History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: June, 1935 Vancouver Medical Association Jun 30, 1935

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 The BULL™
OF THE    \ v\V
VANCOUVER M
ASSOCIATION
Vol. XL
JUNE,  1935
Special Cancer Number
THE CANCER PROBLEM IN BRITISH COLUMBIA
ESTIMATION OF SURGICAL RISK
HOSPITAL ECONOMIES FINEST QUALITY
Halibut Liver
Oil
Biologically tested, imported from Great
Britain. Guaranteed to contain at least
50,000 International Vitamin A Units per
gram.
This fine produce is unsurpassed and is at
your disposal for prescription either in bulk
or collapsible capsules at approximately half
the price of other similar products.
Capsules containing 3 minims (equivalent in
Vitamin A content to 4 teaspoonsf ul of Cod
Liver Oil) 50 in box for $1.00.
Obtainable at all
VANCOUVER DRUG CO.  STORES
Western Wholesale Drug Co.
(1928) Limited
456 BROADWAY WEST
VANCOUVER   -   BRITISH COLUMBIA THE     VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
"Published {fllonthly under the ^Auspices of the Vancouver <tJtledical ^Association in the
Interests of the ^Medical "Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XI. JUNE,  193 5 No. 9
OFFICERS   193 5-193 6
Dr. C. H. Vrooman Dr. W. T. Ewing Dr. A. C. Frost
President Vice-President Past President
Dr. G. H. Clement Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
Additional Members of Executive—Dr. T. R. B. Nelles, Dr. F. N. Robertson
TRUSTEES
Dr. W. D. Buydone-Jack Dr. J. A. Gillespie Dr. F. Brodie
Auditors: Messrs. Shaw, Salter & Plommer
SECTIONS
Clinical Section
Dr. J. R. Neilson ,   Chairman
Du. Roy Huggard      ~-   Secretary
Eye, Ear, Nose and Throat
Dr. E. E. Day —  —- —- -  Chairman
Dr. H. R. Mustard   Secretary
Paediatric Section
Dr. G. A. Lamont     Chairman
Dr. J. R. Davies    -    Secretary
Cancer Section
Dr. J. W. Thomson  —  Chairman
Dr. Roy Huggard _   -i    Secretary
STANDING COMMITTEES
Library Summer School
Dr. G. E. Kidd Dinner Dr- H- A' DesBrisay
Dr. W. K. Burwell „    T T Dr. H. R. Mustard
Dr. C. A. Ryan Dr. Lavell Leeson Dr. J. W. Thomson
Dr. W.D.Keith Dr. J E Harrison Dr. C E. Brown
Dr. H. A. Rawlings UR' A> Lowrie Dr. J. E. Walker
Dr. A. W. Bagnall Dr. J. W. Arbuckle
Publications Credentials
Dr. J. H. MacDermot Dr. H. A. Spohn
Dr. Murray Baird Dr. J. W. Thomson
Dr. D. E. H. Cleveland Dr. W. L. Graham
V. O. N. Advisory Board
Dr. I. T. Day ReP-to B- C- Meclical Assn-
Dr. W. H. Hatfield Dr. W. C. Walsh
Dr. A. B. Schinbein
Sickness and Benevolent Fund — The President — The Trustees
Ms
A1?
hi
,v, Anti-Meningitis Serum
Anti-Pneumococcic Serum   (Type 1)
Anti-Anthrax Serum
Normal Horse Serum
Smallpox Vaccine
Typhoid Vaccine
Typhoid-Paratyphoid Vaccine
Pertussis Vaccine
Rabies Vaccine   (Semple Method)
INSULIN
Price List Upon Request
Connaught Laboratories
University of Toronto
TORONTO 5 - CANADA
Depot for British Columbia
Macdonald's prescriptions Limited
Medical-Dental Building, Vancouver, B. C. VANCOUVER HEALTH DEPARTMENT
STATISTICS—MARCH, 193 5
Total Population  (Estimated)      244,329
Japanese Population   (Estimated)     8,037
Chinese Population  (Estimated) „..   —   7,803
Hindu Population  (Estimated)        276
Total Deaths 	
Japanese Deaths	
Chinese  Deaths	
Deaths—Residents  only	
Birth Registrations—
Male,  15 6; emale,
140.
INFANTILE MORTALITY—
Deaths under one year of age 	
Death rate—per  1,000 births 	
Stillbirths (not included in above) 	
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
May 1st
March, 193 5
Cases     Deaths
Rate
per 1,000
Number
Population
220
11.0
5
7.6
12
18.7
197
9.8
296
14.7
April,
April,
1935
1934
4
7
13.0
28.7
4
12
April
Cases
, 1935
Deaths
Smallpox           0
Scarlet   Fever     37
Diphtheria          0
Chicken Pox :     60
Measles   _       13
Rubella     „      4
Mumps     3 3
Whooping-cough         63
Typhoid Fever 	
Undulant Fever	
Poliomyelitis .  	
Tuberculosis    	
Meningitis   (Epidemic).
Erysipelas   	
Encephalitis Lethargica
5
0
0
46
0
2
0
Paratyphoid     _ .._       0
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indication of a specific gland being at fault, but every indication of a
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Page 7«5 For the rest of your natural life
I sentence you to the hypodermic needlel
THIS is the verdict feared by every diabetic. It is the sentence which the
physician should avoid wherever possible.
For proper indications and in emergencies, there is of course no complete
substitute for insulin. But many diabetics thrive on oral treatment with
Pancrepatine, which contains the hormone of pancreas and liver ACTIVE
BY MOUTH.
Pancrepatine spares insulin and never causes hypoglycemic shock. It spares
the patient the discomfort of the hypodermic needle. It reduces urinary
sugar—frequently clears it up entirely. Also controls polydipsia and polyuria.
Prescribe 2 to 4 globules of Pancrepatine t.i.d. Supplied in bottles of 100
hormone-active globules protected against ferment action.
PANCREPATINE   1
ORAL TREATMENT FOR DIABETES
Obtainable from B. C. Drugs Limited, Vancouver; Georgia Pharmacy, Vancouver; McGill & Ornie, Victoria.
ANGLO-FRENCH DRUG CO., MONTREAL EDITOR'S PAGE
It is with great pleasure that we publish the "Memorandum on Cancer"
handed to us by the B. C. Cancer Foundation recently inaugurated in British
Columbia. We would urge all our readers to keep this number carefully for
future reference. The monograph gives in brief and available form the
latest opinions on the scope of the cancer problem, and the best ideas yet
evolved as to the methods that must be followed if this age-old menace to
humanity, that has lost none of its virulence with the passing centuries, but
has rather taken on new and more potent life in our day, is to be met and,
under the providence of God, mastered or at least controlled.
Perhaps, as some think, it will never be possible to wholly defeat this
enemy, any more than we can ever defeat death or madness—for it is a
madness of the tissues of the body—a senile dementia of the cells. But we
need not therefore adopt a defeatist attitude towards cancer. Quite otherwise—there is every reason to attack this problem with the greatest certainty of ultimate victory. It would seem to us that there are certain lines
that must be followed, and these are the lines suggested by this report.
First, education of a constructive order, and the laying of emphasis on
the essential hopefulness of our position. And education must be directed
not alone to the patient—whom we must try, by convincing logic, to train
to seek advice early—but to our own profession, whose sins of omission, not
less than of commission, are to no small extent responsible for the present
appalling mortality. And, too, governing bodies of all sorts must be
approached and educated to the terrible seriousness of the problem. This
is not a private war, it is on all our doorsteps, and there are no neutrals.
