997 G.L.E. Ullyot 1998 I. White 1999 J.G. Skelly

Notes

Chapter 1 p. 13: Douglas J., 1985, p. 8 p. 21: Maxwell et al., undated, p. 4 Chapter 2 p. 30: Birtles, quoted in Little, 1938 p. 36: Higginson, 1978 p.37:Elkin, 1966 p. 40: Tyre, 1954, p. 76 p.41:Tyre, 1954, pp. 88, 89 p.42:Tyre, 1954, pp. 113,114 p. 45: Buck, 1972, p. 113 p. 49: Matthews, 1888 Chapter 3 p.53:Fahrni, 1976, p. 1 p.53:Fahrni, 1976, p. 42 p. 55:Vincent, 1912, p. vii p. 56:Fahrni, 1976, p. 39 p. 57: Mathers et al., 1908 p.62:Artibise, 1977, p. 106 p. 63: Bell, undated p. 69: Bigelow, 1969, p. 24 p. 70: Bigelow, 1969, p. 20

234 Notes p. 70: Bigelow, 1969, p. 32 p. 71:Bigelow, 1969, p. 51 p. 73: Speedily, 1943 Chapter 4 p. 76: Johnson et al., undated, p. 86 p.76:Boyd, 1916, p. 65 p.77:Boyd, 1916, p. 89 Chapter 5 p.83:Boyd,W., 1932, p. 811 p. 84: Thorlakson,P.H.T., 1967 p. 86: Hershfield, 1973, p. 41 p. 88: Hershfield, 1973, p. 84 p.91:Peikoff,1980,p.21 p. 92: Peikoff, 1980, p. 67 p. 92: Peikoff, 1980, pp. 7-8 p. 93: Reimer, 1983, p. 32 p. 94:Menzies, 1933 p. 95: Montgomery, 1936 p. 96:Walkin, 1941 Chapter 6 p. 101: Hershfield, 1973, p. 41 p. 102:Andison, 1994 p. 105: Speedily, 1943 p. 108: Halpenny, 1919 p. 109:Fahrni, 1976, p. 51 p. 113: Hershfield, 1973, p. 75 p. 115: Black, 1980 p. 116: Clarke and Hincks, 1919 p. 118: "Impressions of B.M. A. Meeting," 1930 p. 119:Bjornson, 1931 p. 119: Bell, undated p. 120: Corrigan, 1974 Chapter 7 p. 124:Taylor, 1944 p. 124: Hillsman, 1948, p. 35

Notes 235 p. 125: Crawford, 1946 p. 126: Crawford, 1946 p. 126: Hillsman, 1948, p. 82 Chapter 8 p. 132:Vaisrub, 1962 p. 140: Doyle, 1995, p. 79 p. 148: Fontaine, 1990 p. 152: Rehab International Congress, 1980, pp. 97-107 Chapter 10 p. 200: Hamerton, 1992 Chapter 11 p. 208:Morison, 1995 p.211:Fahrni, 1987 Epilogue

p. 220:Thorlakson, P.H.T., 1967 p. 224: Buck, 1972, p. 171

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Select Bibliography 245 _. Medicine in Manitoba: The Story of its Beginnings. Winnipeg: Manitoba Medical Association, 1954. _."Dr. Alex J. Douglas." Manitoba Medical Review 38 (1958): 47-48. Mitchell, R.B. [as R.B.M.] "The Medical School, A Glimpse of the Past: Dr. Ferguson." Manitoba Medical Association Review 17 (1937): 9. . [as R.B.M.] "Obituary: Dr. Charles Hunter." Manitoba Medical Review 35 (1955): 306. Montgomery, E.W. "Gordon Bell." Manitoba Medical Bulletin, vol. 7, no. 65 (January 1927): 1-7. ."Tuberculosis in Northern Manitoba." Manitoba Medical Association Review 16 (1936): 231-234. -"J-W. Good: The Most Unforgettable Character I have Ever Known." University of Manitoba Medical Journal 21 (1949): 327-334. Moore, T. "Crumbling Foundation: The Medical School and the Depression." Manitoba Medicine 58 (1988): 139-144. . "Quotas' End." Manitoba Medicine 59 (1989): 29-31. . "The University Takes Charge: Manitoba's Medical School in the Late 1940s." Manitoba Medicine 59 (1989): 115-119. . "Manitoba Medical Service: How Doctors Invented Health Insurance and Why it Didn't Work." Prairie Medical Journal 67 (1997): 45-50. Moorhead, E.S. "Medical Service to Indigents in Winnipeg." Canadian Medical Association Journal 29 (1933): 553-556. Morison,J.B. "The Earliest Prairie College of Physicians and Surgeons:The College of Physicians and Surgeons of Manitoba." Prairie Medical Journal 65 (1995): 139-141. Morton, W.L. Manitoba: A History.Toronto: University of Toronto Press, [1957] 1979. Naimark, A. "Universities and Medical Schools: Reflecting on a Half Century of Canadian Medical Education." Canadian Medical Association Journal 148 (1993): 1,538-1,542. ."The Politics of Medical Research." Prairie Medical Journal 67 (1997): 2934. "Native Healer Programme in Kenora, Ontario." University of Manitoba Medical Journal 52 (1982): 22-26. Naylor, C.D. Private Practice, Public Payment: Canadian Medicine and the Politics of Health Insurance, 1911-1966. Kingston and Montreal: McGill-Queen's University Press, 1986. Neufeld, S. Disaster at Vita. Steinbach, Manitoba: Carillon News, 1955.