Secondly, preventive measures, and here we think that great emphasis
must be laid on periodical health examinations, properly and sincerely carried out. We know that cancer has, in perhaps the majority of cases as we
know the disease at present, perhaps even more as we shall come to know it,
a latent and early period, when cure is almost mathematically certain, with
adequate and thorough treatment. It is perhaps a more chivalrous foe than
we have ever realised, and gives its prospective victim the "En garde!" that
will allow him time to draw and defend himself.
Thirdly, treatment, very much more complete and modern than anything we have in British Columbia as yet. It is not a thought to give us
pride that we are the only province in Canada, except the small province of
Prince Edward Island, that has no publicly owned radium, and that has not
yet considered this problem from a provincial point of view.
Fourthly, research. This must be carried on more and more energetically
if we are to advance beyond a purely defensive stage—if ever we are to
arrive at.the "sterilisatio magna," the much hoped-for and longed-for cure
of cancer. This may not come till long after we have gone—it may not
come in the form we think—but if it is to come, we must as a race earn it,
by the sweat of our brow. For there is abundant proof that there is no royal
or easy road to this goal. When it comes, we shall, in the achieving of this
end, have delved deep into the mysteries of life, its origin, its first causes,
and the reasons for its decay—and this is no easy field to cultivate.
But we in British Columbia have great reason for renewed hope. There
has been great work done in the past few weeks. Beginning some short time ii
?! K'r
Hi if
m r ;■
«1
ago, a Committee was appointed by the B. C. Medical Association to initiate
and devise methods for the control of cancer in B. C. Working in conjunction with the Greater Vancouver Health League and the Board of Trade, a
very strong group of men has organised a British Columbia Cancer Foundation, incorporated itself, and is shortly starting an active campaign for funds.
On the 3rd of June, a large luncheon meeting will be held in Vancouver,
to which a great many men, prominent in public life, and having influence
that will be helpful, will be invited, with a view to getting away to a good
start. It must be understood that this is not a Vancouver project—it is
provincial in scope, and will embrace the whole of B. C. But Vancouver
is in the strategic position for its inauguration, and it is the particular
duty of this city to take the lead, since it is the chief sufferer from the
scourge. At this meeting, and in subsequent efforts of publicity, the extent
of the problem, its various angles, and the suggested lines of attack, will be
pointed out, and the sympathy and active support of the public sought.
And what of us? What can we do? We must give this thing our fullest
support. It is again a question of the responsibility that comes from privilege. In any case, we are the troops, and will have to do the actual fighting
in this campaign. We do not doubt the loyalty .and hardihood of our troops
—but we feel that the actual extent of the war, and the tactics necessary to
win it, are not yet well understood by the rank and file—and it is therefore
incumbent on every one of us to familiarise himself with the aspects of the
situation. Meantime we wish the new B. C. Cancer Foundation the greatest
success in the work that it has undertaken. The list of names of the men
who have begun this work will be of interest to our readers and we publish
them herewith:
W. J. Twiss, W. C. Ditmars, Norman Levin, B. J. Harrison, M.D.,
H. H. Milburn, M.D., G. F. Strong, M.D.
Last month we commented on the changes in the Council of the College
of Physicians and Surgeons. There is one more change that deserves to be
chronicled, but which had not at that time been made. That is the definite
appointment to the position of Registrar of Dr. John A. MacLachlan of
Vancouver.
Dr. MacLachlan has been acting Registrar since the death of Dr. A. P.
Procter. He has been a member of the Council for some nine years, and is
amply fitted by experience as well as other qualifications to fill this most
important office. The Registrar of the College is a very busy man and very
much a "key" individual. He is the first line of defence between the College,
and that is the medical profession, and the public at large. As he acquires
wisdom and tact and ability to judge people, he becomes really essential.
But to do this he must have in him certain native qualities of kindliness and
friendliness, as well as mere ability. Dr. MacLachlan has these indispensable
qualities in no small degree, and those of us who have had to deal with him
in an official capacity have marked his ability to keep his temper, and see the
other man's point of view. We may seem to be making rather much of an
appointment which perhaps compares unfavourably as regards salary and
opportunities for publicity with many other positions—but after all, it
concerns us all vitally that the man who fills this position should be of the
right type and calibre, and we feel that the Council acted wisely when it
made its choice.
Page 187 NEWS AND NOTES
Do not forget to buy your ticket for the Summer School, June 18, 19,
20, 21. These are now on sale.
The Editor acknowledges with thanks an anonymous letter designed to
brighten life by suggesting a suitable crest for the Association. We commend its ingenuity, but feel that the suggestion, while distinctly good, is
lacking in one or two particulars.
In the first place, as regards the Book. We applaud the idea of having a
Bible—it does great credit to the mind that conceived it—and we are sure
that, given time and some intensive training, the medical man at large might
be induced to read it; and it would do him a lot of good if he could understand it. But at present for most of them, we fear, it is a foreign language,
and does not really reflect the Medical Association at all accurately. So
perhaps we might make a start with Gray's Anatomy, or Anthony Adverse.
Then the field: argent. This again would be quite strange to the doctor,
if, as we believe, it means silver. Only Dan McLellan knows much about
silver, and, of course, the g.u. men such as Lee Smith. If a white surface
were required, mercury might be more appropriate, if a bit unstable. Zinc
oxide would do perhaps, though inclined, like all of us, to acquire a slightly
yellow" tinge as it grows older. Has he not got his adjectives mixed, too,
when he speaks of a skull couchant, and an obstetric forceps rampant? We
should be inclined to reverse them and say " accouchant" instead of con chant.
Otherwise the crest is excellent, and we endorse it thoroughly.—Ed.
A rather poorly attended meeting was held in the Medical-Dental lunch-
counter at 9:15 a.m., April 27th. His Worship Mayor G. G. McGeer was
in the chair (the one nearest the street door). On his left was seated Dr.
Lyle Telford. Proceedings were opened by the Mayor hammering the counter with a knife-handle and calling for dry toast. The situation developed
rapidly after that and the reporter has the impression that what commenced
as an impassioned plea for something on the part of the Mayor developed at
once into a debate with Dr. Telford. His Worship was understood to say
that the situation was impossible, but when he had finished with two or
three matters which he had now on hand, then, ind then only, could he
give his undivided attention to something else. Dr. Telford appeared—for
once at least—to express agreement. At least fifty per cent of the audience
had departed by this time, leaving the reporter alone. A silver collection
was taken by Agnes. The meeting then broke up and the windows and
plates ceased to rattle.
We congratulate Drs. R. E. McKechnie, Isabel Day and George Seldon on
the presentation to them by His Majesty the King of Jubilee Medals ,for
public service well done. It has been rumoured in the paper that many people
have felt that they, too, should be rewarded. Perhaps one reason why the
new silver dollars were issued about the same time as the medals was so that
nobody should feel slighted. Except the Editor of this journal, who received
neither one nor the other.
Dr. G. F. Amyot has left for the East, to study public health matters.
His work is being taken by Dr. S. Stewart Murray.
The Council of the College of Physicians and Surgeons has appointed
Page 188 Dr. W. E. Ainley, one of its members, to be Chairman of the Health Insurance Committee of the Council. The following are the members of this
Committee: Dr. G. F. Amyot, Dr. L. H. Appleby, Dr. W. A. Clarke, Dr.
J. A. Gillespie, Dr. B. D. Gillies, Dr. J. J. Gillis, Dr. G .C. Kenning, Dr. J.
H. MacDermot, Dr. N. E. McDougall, Dr. W. H. Sutherland, Dr. Wallace
Wilson, Dr. F. N. Robertson and Dr. R. L. Miller.