246 Select Bibliography Nicholson, G.W.L. Seventy Years of Service: A History of the Royal Army Medical Corps. Ottawa: Borealis Press, 1977. Nitychoruk, M., and L.A. Nicolle."A Brief History ofWbmen in Medicine in Manitoba." Prairie Medical Journal 64 (1994): 6-10. "Obstetrics Department and Abortion Bill." Manitoba Medicine 60 (1990): 46. O'DonnellJ.H. Manitoba as I Saw It: From 1869 to Date. Winnipeg: Clark Bros., 1909. Ostry, A. "Public Health and the Canadian State:The Formative Years." Canadian Journal of Public Health 85 (1994): 293-294. Paine, A.L. "Manitoba Perspective on Tuberculosis." University of Manitoba Medical Journal 52 (1982): 21-37. Peirce, SJ.S. "Typhoid in the Winnipeg General Hospital." Canadian Medical Association Journal 1 (1911): 503-508. PennefatherJ.P. ThirteenYears on the Prairies,from Winnipeg to Cold Lake. London: Kegan Paul, Trench andTrubner, 1892. Perry, F.M."BGH 100: A History of Brandon General Hospital, 1883-1983." Brandon, Manitoba: Brandon General Hospital, [n.d.]. Persaud,T.V.N., ed."Birth Defects." Manitoba Medicine 61 (1990): 45-73. Pettigrew, E. The Silent Enemy: Canada and the Deadly Flu of 1918. Winnipeg: Western Producer Prairie Books, 1983. Pincock,T.A."A Half Century of Psychiatry in Manitoba." Canada's Mental Health 14 (1970): 5. Postl, B.D, ed."Northern Medicine. "Manitoba Medicine 59 (1989): 87-107. Postl, B.D., and D.B. McEwan. "More on Klinic." University of Manitoba Medical Journal, vol. 44, no. 2 (1974): 24-25. Powell, C."Is Geriatrics the Answer to Old Age?"Manitoba Medicine 57 (1987): 84-87. Rath, O.J.S. "Public Health Practice among the Indian Population." Manitoba Medical Review 45 (1965): 644-649. Ray, A.J. Indians in the Fur Trade: Their Role as Trappers, Hunters and Middlemen in the Lands Southwest of Hudson Bay, 1660-1870. Toronto: University of Toronto Press, 1974. ."Diffusion of Disease in the Western Interior of Canada." In Medicine in Canadian Society Historical Perspectives. Ed. S.E.D. Shortt, 45-73. Montreal: McGill-Queen's University Press, 1981. "William Todd: Doctor and Trader for the Hudson's Bay Company, 18161851." Prairie Forum 9 (1984): 13-26. Reed, M.H., ed."Medical Imaging." Manitoba Medicine 58 (1988): 2-19.

Select Bibliography Rehab International Congress. "Respiratory Polio: Rehabilitation in Manitoba." Proceedings of the Manitoba Symposium of the Rehab International Congress, Winnipeg, June 1980. University of Manitoba Medical Journal 50 (1980): 78-101. [Commentaries by ex-patients, 97-101.] Revfik, K. History of the Brandon Mental Health Centre, 1891-1991. Brandon, Manitoba: Brandon Mental Health Centre, [n.d.]. Rich, E.E."The Fur Traders:Their Diet and Drugs. "The Beaver, outfit 307,1 (1976): 42-53. Riddell,W.R. "Popular Medicine in Upper Canada a Century Ago." Ontario Historical Society Papers and Records 20 (1-5): 1929. Ronald, A. "What Role for Canadians?" Manitoba Medicine 57 (1987): 43-46. Roos, L.L., E.S. Fisher, R. Brazauskas, S.M. Sharp, and E. Shapiro. "Health and Surgical Outcomes in Canada and the United States." Health Affairs (1992): 57-72. Rose, M."Lead, Follow, or Get Out of the Way: What is the Physician's Role in a Changing Society?" Canadian Medical Association Journal 155 (1996): 209-211. Rutty, CJ."The Middle Class Plague: Epidemic Polio and the Canadian State, 1936-37." Canadian Bulletin of Medical History 13 (1996): 277-314. Schacter, B.A. "Cancer Control in the Prairies:The Manitoba Model." Prairie Medical Journal 65 (1995): 54-56. Schipper, H., and A. Nemecek. "The Manitoba Cancer Foundation Outreach Program: The End of Cancer Sanatoria?" Manitoba Medicine 58 (1988): 92-94. Shapiro, E. "Universal Home Care: The Implementation of the Manitoba Program." Unpublished manuscript. Shephard, D.A.E. Watching Closely Those Who Sleep: A History of the Canadian Anaesthetics Society, [n.p.]: Canadian Anaesthetists Society, 1993. Shepherd, L.M. "Our Hospitals through the Years: An Account of the Winnipeg Municipal Hospitals."Winnipeg: [n.p.] 1958. Sinaisky, M. "A Visit to the Department of Bacteriology and Immunology." University of Manitoba Medical Journal 32 (1960-1961): 19-21. Smith, D. "Workers' Compensation Laws in Manitoba Prior to 1916." Focus on Occupational Health and Safety 5 (1994): 1-3. Solomon, S."The Medical Research Council of Canada: The First 25 Years." In the program of MRC symposium, Research Today - Health Tomorrow. University of Manitoba, 25 October 1985. Speedily, H.M. "Ninety-eighth Annual Meeting of the British Medical Association. Winnipeg, August 26th to 29th." London Hospital Gazette 34 (1930): 69-73.

247

248 Select Bibliography . "The Coroner in Rural and Urban Manitoba." Manitoba Medical Review 23 (1943): 7-11. Stewart, D.A."The Half Century and the New Medicine." Convocation address, 1934. University of Manitoba Medical Journal 50 (1980): 60-68. Stewart, D.B. Holy Ground: The Story of the Manitoba Sanatorium at Ninette. Killarney, Manitoba: J.A.V. David Museum Inc., 1999. Stogryn, R., andW. Fleisher. "The Klinic: An Alternative Form of Health Care." University of Manitoba Medical Journal, vol. 44, no. 1 (1974): 24-25. Taylor, E.F."Notes on Common Infectious Diseases, King George Hospital." Manitoba Medical Review 24 (1944): 164-165. "Tells of Mission Work in China" [Medical Missionary Dr. Isabel McTavish]. Winnipeg Tribune, 21 January 1937. Thomson, A.E. "InVivo Dialysis in Therapy." Manitoba Medical Review 41 (1961): 295-298. . "Renal Medicine in Manitoba." Paper read at the Symposium on the History of Medicine in Manitoba, Winnipeg, 30 October 1995. Typescript. Thorlakson, P.H.T. Proceedings of Cancer Chemotherapy Symposium, June 22, 1967. Montreal: Frank W Horner Ltd., Publishers, 1967. Thorlakson,T.K. "A Patient and His Pioneer Doctors." Winnipeg Clinic Quarterly 20 (1967): 33-47. . "The Winnipeg Clinic: How an Idea became a Reality." Manitoba Medicine 62 (1992): 135-142. Vaisrub, S. Editorial,"Consultation." Manitoba Medical Review (May 1962): 297. Van Dyk,J., and others. "Approaching 100 years in Medical Physics and Radiation Oncology: Past, Present and Future." Symposium. Annals, RCPS 28 (1995): 228-238. VarsamisJ. "The Winnipeg Psychopathic HospitakThe First in Canada." Manitoba Medicine 62 (1992): 143-147. Victoria General Hospital, 1911-1986. Winnipeg:Victoria General Hospital, 1986. Vincent, S. Preface to Internal Secretion and the Ductless Glands, vii. London: Edward Arnold, 1912. Vogel,VJ. American Indian Medicine. Norman and London: University of Oklahoma Press, 1970.