It is more than probable that Dr. Grant Fleming will be out here again
this summer, and will be available for advice and help by the profession.
Dr. Gordon M. Kirkpatrick has joined the medical staff at Essondale.
Dr. Earle Hall, recently of Nanaimo, has begun practice in Vancouver.
He is confining his work to urology.
Definition of a "general practitioner": One who can tell measles from
rheumatism without the help of a laboratory girl.—Maclean's Magazine.
INCOME   TAX   DEPRECIATION   ALLOWANCES
The Secretary,
College of Physicians and Surgeons,
Vancouver, B. C.
Sir:—For your nformation, I am enclosing herewith an extract from a
Departmental ruling recently issued regarding depreciation allowances,
insofar as it affects the Medical Profession.
Perhaps you will see fit to circularize your members in accordance therewith.
Yours faithfully,
CHAS. R. BROWN,
for Commissioner of Income Tax.
PROVINCE OF BRITISH COLUMBIA
The following rates and general principles relating to depreciation are
effective in respect of fiscal years ending on and after September 30, 1934.
The rates hereinafter set out, or such lesser rates as the taxpayer may
adopt, must be consistently applied, irrespective of whether operations are
profitable or otherwise.
Maximum
Classification Rates
Furniture and fixtures          5%
Professional equipment  (medical, surgical, dental, engineering; including standard reference books) *_       5%
(Miscellaneous instruments and current text-books should
v  charged directly to expense.
Autos and trucks (see below)     20%
The method of application will be the "straight line," as heretofore.
The depreciable amount, to which these rates will be applied in computing annual depreciation allowances, is:
(a) As to the original owner: cost.
(b) As to a subsequent owner:  his purchase price, provided it does
not exceed the original cost, less depreciation allowed.
The residual value: The policy adopted in 193 3 of establishing a residual balance and discontinuing depreciation allowances when they have reached
75c/i of the depreciable amount, will continue in effect. When any asset is
discarded and actually replaced, the residual value, less realized salvage, will
be allowed as a deduction from income from the year in which replacement
is made; conversely, if the realized salvage exceed the residual value of an
asset so replaced, such excess constitutes taxable income. However, in the
case of discarded assets which are not replaced, no further deductions from
income will be allowed nor will realized salvage be treated as income, except
in the case of such assets as may have been wholly depreciated heretofore.
Amended assessments will be made in every case where depreciation at
approved rates, in respect of any assets has exceeded:
(a) 100%  as at the close of a fiscal or business year ending prior to
September 30, 1933.
(b) 75' '(  for years ending on and after that date.
Treatment of Repairs, Renewals, Replacements and Additions.—An
allowance for depreciation is made to compensate the taxpayer for wear and
tear, occasioned by the use of an asset in producing income, and the annual
depreciation allowances are accumulated in a reserve, for the express purpose of providing for the anticipated cost of the renewals and replacements,
which will be necessary, in addition to minor repairs. These minor repairs
are, of course, allowed as a direct expense, but renewals, replacements and
major repairs must, in all cases, be charged to the depreciation reserve. Only
in the case of additions and extensions may the cost be capitalized and the
depreciable amount, on which the annual allowances are based, be increased.
Exceptional Cases.—An exception is made to the foregoing in the case
of the following: Autos and trucks—annual allowances 20%.
The full cost of these assets may be depreciated at the stipulated rates
with the proviso that any difference between the amount of realized salvage
and the undepreciated balance will be treated as a taxable profit or deductible
loss, as the case may be.
Commissioner of Income Tax.
ft!
8
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RECENT ADDITIONS TO THE LIBRARY
Surgical Clinics North America.   Philadelphia number.
Carson's Modern Operative Surgery, new edition, 1934.
Industrial Toxicology: Alice Hamilton, 1934.
Life of Dr. Francis John Shepherd: W. B. Howell.
The Autonomic Nervous System, 2nd ed.: Kuntz.
Pharmacology and Therapeutics: Cushny, 1934.
Transactions of section of Ophthalmology, A.M.A., 193 5.
Transactions American Otological Society, 1935.
The Harvey Lectures, 193 5.
Transactions American Ophthalmological Society, 1934.
Bronchoscopy, Esophagoscopy and Gastroscopy: Chevalier Jackson, 1934.
Heredity and Disease: O. L. Mohr, 1934.
Treatment of Fractures: L. Boehler, 193 5.
Medical Clinics North America.  March, 193 5.  Chicago number.
Surgical Clinics North America.  April, 193 5.  New York number.
Tropical Medicine: Sir Leonard Rogers, 193 5.
Respiration: Haldane and Priestley.  New edition, 1935.
Problems of the Deaf: Max Goldstein.
'• *
Page 190 THE CANCER PROBLEM IN BRITISH COLUMBIA
Historical
Cancer is not a disease of civilization. It is a disease older than man
himself. Tumours in the fossil bones of extinct animals were first recognized
among the cave mammals of Europe, which inhabited the earth twelve million years ago, and further evidence of bone cancer is found in each succeeding geological period. The first mention of it in medical writing in the earliest
medical documents yet discovered, is in the Evers Papyrus written about
1500 B.C., and in the development of medicine through the succeeding
centuries we find the problem of cancer compelling the attention of leaders
of medical thought. Democedes, a distinguished Greek surgeon, and employed as city physician in Athens at a salary of $2000.00 a year, describes
the surgical cure of a breast cancer in 520 B.C. Later we have such outstanding men as Celsus, a contemporary of Christ, and Galen a century
later, devising means of treating this dread disease.
After this early enthusiasm of Greek civilisation there follows a long
sterile period of about 1000 years, when even the practice of surgery was in
disrepute owing to the ban of the Church placed upon it in 1162 by the
Council of Tours.
With the Renaissance and the invention of printing came a great impetus
to the spread of medical as well as other knowledge, and in the succeeding
years the majority of the master minds in medicine were intrigued by the
problem of cancer. Surgeons, physicians, pathologists, biologists, and more
recently radiologists, have devoted their lives to this important and interesting subject and have enriched our knowledge by many valuable discoveries. However, in spite of all this effort and devotion, the fate of the great
majority of cancer patients was a tragic one.
In the eighteenth century cancer was regarded as contagious, a view
which led to infliction of unnecessary cruelty upon the sufferers from this
disease. They were excluded from general hospitals and forced to shift for
themselves. A Canon of Rheims, Jean Godinot, founded the earliest cancer
hospital in 1740, which was equipped with only twelve beds. So to France
must be accorded the honour of having provided the first hospital for the
treatment of patients suffering from cancer. In England the honour goes
to the Middlesex Hospital with the formation in 1791 of its Cancer Charity,
which has devoted unremitting attention to the subject up to the present
time.
The modern era of systematic and scientific research began in 1901,
with the work of the Danish pathologist Jensen. In 1902 in England the
Imperial Cancer Research Laboratories were opened, and institutions formed
on similar lines have been established in most civilised countries. Thus we
have the Marie Curie Institute in Paris, the Radium Hemmet in Stockholm
and the Radium Institute in London, and to come nearer home, the Memorial Hospital in New York, the radiological institutes in Montreal and
Toronto and in our own western provinces of Saskatchewan and Manitoba,
all equipped with the best that science has provided in the way of radium
and x-ray appliances, and staffed by men highly trained in their respective
specialties. In all these places the education of the public on the subject
of cancer has been assiduously pursued by emphasizing the fact that cancer
if taken in time and adequately treated is curable in the great majority of
cases.