Wagner, E. Eighty Years of Grace: A Brief History of Grace General Hospital Winnipeg, 1890-1970.Winnipeg: [n.p.,n.d.]. Walkin, F. "Social and Medical Aspects of the Manitouwapah Indians, Ashern Manitoba." Manitoba Medical Review 21 (1941): 157-160.

Select Bibliography 249 Walton, C.H.A."A Canadian General Hospital Overseas." Manitoba Medical Review24 (1944): 277-281. Warren, C.P.W, ed."Occupational Health."Manitoba Medicine 59 (1989): 3-10. Webster, W. The Science and Art of Anesthesia. St. Louis: Mosby, 1924. Wilton, P. "Influenza." Manitoba History 23 (1992): 17-18. Winnipeg General Hospital. "Annual Report for the Year 1884, with List of Life Governors and Members ."Provincial Archives of Manitoba, Winnipeg, 1884. Young, D., G. Ingram, and L. Swartz. Cry of the Eagle: Encounters with a Cree Healer. Toronto: University of Toronto Press, 1989. Young, F.A. "Robert Johnston Blanchard, M.D. C.M. (Edin.) LL.D. F.A.C.S." University of Manitoba Medical Journal 1 (1929): 38-40. Young, G. Manitoba Memories: Leaves from my Life in the Prairie Province, 18681884. Toronto: Briggs, 1897. Young,T.K. "Indian Health Services in Canada: A Sociohistorical Perspective." Social Science and Medicine 18 (1984): 257-264. ."Health Care and Cultural Change:The Indian Experience in the Central Subarctic."Toronto: University ofToronto Press, 1988. . The Health of Native Americans: Toward a Biocultural Epidemiology. New York and Oxford: Oxford University Press, 1994. Yule, R.F. "A Year with The Indians." Manitoba Medical Review 22 (1942): 246-

247.

Select List of Manitoba Medical Biographies

Angel, B., and M. Angel. Charlotte Whitehead Row.Winnipeg: Peguis Publishers, 1982. Bigelow,W.A. Forceps, Fin and Feather. Altona, Manitoba: Friesen Printers, 1969. Bishop, G. Davidson of Manitoba: Cancer Pioneer. London: Bishop L. and N., 1974. Buck, R.E. The Doctor Rode Sidesaddle. Toronto: McClelland and Stewart, 1972. Carr, I. William Boyd: Silver Tongue and Golden Pen. Markham, Ontario: Associated Medical Services; Fitzhenry andWhiteside, 1993. Corrigan, C.E. Unpublished autobiography. University of Manitoba Health Sciences Library. Cunnings,T.A.J. The Saga of Dr. Thor: Paul H.TThorlakson, C. C. M.D.Winnipeg: University of Manitoba Press, 1986. Doyle, P.P. A Doctor's Journey: Forty-ftveYears of Challenge. Steinbach, Manitoba: Derksen Printers, 1995. Dr. Amelia Yeomans. Manitoba Culture, Heritage and Recreation, Historic Resources Branch,Winnipeg, 1985. Dr. David Alexander Stewart. Manitoba Culture, Heritage and Recreation, Historic Resources Branch, Winnipeg, 1958. Duncan,A. Medicine, Madams and Mounties: Story ofaYukon Doctor.Vancouver: Raincoast Books, 1989. Edge, F. The Iron Rose. The Extraordinary Life of Charlotte Ross, M.D. Winnipeg: University of Manitoba Press, 1992. Fahrni, G.S. Prairie Surgeon. Winnipeg: Queenston House, 1976. Ferguson, C.C. One HundredYears of Surgery, 1883-1983: Professors of Surgery, The University of Manitoba. Winnipeg: Peguis Publishers, 1983. Hershfield, C.S. Medical Memories. Winnipeg: Privately published, 1973.