Page 191 Importance of Problem
"Greatest of all public health problems."—Dr. Robb.
Cancer is now second among all causes of death. The mortality is higher
than that due to all infectious diseases combined (excluding pulmonary
tuberculosis), and has been rapidly increasing during the past ten years.
During that time cancer has increased 3 3 % and tuberculosis has decreased
25%. In 1926 there were 7614 deaths from cancer in Canada, and in 193 3
10,646—an increase in the death rate from 81 to 100 per 100,000. In 1933
one in every ten deaths was due to cancer. British Columbia is in an even
worse situation as it has the highest cancer death rate of all the Canadian
provinces. This has increased from 457 in 1924 to 836 in 1934 and there
is almost an identical increase in Vancouver itself. There is a similar rise in
mortality rates all over the world. The Metropolitan Life statistician thinks
that 193 3 may be the peak year but this cannot be accurately confirmed for
several years to come.
This rise in mortality constitutes the biggest problem facing organized
medicine today and is the direct result of our failure to face the situation.
Measures now available, if properly applied, would reduce the mortality to
less than one-half the present figures.
Cancer differs from all other diseases in that there is no natural cure.
There is but one opportunity for cure. This opportunity overlooked or
ineffectively seized, the patient is doomed. The patient from the start must
have the best possible care—anything less than this is useless. Ewing once
said: "There are but two types of cancer organizations—the efficient and
the farcical.
The Causes of the High Cancer Mortality
1. The view that cancer cannot be prevented and is hopeless from the
start. This viewpoint paralyzes all efforts to control the situation and
explains many time-wasting and disastrous procedures. Once admit that
in a reasonably high percentage of cases skilled treatment will cure cancer
but that the opportunity is fleeting, and you are driven inevitably to the
provision of an efficient centre, to which patients may be referred as soon as
the disease is suspected.
2. One of the greatest difficulties attending the treatment of cancer
with any hope or possibility of success has been the delay, usually prompted
by fear, in seeking medical advice. Not unnaturally, the patient felt that
to get a definite diagnosis of cancer was the equivalent of passing a death
sentence. Delay simply means that a condition that in its early stage will
respond to treatment, has become so extensive that when submitted for
expert advice it has become almost hopeless. Even if cancer is a biologic
process held to possess mysteries as unfathomable as life itself and even if its
cause should never be discovered, there are enough known facts, if properly
and intensively applied, to solve the cancer problem.
The American College of Surgeons recently put on record 24,448 five-
year cures. These definite cures reported by accepted authorities from all
parts of the United States encompass every major organ and tissue of the
body. The heart of the cancer problem today is early diagnosis followed by
prompt application of now well known and established methods of treatment. For instance, to quote the latest British statistics of cancer of the
breast, 90.1% are alive after ten years if the cancer is limited to one breast.
That is an early case. In advanced cases 94.4% are dead within ten years.
So it rests with ourselves whether the 90% is with the living or the dead.
Page 192 Looked at from one aspect, cancer is a psychological problem, and it is from
this viewpoint that public education can be so valuable in changing the
^eneral outlook and in reducing the average time of seeking medical advice
from twelve months to a few days. Unnecessary fear has been held up as a
bogey of public education, but it is easier to cure a fear than it is to cure a
cancer.
3.    Bad Diagnosis and Ineffective Treatment.
(a) The General Practitioner. The average general practitioner does
not see more than two cases of cancer in a year. His interests of necessity
lie in other directions. His whole instinct is to refrain from diagnosing
cancer until he is sure. With his scanty experience of malignancy he may be
late in suspecting cancer and still later in reaching a final diagnosis, so that
the case is that much more advanced and the chance of successful treatment
that much diminished. Even when a diagnosis has been reached, he has not
the proper facilities for efficient treatment.
(b) The Operating Surgeon. Technical skill in operating does not
make a successful cancer surgeon. He must have special training and
experience and be familiar with all procedures, surgical and otherwise,
available for the treatment of his patient.
(c) The Cancer Clinic. Here lies the best hope of the cancer patient
for effective treatment. It is therefore imperative that the organization of
the cancer clinic shall be the best that can be obtained. It is unreasonable to
expect the general practitioner to hand over his cases to a central clinic that
falls short of this ideal.
1.   The object of any cancer organization must be the lowering of the now
increasing death rate by:
(a) Diminishing the incidence of the disease. Preventive measures are
available in many types of cancer and are effective.
(b) Lowering the case mortality through the media of earlier diagnosis
and more effective treatment.
(c) Every tumour should be made reportable.
There is no reason to anticipate any new or revolutionary treatment in
the immediate future. The effective application of our present knowledge would reduce the mortality from thirty to fifty per cent of the
present figures.
3.   A campaign to accomplish this requires:
(a) Education of the general public.
(b) The unselfish whole-hearted support and co-operation of the medical profession.
Puelic Education
The aim in public education should be to convey to every adult in the
province of British Columbia certain essential facts about cancer, e.g.:
(a) That the present "hopeless" attitude is not justified by facts and
that cancer is often preventable and nearly always curable if
treated in time.
(b) That cancer is often insidious but that certain suggestive signs
may easily be recognized.
(c) That after recognition of these signs the doctor should be con-
ulted without delay and that delay may mean death.
(d) That quacks have nothing to offer and, if nothing worse, simply
waste the short time during which cure is possible.
(e) That periodic health examinations will help to prevent cancer
and will reveal the disease in the early curable stage.
Page 19) (f)   That  all  treatment  should not  be regarded  as  useless  because
palliative measures do not cure hopeless cases.
2.   The educational programme would make use of every effective agency,
e.g.:
Lectures illustrated by lantern or moving pictures.
Newspaper articles and booklets sponsored by a central body.
Education of teachers and clergy to form centres of information.
Co-operation of the dental profession.
Annual Day or Week of concentrated effort.
Instruction in all educational institutions.
Use of  all organizations—churches,  service  clubs,  extension departments, women's organizations.
The Profession in General
1. Education along the following lines:
(a) Prevention of cancer:
Education of community.
Recognition and treatment of precancerous conditions.
Treatment of patients to remove all conditions predisposing to
cancer.
(b) Early diagnosis.
Diagnostic methods.
Dangers of biopsy and its proper use and value.
(c) Necessity of transfer of patient to central clinic immediately,
not after one has made ineffective attempts at treatment.
N.B.—First therapeutic attack usually decides the fate of the
patient. Therefore it must be well thought out and adequate.
Only by treatment under the best conditions is the patient's life
reasonably protected.
(d) Necessity for accurate diagnosis. Therefore in any doubt patient
should be referred to central clinic. Late diagnosis makes for
prolonged and expensive treatment and in the end is too often
futile.
(e) Danger of delay.
2. Co-operation may be secured by:
(a) Special clinics at cancer clinics.
(b) Relief from responsibility and care of many cancer patients in
the advanced stages.
(c) A patient saved by proper treatment will remain his patient.
Cancer Clinics—General Considerations
1. The sole guiding principle in organization must be to seek the welfare
of the individual patient. No private consideration or professional
interest must interfere with this.
2. Should be central.  Decentralization is dangerous.
3. Must command the respect of the profession and of the general public.
A scientific background is essential. Any suggestion of commercialism
should be eliminated.
4. Appointments should be permanent. A staff continually changing is no
better qualified than many other men in the province and cannot command their support.
5. Specialism should be encouraged.   As far as possible men should be
■lllected whose first interest is cancer.  To each a special field should be
Page 194 d and to him all cases in that field should be allotted.   Only in
this way can specialized skill be developed.
The duties of the clinic:
(a) Diagnosis and treatment of the individual case.
(b) Preparation of accurate records.
(c) The following up of every case.
(d) The dissemination of recent knowledge of cancer to the general
profession.
(e) Later, the carrying on of research.
7.   Ideal organization for British Columbia.  The following report has been
adopted in principle by the Cancer Committee of the British Columbia
Medical Association, and has been based on work already completed in
other countries.
Cancer Institute
Objects:
1. The adequate treatment of cancer.
2. The necessary education and publicity.
3. Any research work that may seem desirable.
Organization:
The problem of the surgical treatment of cancer is already solved by
the present facilities of surgical hospitals and surgical wards.
The utilization of radiotherapy for cancer is at the present time,
throughout the world, the subject of the very keenest interest. Everywhere this problem, which undoubtedly presents the most vital and urgent,
perhaps ,uso the most difficult, task in the organization of practical cancer
control, is being investigated.
In Canada, as in the majority of other countries, it was private medical
practitioners who took up radiotherapy for cancer. Later roentgen and
radium treatment was taken up by those hospitals which established facilities for such treatment.
As the need for special training in radiotherapy became evident, the
demand grew for physical equipment, standardization and technically
trained personnel. The medical faculties of the University Hospitals took
the initiative in providing these and establishing Cancer Institutions for the
work. These organizations face two main tasks: First the scientific testing
and proving of advancing Curie and roentgen therapeutic methods, and
secondly the finding of suitable methods and means for efficiently incorporating the same in the whole hospital system in those spheres of tumour
therapy where they have been found effective.
The great possibilities which radium and roentgen therapy present can,
therefore, be fully developed and utilized only in an independent radio-
therapeutic centre where the methods of radiotherapy can be'tested and
improved under uniform and scientifically trained management. British
Columbia presents, in common with the rest of Canada and the world, an
increasing cancer morbidity and mortality. It is on the increase—from
457 deaths in 1924 to 811 in 1933 and 836 in 1934 is alarming. On the
usually calculated basis of three to four existing active cases to each death,
it means about three thousand cancer victims annually, all of which should
receive early diagnosis and adequate treatment. On the above basis one
thousand, or thirty-three and one-third per cent, require radiation therapy,
another one thousand combined surgical and radiation treatment, and the
remainder are still purely surgical.
As distances are great, population scattered, special diagnosis, care and
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Ptftff J 9 6 supervision essential, physical equipment expensive and adequately trained
personnel few in number, our need then calls for a provincial centre for
radiotherapy such as already exists in most of the other provinces in Canada
and other countries.
One object of such an institution would be the study, from a scientific
and clinical point of view, of the effect of radiation on malignant tumours
and of all affections susceptible to radiotherapy. Special stress would be
laid when possible on research in telecurie therapy with large quantities of
radium and on roentgen therapy with very high tensions.
Such an institution and organization in British Columbia should provide for present needs and looking to the future should be prepared to serve
a population of approximately one million.
It would provide:
Radio-therapeutic service including—
1. Building unit of thirty to forty beds.
2. Radium, 2 gms. (minimum) ; also telecurie therapy, 4 gm. bomb if
possible, emanation; radon.
3. Roentgen apparatus.
3 units of 200 K.V. apparatus (minimum); also provision for apparatus capable of other voltages, both lower and higher.
4. Roentgen diagnostics (one).
5. Physicist. Physical standardization and supervision.
6. Diagnostic and consulting services.
7. Pathological laboratory and post mortem room.
8. Records and secretariat (including library).
9. Social services.
The above would provide, in the light of present medical knowledge and
organization, for adequate treatment and research, medical education and
publicity and trained personnel, also assist in statistics, records and general
publicity and education in co-operation with the Canadian Medical Association Cancer Organization.
Cost:
Radium—2 gms. and accessories $150,000.00
Telecurie—bomb and emanation plant (radon) not included. Both these are desirable and would be provided for as
means and circumstances permit.
Roentgen—3 therapy units, 1 diagnostic   100,000.00
Building   150,000.00
Endowment—Physicist and research (clinical)   100,000.00
Total  $500,000.00
Above provides for organization building and equipment but
not for maintenance or personnel, which latter would be
met by:
1. Pay patients.
2. Government assistance and allowance for indigents.
3. Annual public appeal for funds through the Anti-Cancer
League, etc.
4. Endowments.
Annual maintenance estimate     150 000.00
$650,000.00
Page 197 CANCER
Death Rates in Vancouver from Cancer per 1000.
Total Deaths from All Causes in Various Age Groups.
Male
1934—
Deaths
Rate
193 3—
Deaths
Rate
1932-
1931—
-Deaths
Rate
Deaths
Rate
1930—Deaths
Rate
Total /Deaths
5 yrs. JRate
1934—:
Deaths
Rate
1933-
-Deaths
Rate
1932—
Deaths
Rate
1931-
-Deaths
Rate
1930-
-Deaths
Rate
Total
5 yrs.
•Deaths
iRate
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5
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6
76
283
202
186
170
11
132
42
199
148
219
165
170
129
164
122
165
123
917
137
Female
1934—Deaths
Rate
1      9
211196
~2\~To
39|185
37
440
31
326
37
296
34
193
31
168
3 81
217|
8
95
5
60
157
184
1933—Deaths
Rate
1
1
55l  48
380 284
189
210
1932—Deaths
Rate
2|
*3I
1   12
|190
1    7
|llS
30
390
29
281
Ts
266
331   35
258[202
17|     8
93|  68
311   12
199|l45
137
147
1931—Deaths
Rate
3
1   31
ll
29
39
320
40
323
36
228
i 36
252
158
177
1930—Deaths
Rate
1
9
ll
34
1|   10
13J154
22|
148
5
67
38
89
1
100
1
15
142
162
Total ? Deaths
5 yrs.^Rate
4
9
4
26|
4|  48
14|166
152
336
204
315
189
229
139l
164J
783
176
Both Sexes
i!
i
22
3|
131
2
27
3
13
1
13
4 12 65
4l|l08|252
4\~L$\~58
40 146 215
90 91
214 188
110 120
284259
1|
4|
II   17|   50   711  90
9|122|222 179|206
l|_14| 591 861 79
7} 90ll99l234|189
13 45| 86 92
90|lSl 217217
2|     3
32j   21,
9\     6\   131  74|277[443|472
8    19|   22|110|205|225 212
I
731   19
172   97
87
211
56
135
61
167
48
10
51
17
72
18
98
1(
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325|
167!
1
63
80|
89
356
162
408
J. 8 3
To 7
137
322
144
307
138
1700
153
Page 198
m
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I
M What Is Being Done in Other Countries
Sweden—Sweden began the organized fight against cancer in 1910 with
the establishment of its Radiumhemmet in Stockholm and has today what
is considered to be the best cancer organization in the world.
France—France also began the fight early and a centre for research and
treatment was projected by Regaud before the war but was not completed
until 1919. Now in addition to the Curie Institute in Paris there are sixteen
provincial centres.
Great Britain—The Imperial Cancer Research Fund was established in
1900, the Medical Research Council in 1915 and the British Empire Cancer
Campaign in 1923 which gave the great stimulus to public interest in
cancer. There are 12 national radium centres in addition to the five special
cancer hospitals in London. There are seven laboratories devoted entirely
to cancer research. Great Britain has in all about seventy grammes of radium,
partly supplied by public subscription and partly by national and local
governments.