Medical Biographies 251 Hillsman,J.B. Eleven Men and a Scalpel.Winnipeg: Columbia Press, 1948. Mayba, I.I. Bonesetters and Others: Pioneer Orthopaedic Surgeons. Winnipeg: Henderson Books, 1991. Moore,T.Joe Doupe, Bedside Physiologist. Toronto and Oxford: Hannah Institute; Dundurn Press, 1989. PeikofF, S.S. Yesterday's Doctor: An Autobiography.Winnipeg: Prairie Publishing, 1980. Peterkin, A., and M. Shaw. Mrs. Doctor: Reminiscences of Manitoba Doctors'Wives. Winnipeg: Prairie Publishing, 1976. Reimer, M. Cornelius W.Wiebe,A Beloved Physician: The Story of a Country Doctor. Winnipeg: Hyperion Press, 1983. Robinson, C.L.N. J.C. Boileau Grant: Anatomist Extraordinary. Saunderson, PJ. Dr. Henry H. Chown: Biography. University of Manitoba, 1985. Tyre, R. Saddlebag Surgeon:The Story ofMurrough O'Brien, M.D. Toronto and Vancouver: J.M. Dent, 1954. Vandervoort,J. Tell the Driver: A Biography of Elinor E.F. Black. Winnipeg: University of Manitoba Press, 1992. Walton, C.H.A. Medical Odyssey: Vignettes of People and Events at Home and Abroad. Winnipeg: Winnipeg Clinic, 1980. Wilson, K.John Pyne Pennefather: Canadian Biographical Series, Faculty of Education, University of Manitoba, 1991.

Index Abbott, C. 109 aboriginal health and medicine 5,9,21,22, 39, 95 et seq, 145 et seq abortion 193 et seq AdamsonJ.D. 107,108,118 ague 13 alcohol 84, 108, 202 Allen, F. 55 allergists 177 anaemia, pernicious 80 anaesthesia 112 et seq, 181 et seq anatomy 57,104,101,161 Andison,A. 102 appendicitis, acute 51, 92 Arctic Medical Research Unit 146 Auld,W. 12 bacteriology. See microbiology Baldwin, Dr. 24 Bay (Hudson), medicine on 10,17 Beamish, R.E. 175,214 Beath,T. 57,58 Beazley, G. 139 Beddome,H. 19,24,208 Bell,G. 47,55,62,68,100,119,211 Bell,L. 88,119,155 Bennett,]. 179 Bichat.F. 7 Bigelow,W 69 biochemistry 56,164,169 Bird,C. 20,208 Birt.A. 178 Birtles.E. 30 Bjornson,O. 115,119 Black, E. 154,192 Blanchaer.M. 157 Blanchard,R. 54,214 blood transfusion 71,167,168 Board of Health 61,62; Bacteriological Branch of 62 Bond, A. 59 Boyd.W. 76,77, 83,100 et seq, 114 Brandon asylum 47 Brandon Mental Hospital 62 Brandson,B. 110

British Medical Association meeting 117 brucellosis 87 Bryce,P.H. 97 Buck, R. 224 Buller.R. 55 BunnJ. 14,15 Burns, C. 184 Burridge,A. 80 Cadham, F. 64, 80,101,116,165 Caesarean section 42 Caldwell,W.B. 18 Cameron,A.T. 56,101,104,122 Canadian Medical Association 52, 54 cancer 37,113 et seq, 178 et seq; of bronchus 80; oflung 104, 176 cardiology 174 et seq Carruthers.J. 11 Casperson, C. 10 Centennial Program, Faculty of Medicine 221 Cheeloo University 126 Cherniack, R. 177 Chernick,V. 197 child health 59, 60, 67, 196 et seq childbed fever. See puerperal fever childbirth 31 et seq, 56,71,72,114 et seq, 190 et seq Childe,A. 170,188 Chown.B. 108,198 Chown.G. 60,108 Chown, H. 27 et seq, 45,48,51,52,65,68,211,214 cigarette smoking 176 clinics 88 Cohen, M. 186 Colcleugh's drugstore 102 College of Family Physicians 139 College of Physicians and Surgeons of Manitoba 25, 207, 229 et seq colleges, royal 105,106. See also specialism, medical congenital heart disease 186 contraception 93, 193 Convalescent Home ofWinnipeg 58,59 coronary artery disease 80,174 coroner: country 83; physician as 72,73 Corrigan,C. 120,125,184

Index 253 Covenant, Dr. 19 Cowan, W. 18 Crawford, J. 125 Crawford, M. 67 Cuddle, A. 14 Gumming, G. 214 cytology, cervical 168 Davidson, A. 178 Davidson, J.R. 114 Day, Dr. 108 deans, Faculty of Medicine 229 Depression years 79,102 dermatology. See skin disease diabetes mellitus 80 diphtheria 28,34,36,41,42,61,125, 227 Douglas, Alexander J. 64 et seq Douglas, John 13 Doupe,J. 162 et seq Downs,A. 187,189 Doyle, P.P. 139,140 Dr. Chase's New Receipt Book 39 drug addiction 204 DuMoulin, Father 6 Duncan, Dr. 18 Dwyer.E. 203 ear, nose, and throat disease 189 Edinburgh medical school 11, 99 Edwards, A. 12 electrocardiography 80,175 Elvin,N.L. 189 emergency medicine 204 encephalitis 83, 123, 166 endocrinology 55,177 endoscopy 178 epidemics 16,18 et seq, 34, 40, 41, 61, 64 et seq, 82 Evatt,RJ. 57 eye disease 110,189,190 Faculty of Medicine 99, 184 Fahrni, G. 53,109 et seq, 120,184,211 family planning 193 family medicine 138 et seq Fawcett,J. 26 Ferguson, A.H. 38,39,48,55 Ferguson, C. 182 et seq Ferguson, M. 217 Fergusson.A.M. 31 Fergusson, R.B. 29 et seq fetal physiology 195 FindlayJ. 148

Fish,D. 136 Fleming, A. 35 Flexner Report 57, 73 flood, Winnipeg, 1950 148 et seq Fontaine,?. 148 forensic medicine 72,73 FortescueJ. 13 Friesen, H.P.H. 162,163 Friesen.R. 199 Galloway, H.P.H. 110 gas warfare 76 GemmellJ. 162 general medical practice 138 et seq general surgeons 185 genetics, human 199 et seq geographical full-time physicians 161 geriatric medicine 142 Gibson,A. 57,103,110,119,133 GilliesJ. 179 Gilmour, C.R. 88,102,104,107 gonorrhoea 87,96 GoodJ.W. 27,40,110 Goodwin, A. 168 GrantJ.C.B. 100,101,104 GrayJ.S. 33,209 Great-West Life Assurance Company 52,54, 114,214 Greater Winnipeg Medical Relief Plan 121 Grey Nuns 3,15,33 Guest,WC. 189 GunnJ. 54,110 Gunston, F. 189 gynaecology 190 et seq haemolytic disease of newborn. See Rh haemolytic disease Halpenny, J. 100,108 et seq, 210 HamertonJ. 200 Hamilton,T.G. 217 Hamlyn, R. 14 health, environmental and occupational 203 Health Sciences Centre 137 heart attack 174 Hendry.Dr. 14 Henteleff,P. 144 Hershfield, C.S. 73,85,101,113 Higginson,A. 36 HildesJ.A. 147,151,163,175 HillsmanJ. 124,126 Hincks,C. 116 home care 143 hospitals: Bethel 93; Brandon General 35, 70; Brandon Mental 62,201; Children's

254 Index 59etseq, 105,160,186,197; Concordia 82; Deer Lodge 77, 129; Grace 57, 58; King Edward 58; King GeorgeV 58,82; Misericordia 57, 58; Maternity 192; Municipal 58; Princess Elizabeth 143; St. Boniface 15,29, 33 et seq, 57,69,137,160; St. Joseph's 82; Selkirk Mental 46,202; Seven Oaks 138; Tuxedo Military 123;Victoria 58;Vita 89 et seq, 149;Winnipeg General 29 et seq, 48,57, 66,136,137;Winnipeg Psychopathic 117; Women's 132 HossackJ. 217 Hudson, E.D. 72,141 HudsonJ.E. 72,141 Hudson's Bay Company 6,12 Hughes, G. 216 Hunter, C. 107 Hutchins.T. 11 hydatid disease 37 hypertension 174 Icelandic colony 19,24,25 immunology 166 impetigo 96 Indian. See aboriginal health and medicine infectious disease. See epidemics infertility 195 influenza 20, 82, 83, 96, 97 Inglis,M.S. 47,65 initiation 101 insulin 101, 121 insurance medicine 214 et seq intensive care 204 internists, internal medicine 106,173 Israels,!. 168,180 Jackson, EW. 81 Jews, Jewish 24,153 Johnson, Dr. 76 Johnson, G. 136 Jones, J.R. 27 journals, medical 26,48,49,216 et seq jubilee, Manitoba Medical College 118 Keenberg,A.A. 94 Kerr.A. 216 KerrJ. 27,39,48 kidney: artificial 176; transplantation 176,188, 189 Klass,A. 187 Klinic 141 laboratory: physicians 165; provincial 63,105, 165 et seq