United States—'The government has taken no special steps to combat
cancer. There is an endowed American Society for the Control of Cancer
and most of the States have treatment and research centres. A great deal
of experimental work is under way with super high voltage x-ray apparatus,
notably in New York, Chicago and California.
New Zealand—Is a branch of the British Empire Cancer Fund and a few
years ago raised $3 50,000.00 by public subscription.
Australia—Australia ten years ago raised $650,000.00 by public subscription. The government bought ten grammes of radium and appointed a
radium advisor. In addition to this, local efforts were encouraged by grants
to each research and treatment fund as it was raised.
At the 1934 International Radiological Congress at Zurich no less than
twenty-seven different nations reported efficient programmes of cancer
treatment and control and it is significant to note that they are all engaged
in practically the same line of endeavour, that is, centralized work, with
consultation for diagnosis and treatment, and a three-fold clinical attack
with surgery, x-ray and radium.
Salient Points
Cancer is curable.
Cancer is preventable.
Cancer is at first a local disease.
Cancer does not attack healthy organs or tissues.
5. Cancer is usually painless.
6. Cancer is not contagious.
8. Second of the causes of death.
9. The importance of periodic health examinations, i.e., preventive
medicine.
10. Danger of delay.
11. Every tumour should be reportable.
12. An economic as well as a humanitarian problem. The deaths are an
economic loss to the community and the incurable cases a charge
on it.   .
13. British Columbia has the greatest opportunity of improving results
because farthest behind.
14. Necessity of centralization of diagnostic and treatment facilities-
co-ordination of personnel; i.e., cancer institute.
15. Begin and end with hope.  Cancer is curable.
Page 199 4.
5.
Suggested References for Further Material
Cancer—No. 1 Canadian Public Health Series (obtainable at all
book stores).
The National Health Review, Vol. 3, April, 193 5—"The Cancer
Problem." Obtainable free of charge from Dept. of Pensions and
National Health, Ottawa.
Saskatchewan—Cancer Commission Reports (obtainable from the
Government of Saskatchewan).
Bulletin of the American Society for the Control of Cancer (obtainable at their headquarters, Rockefeller Center, 6th Ave., New
York).
Report of Ontario Royal Commission on the Use of Radium and
X-Ray in the Treatment of the Sick (obtainable from the Ontario
Government).
DEATHS FROM CANCER—PROVINCE OF B. C.
Cause of Death
1929
1930
1931
1932
1933
Buccal cavity
17
21
27
30
25
Stomach and liver
236
249 |
202
211
246
Peritoneum, intestines, rectum
129
125
127
130
199
Female genital organs
74
73
75
83
84
Breast
62
58
68
83
98
Skin
12
8
6
5
8
Other sites and unspecified
162
174
219
220
183
Totals
692
708
724
762
843
Rate per cent, all deaths
10.82
11.06
11.84
12.39
13.55
Rate per 1000 population
1.04
1.04
1.04
1.08
1.18
The number of deaths from cancer continues to show an increase—a tota
of 843 for the year 193 3, as against 762 in the previous year; the rate
being 1.18, as against 1.08 for the year 1932.
ESTIMATION OF SURGICAL RISK
F. N. Robertson, M.D.
Mr. Chairman and Gentlemen:
What I have to say tonight must be considered in the nature of an
introduction to some further studies and not as a complete paper.
The statistics so far obtained are not sufficient to justify any definite
statements but are of sufficient interest to attract your attention, and I
think warrant further investigation.
For some time past I have been trying to find some way to estimate
the reserve power of a heart or to estimate its present ability. In testing out
these hearts by the simple method to be described, there was found to be a
mathematical standard of improvement coinciding with the clinical improvement. Thus as a heart improved under digitalis treatment the improvement could be measured mathematically.
At first this was considered to be true only of heart cases, but it was
soon found that in any condition the clinical and mathematical improvements were parallel.  The improvement could be mathematically estimated
Read at the Staff Meeting, Vancouver General Hospital, February 26th, 193 5.
Page 200 ft   '44!
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and recorded in percentages. Thus an absolute record of the improvement
could be made in medical cases and one's judgment or memory need not be
relied upon. In anasmia we do not rely upon our memory of the patient's
appearance but upon the record of the blood count. The x-ray tells us of
improvement in the tuberculous lung. The scales tell us if a baby has
gained sufficiently—and so on, with other cases. But for a heart or for the
convalescent patient, we usually rely upon our memories, whereas by this
method we have a definite record.
Numerous requisitions from the surgical department come in, asking
for a medical opinion as to whether a certain patient is in condition to stand
an operation. Now the medical staff has no better means of estimating that
condition than the surgical staff, except perhaps that they have more practice in listening to hearts. So a medical opinion largely rests upon what
can be heard by the stethoscope. This, I think, is not sufficient, as there
are other factors to be considered besides a man's heart.
The method to be described takes into consideration not only the state
of the heart and blood pressure, but also how these react to exercise, and
the effect on the general metabolism.
The method is based upon Reid's formula for estimating the B.M.R.
You have all undoubtedly heard of this formula, but for those to whom it is
unfamiliar, it is as follows: B.M.R. = .683 (P.R. plus .9 P.P.) minus 71.5;
where P.R. is the pulse rate and P.P. the pulse pressure.
I do not intend to enter into any argument as to the accuracy of this
procedure nor how it was obtained, but ask you, for the present, to accept
it as a rough means for estimating the B.M.R. With regard to its accuracy
I would refer you to Rabinowitch's article in the C.M.A.f. for February.
Technique: At any hour of the day the M.R. is taken, or, in other
words, no fasting period is required. This is not the basal metabolic rate but
the metabolic rate at that instant.
The blood pressure is taken while an assistant takes the pulse rate. The
cuff of the sphygmomanometer is not removed, but the patient is then
asked to raise the other arm, to the full extent without bending the elbow,
ten times in approximately ten seconds. Immediately upon completion of
this exercise the blood pressure and pulse are taken again before there is any
chance for either to fall.
The two metabolic rates are now calculated by the above formula and
their differences noted.
e.(
Aft
er exercise
Before exercise
128
72
124
70
70
— 68 =
10.73%
2.60%
Interpretation: If the patient is in poor condition the difference in
metabolic rates is high, but if in good condition the difference is low.
The exercise of lifting the arm ten times in ten seconds has been arbitrarily chosen as it can be used whether the patient is in bed or not. Some
other form of exercise might be found just as suitable, but this has seemed
very simple and satisfactory, and not too hard upon the patient.
The records I have to present have been taken by different observers
and show considerable variation, possibly due to not adhering strictly to
the technique. I wish here to express my appreciation for the work and
interest taken by these observers.
Page 201 The cases recorded are divided clinically into surgical risks: poor, fair
and good. They were not necessarily surgical cases but just some individuals
who, if requiring an operation, would be considered as a good, fair or poor
risk, and the nature of the disease was not considered.
Although this has been tried on many patients I have the actual figures
for only 40 cases. Of these 40 cases, 25 were males and 15 females. The
ages ranged from 16 to 69. The difference in the two metabolic rates ranged
from l'< to 24.47% or an average difference of 6.87%. This shows that
there is always some elevation of the metabolic rate.