Laennee, R. 7 Laserre,P. 12 LaVerendrye 6,15 Lawson, Dr. 72 Lederman,J. 167 leprosy 61 Lewis, M. 198 libraries, medical 215,216 lice 96 licensing 25 lithotomy 28 Lynch, J.S. 20,24,208 MacCharles, M.R. 88, 179,184 MacEwan,D. 170 MachrayJ. 103 Mackay,D.S. 115,116 Maclean, NJ. 55,88 Magee,D.R. 189 Manitoba Clinic 88, 138 Manitoba Health Services Commission 135 Manitoba Hospital Commission 133 Manitoba Medical Association 210-213; presidents 231-232 Manitoba Medical Centre 137 Manitoba Medical College 25 et seq, 51, 99 Manitoba Medical Services Foundation 135 Manitoba Medical Services Incorporated 132 et seq Manitoba North West and British Columbia Lancet 26,48,216 Mann,W.L. 214 Manning, F. 194 mass grave, Patterson Lake 40 maternity. See childbirth Mathers,A.T. 100,102,116,153,184,200 Matheson, E. (Scott, E.) 45, 67, 224 Mathewson,F. 175,214,217 Matthews, Dr. 49 McCalman.D. 56,100,115 McDiarmid,A. 33 McDiarmid,W. 200 McDonnell, J. 142 McGuiness, EG. 191 McIntyre,S. 215 McKeevor,T. 12 McKentyJ. 86 McLean, H. 148 McQueenJ. 76,191 McTavish,!. 126,148 measles 20,40,41,96 Medical Research Council of Canada 159 medical: consultation 132; education 25 et seq, 50 et seq, 99 et seq, 156 et seq, 158;

Index 255 ethics 213; practise 84; specialism 105, 173 et seq; students 101 Medical Revolution 7,130 medicare 132 et seq Medicine Society. See Midewiwin Medovy, H. 196 et seq mental handicap 202 mental illness. See psychiatry Menzies.A.F. 93,140 MenziesJ.C. 140 Menzies.R.J. 141 Mewburn, F. 38 microbiology 62 et seq, 105,165 Midewiwin 22 mission hospitals, missionary doctors 89,148 Mitchell, R. 192,211,215,217 Monk.R. 215 Montgomery, E.W. 95,100,106,113,119 Moore, K. 162 Moore, P. 97 Moorhead, E.S. 134 Moorhouse,VH.K. 104 Morgentaler, H. 194 MorisonJ. 135,208 Morse, H. Ill mortality, maternal 190 Mount Carmel Clinic 82,141 MunckJ. 6,10 Municipal Doctor Scheme 94, 95 myocardial infarction. See heart attack Naimark.A. 155,162,221 National Cancer Institute of Canada 160 National Research Council 159 neurology 177 neurosurgery 187,188. See also neurology Nicholson, D. 105,113,114,167 Nickerson, M. 164 Northern Medical Unit 147 Northwest Company 6,12 O'Brien, M. 40 et seq, 82,83 obstetrics. See childbirth O'DonneUj.H. 28,208 Olson, B.H. 214 oncology 178-181 ophthalmology 189-190 Order of Canada 228 Osier,W. 26,27,52,217 otorhinolaryngology 190 paediatrics. See child health Paine, A. 82 palliative care 144 et seq ParkhouseJ. 182

Parkinson, D. 188 pathology 165,168 Paxton.Dr. 19 PeikofF,S.S. 91,92 penicillin 125 Penner,D. 167,168 PennefatherJ.P. 48, 216 pest house 65 pharmacology 164 physiology 56,161 Physiology, Department of 56 Pierce, S. 71 Pmcock.T.A. 116,200 pneumothorax 68 poliomyelitis 83,123 et seq, 149 et seq prisoner-of-war camp 125 prohibition, of alcohol 84 prolactin 163 Prosen,H. 201 prostatic disease. See surgery, urological Provencher, Father 6,15 Prowse,S.W. 99,100,103,111 psychiatry 45,116 et seq public health 67, 80 et seq, 85 puerperal fever 32,116 quarantine 85 quotas, for entry to medical school 153 et seq radiology 47, 48,113,114,169 et seq radiotherapy 113,114,179 Read,W.W 90 Red River Colony 6 Red River fever. See typhoid Reed, H. 190 rehabilitation medicine 142 research medical 159 et seq respirology 176 et seq Rh haemolytic disease 198 et seq rheumatism 13 Rice,H. 188 rickets 96 Riddell, 13 Riel rebellion: first 19,23; second 24,210 Roblin.D. 135 Rockefeller Foundation 103 Roddick, T. 31 Rorke,R. 60,108 Ross, A. 141 Ross, C. (Whitehead) 43 et seq Ross,E. 112 Ross, R. 177, 188, 215 Roulston, M. 193 rural medicine 39 et seq, 69 et seq, 89 et seq, 139 et seq

256 Index salvarsan 51,85 sanatorium 68,178 Saunders, C. 14 Saunders.M. 170,187,188 scabies 96 scarlet fever 34,40,41,61,67 SchulzJ.C. 20,208 Scientific Club ofWinnipeg 56 Scott, E. (Matheson, E.) 45, 67, 224 scurvy 11,12,17,96 Sehon,A. 167 Selkirk asylum 46 Selkirk, Lord 6 serotherapy 80 shaman 9 ship fever 12 shock 164 Simpson, F. 14 Simpson, G. 14,15 Simpson, R.M. 68 Sisler,G. 201 skin disease 178 smallpox 14,20,21,24,34,42,64 et seq, 81 Smellie,W 17 Smith, WH. 117 Speedily, H.M. 72,73,104 St.Amant,B. 202 Stewart, C.B. 188 Stewart, D.A. 48,67,213 Stewart, O. 215 Stone, E.L. 97 Stranaghan, Dr. 19 strike, doctors' 119 et seq sulphonamides 87 surgery 30 et seq, 37,38,54,55,69 et seq, 85 et seq, 108,133 et seq, 105 et seq, 183 et seq; cardiac 186 et seq; neurological 111,187,188; orthopaedic 110,189; vascular 187,188;urological 85,111,188 sweat bath, sweat lodge 10 syphilis 51,71,76,86 tapeworms 96 Taylor, E. 124 tetanus 69,96 Thiboult,L. 33 Third Casualty Clearing Station 54 Third Field Ambulance 54 Thomson, A. 176 Thorlakson, K. 38 Thorlakson, P.H.T. 55,84,88,184,220-221 thyroid 51,109 ToddJ.O. 69

Todd,W. 14,21 tuberculosis 11,61,67 et seq, 80,81,87,96, 97,176 typhoid 34, 61, 66, et seq, 226 typhus 12, 13 TysonJ. 194 Uchida, I. 200 ultrasound 170 University Act 55 urology. See surgery, urological vaccination 65, 81 Vaisrub.S. 217 Vanstone, C.M. 214 venereal disease 87 Vincent, S. 55,56,100,215 WadeJ. 182,183 Waldon,H. 90 Walkin,F. 96 Walton, C.H.A. 87,97,125 Walton, R. 179 War: First World 54,75 et seq, 116; of 1812 13; Second World 123 et seq; South African 51,80 Washington, EJ. 190 Waugh.O. Ill Wawanesa Mutual Insurance Company 214 Webster, W 112 Wellington 7 Wheeler, D. 169 White, F. 164 WhiteJ. 12 whooping cough 20, 41, 96 Wiebe,C. 92 Wills, Dr. 17 Wilson, DM. 26 WiltJ. 165,166 Winnipeg Clinic 88,138 women: admission to medical school 4,153 et seq, 225; physicians 43 et seq, 124 Women's Christian Union 32 Women's Aid Society 35 Women's Hospital Aid Society 30,58,59 WyattJ. 168 x-rays 36,47,48. See also radiology Yeomans,A. 43 Yeomans.L. 43,209 Young, D. 24,46 Youville, M. d' 24