Difference in Metabolic Rate
Clinically  Good  Risks        1% 9.97%
Average  for   18   cases     4.21%
Clinically   Fair   Risks           4% 7.61%
Average for 6 cases. .      5.93%
Clinically   Poor   Risks        9.62% 24.47%
Average for 16 cases     9.62%
The diseases in the good risks were: pleurisy, mucous colitis, rheumatoid
arthritis, chronic appendicitis, duodenal ulcer, pyelitis, rheumatic fever,
duodenal ulcer, inguinal hernia, acute cholecystitis, chronic mastitis, fractured femur (2), T.B. knee, fistula in ano, perforated gastric ulcer, peptic
ulcer, one case undiagnosed.
The diseases in the fair risks were: toxic goitre, acute bronchitis, influenzal pneumonia, diabetes with infection, rheumatoid arthritis and rheumatic fever.
The diseases amongst the poor risks were: subacute bacterial endocarditis, coronary thrombosis, coronary sclerosis, carcinoma, psoriasis, pneumonia, chronic myocarditis with decompensation, auricular fibrillation with
decompensation, pulmonary aneurism, cardiac decompensation, cerebral
haemorrhage, duodenal ulcer, peptic ulcer, acute appendicitis.
Now it may be argued that practically all these poor risks cases show
some cardiovascular disease. Apparently that is true, but it must be remembered that most of these cases were from medical wards.
Also let me point out that the duodenal ulcer case, who by test was the
worst of all, showing a difference of 24.47% in his metabolic rate, yet was
rated as a good risk clinically. He was sent up for operation but could not
stand the anaesthetic and was returned to the ward without operation. He
had an electrocardiogram taken which showed a" perfectly normal heart
except that it was slow. He was to be operated on again and the difference
was 24.47' { . With a week's rest it fell to 10.93% and he stood the operation well.  The next highest case was one of acute appendicitis.
There were 7 cases who rated as higher risks by test than the average
good risk, 4.21' ( , but who were classified as good or fair clinically. These
cases have the following diseases:
Influenzal   pneumonia .      rating
Bilateral   pyelitis  	
Diabetes     „       	
Rheumatoid   arthritis    	
Rheumatic Fever _ 	
Rheumatic Fever        --.
Toxic Goitre     	
Consider now the disease and not the patient, and in looking over these
cases, no one would care to operate or give an anaesthetic to any of them
except the case of rheumatoid arthritis, without very careful consideration,
and there may have been some other complication present in this particular
case.
On the other hand, cases listed as good by this method of estimation
Page 202
7.11%
6.83%
6.42%
5.46%
7.61%
7.61%
5.00%
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were all considered good surgical risks clinically. In other words, 7 cases
out of 40 or 17^4% were discovered by this method as being not good
surgical risks and perhaps even poor risks, whereas they were passed clinically
as being good risks.
I quite realise that 40 cases is too small a number from which to draw
conclusions or from which to strike averages, but I would like to see this
simple procedure tried out over a period of time or on a given number of
cases, as I am convinced that it has merit. I do not suggest that this method
should be an attempt to supersede clinical knowledge or intuition. Those
only come by long years of experience and after passing through the fires
of bitter disappointment many times. It is only something added to our
armamentarium, the same as any laboratory proceeding. It does, however,
place the patient on a mathematical basis, understandable to the surgeon,
anaesthetist and clinician alike, just as would a blood count. Blood may be
good, fair or poor, but the count expresses it mathematically so all have a
common understanding.
The averages which I have struck—4%, 6% and 9%—may be very
far wrong. Nothing but further trial will settle the point. But of one
thing I am certain and that is, that if simply lifting the arm ten times disturbs a man's metabolism 10% or more, an. anaesthetic or an operation
with its attendant shock would upset it still more. Such an individual
cannot be considered a very safe surgical risk.
In closing, I wish to point out the absolute uselessness of estimating the
B.M.R. or even the use of the machine unless the proper technique is followed and every possible muscle and emotion quieted.
BI;
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L
HOSPITAL ECONOMIES
H. S. Stalker, M.D.
(Read before the Osier Club)
I feel that I owe an apology to this Society for presenting the following
paper, as it cannot, in any way, be labelled "scientific." However, the last
time it was my privilege to read a paper before you, it contained problems
incidental to the administration of a large hospital, and as at that time some
of your members stated that they would like to hear about additional hospital difficulties, I will try tonight to give you some idea of how the General
Hospital has tried to economise during the past few years.
The beginning of this economy campaign was in January, 193 3. At that
time the Board of Directors had completed the budget for the year. All
hospital employees had received a cut in wages ranging from 6% to 20%,
but even with this saving in salaries there was an estimated deficit of
$165,000. The City Council, a few weeks after our budget was completed,
informed us that it would be necessary to pare off another $65,000. At
that time, the job appeared almost impossible, as the budget had been prepared very carefully and contained no capital expenditures. The initial
steps taken were to call together the heads of all departments, explain the
situation to them, and ask them for any suggestions as to where we could
save money in their respective departments. It was explained very forcibly
to them that a reduction in their own budget for the year was an absolute
necessity and that, if they could not effect economies, it might be necessary
to replace them with those who could. All of the employees of the hospital,
including nu.rses, were interviewed either individually or collectively,
especially those coming in contact with the preparation and serving of food
Page 203 1*
and the handling of supplies. They were made to understand that their very
jobs depended on their being careful and cutting down on hospital costs.
Actual examples were mentioned: e.g., in the nursing department,
where nurses were encouraged to use as few sponges and dressings as possible. Most of you will admit that very frequently the outside large dressing does not require changing each time you dress a wound or, if it requires
changing, it could be replaced with non-sterile dressings. Every time one
of these dressings is saved the hospital saves eight cents, and it does not take
long for this to add up to a considerable amount. The nurses were also told
to supply only two or three sponges for the sterilization of a wound and to
be careful with the amount of iodine, alcohol, etc., used. In the matter of
food they were told to be careful, especially in the serving. For example,
they were told to place one slice of bread on a patient's tray and to give
more if the patient wished it. This way of serving food has resulted in a
considerable saving and in some wards is done almost entirely. The patient
is asked what he wants from the menu for that particular meal and it is
served to him as he wishes. The large heated food wagons make this possible.
Where every plate is identical for all patients there is bound to be waste,
as everything returned on the tray is, of course, discarded. This discarded
food is not a total loss as it is sold to farmers for pig fodder.
As a result of the meeting of the department heads, the following reductions in the various budgets were made:
First, in the laundry department, a saving of $3,822 was effected in the
following way: The subordinate staff of the hospital had always enjoyed
the privilege of having their personal laundry done at the hospital. This
had been a custom dating back to the time when they lived in the hospital.
It was discontinued. In addition to this, the linen in the Private Ward
Pavilion was reduced in amount by changing the sheets three times a week
instead of daily; similarly, in the semi-private wards and public wards the
linen change has been reduced unless the condition of the patient is such as
to necessitate its being done oftener.
These reductions, besides! saving a certain amount of wear and tear on
the linen, have allowed us to dispense with three laundry employees at a
yearly saving of $2322. The laundry was also able to reduce their vacation
relief to a point where they brought in only one or two men to relieve
during vacation time, resulting in an annual saving of $1S00, bringing
their total up to $3922.
In our maternity department, we placed an additional burden on the
nursing staff by having them take over some of the duties of the ward
maids, which allowed us an annual saving in wages of $1275.
In our physiotherapy department we cut down the staff to the extent of
one whole-time technician and half the time of one technician, an annual
saving of $1464; the service provided by the hydro department was, of
course, curtailed. Quartz light treatments on the wards were discontinued
and, as far as possible, no cases are treated in the wards who can possibly
be moved to the department.
In the housekeeping department we saved a total of $1774 by closing
the patients' clothes room at 6:00 p.m. and dismissing one employee from
the linen room. The matrons were removed from the nurses' homes during
the mornings. This means that there was no one in charge when the majority
of the girls were on duty and necessitated each nurse having a key for her
room and being responsible for keeping it locked.
In our carpentry department the following savings were effected: The
walls of the corridors and_ wards, etc., were washed once every two years
Page 204
Nt
■lit
il' 'i
'K instead of annually, an annual saving in wages of $1836. This, we all
realized, was a doubtful economy, as the walls become so dirty that we have
almost to take the paint off ever to get them clean again. Two gardeners
usually employed for six months of each year were deleted from the budget,
effecting a saving of $540, and one other employee at $45 per month usually
hired for six months of each year was discontinued, saving $270. For the
whole department the saving amounted to $2646. It must be remembered
here that there was no paint programme going on during that time. The
buildines had been left to look after themselves since 1929.
In our orderlies' department it was difficult to see where any saving
could be effected. Finally it was decided to reduce the night orderlies'
vacation from three weeks to two weeks, an annual saving of $225. In
addition to this the chief orderly was told to reduce his budget by $2 500.
This he accomplished by dropping two orderlies and two cleaners, much to
the detriment of the service his department was supplying. The total saving
for his department amounted to $2775.
The engineer was forced to operate with one less labourer in the power
house, saving $912.
The laboratory and x-ray department both reduced one of their full-
time technicians to half time, saving $1200.
In our dietary department we dispensed with one tray girl in the Private
Ward Pavilion at $402, and one wagon man was dismissed, saving $621. It
was decided that cake should not be supplied for staff lunch, which saved
$12 twice a week, amounting to $1248 in a year. This department also
guaranteed to save another $1000 in minor economies, a total of $3 371.40
for the department. The training school department effected one of the
largest savings, approximately $16,000. The student nurses, who had been
told of the existing conditions, met and decided amongst themselves that
they would reduce their monthly stipend from $6, $8 and $10 per month
to $5, $6 and $8, resulting in a saving of $7000. Graduate nurses receiving
special training previously had received $10 per month and were cut to $5,
saving $300. The second floor of the Private Ward Pavilion, which at that
time was empty, was used to house 29 graduate nurses, saving the hospital
their rental allowance of $15 per month, amounting to $4200 for the year.
Graduation exercises for the Senior Class were held in the King Edward
High School, saving the cost of rental of a hall and transportation amounting to $272.
One operating room was closed in each of the Eye, Ear, Nose and Throat
department, Main O.R. and the P.W.P. operating room, which freed four
senior students to replace four nurses on general duty, saving approximatelv
$3600.  Total for the department $16,000.
The interne service was not reduced in any way, but the King Edward
School badminton courts usually reserved for them at $75 a season were
not obtained.
Twenty-two telephones were removed from various parts of the hospital, saving $5 80, and causing considerably more work for many of the
staff.
The publicity department of the hospital was done away with, saving
$600 for the year.
These economies amounted to the sum of $36,500, but they left the
hospital short-staffed and in a position where we were not able to supply a
complete service; in fact, in some of the departments of the hospital it was
found impossible to operate with the reductions. Some of the employees
were, at a later date, re-engaged. This was particularly true in the case of
Page 205 the cleaners and orderlies, and, at times, additional staff has had to be placed
in some of the operating rooms. Our hospital, we felt, was not overstaffed,
and these reductions, we realized, curtailed our service, but with the financial condition of the city as it was, it was decided that these reductions
should go into effect.
The economies thus enumerated resulted in a saving of $36,500. There
was still an additional saving of almost $30,000 to be made. This was
almost accomplished through our purchasing department and in the wards
themselves, and I will try and give some idea as to the work involved in this
programme.
Any of the staff who had suggestions as to savings which could be made
were invited to bring them to our attention or to the attention of the head
of their department, and, in this way, we think almost all of our employees
realized the seriousness of the situation and worked with us in an effort
to help.
The purchasing department, about this time, put into effect what is
called a cost accounting system. By that I mean a system whereby we could
check up on each department and could say that we knew exactly what
they were spending. This system included everything except repairs and
salaries. This was done in the following way. All supplies and goods were
received by the various wards and departments on requisition. These requisitions were priced and filed with the purchasing department and totalled at
the end of each month, so that when this mass of detailed work was completed, we knew exactly how much they had cost the hospital. Not only
that, but we knew how much of each commodity they had used. This
showed us that some wards were much more expensive than others of the
same class and size, and we promptly got the head nurses together to find
out why. Some of them which had been costing us hundreds of dollars
more than others did an about-face and began to come down the scale. The
only danger was that they might try to be too economical at the expense of
the patients in their anxiety to make a good showing. The second month
that this statistical sheet was issued there was a drop of $2000 in our
expenses and the reduction in expenditure continued downward for three
months and then became fairly steady. Four months after the introduction
of this system the total cost of supplies for ward use, including all food,
surgical supplies, dressings, etc., dropped from' $18,940 to $15,000, and
there it remained stationary.
Some of this saving was due to the fact that the head nurses, in their
anxiety to make a good showing, allowed their ward supplies to become
depleted, but even allowing for that it is evident that this system has, from
the time of its inception, saved the hospital at least $1000 per month.
It is interesting to watch the progress of some of the wards. For
example, the charges against Ward S & T for January 193 3 were $709.80,
in February $572.98, March $499.50 and April $400. For the remainder
of the year it continued at between $400 and $450. This sum includes the
cost of all commodities obtained by the wards as follows: printing, stationery, cleaning supplies, crockery, gauze and bandages, linen, surgical instruments and equipment, ice, groceries, meat, fish, poultry, eggs, ham and
bacon, butter, bread, milk and cream, fruit, vegetables, toilet sundries,
cooked foods and drugs.
The daily requisitions began to exhibit marked changes. Instead of 3
to 5 pounds of butter being ordered each day, one pound or l/z pound is now
ordered. Soda crackers, which were ordered by the dozen, are now only
ordered for patients requiring them and are usually obtained in half-dozen
Page 206 lots. Practically everything else has shown the same reduction. Ward S & T
is no better or worse than the other wards as they all show a decided reduction in cost, attributable to careful ordering and serving. Eating in the
ward kitchens by the staff has been discouraged and orderlies are allowed five
minutes during the morning in which they can have a cup of coffee and a
piece of bread in their own dining room. Similarly, the nursing staff can
obtain afternoon tea in their own dining room. This has resulted in quite
a remarkable saving.
In the purchasing department a great many economies have been effected
because of different methods of buying, some of which I would like tO' detail.
Prior to two years ago, we used 22 5,000 yards of gauze yearly, and since
the wards have been definitely trying to cut down on the use of dressings
it has dropped to 190,000. In addition to that, we decided to try a lighter
stock and it has proven quite satisfactory and at a cost of $1.90 per 100
yards as against $2.2 5 for the type formerly in use. The saving'in the buying
and in the economy in the use of the gauze has amounted to $1560.
For our ward dressings we did much the same thing. We used to buy
200 gross of large dressings 24 inches by 10 inches and cut them in two.
We now buy them 2 inches narrower and have saved $1200 and, to the best
of my knowledge, we have received no complaints because of smaller dressings. We also use 13 gross less of the large dressings than we did formerly,
which amounts to over $50.
"Peri" pads are also reduced in width from 5 inches to 4 inches and we
use 200 gross a year less than we used before at a saving of $250.
Our cotton we formerly bought in 1-pound rolls at 3 lc a roll; by buying it in 5-pound rolls we get it for 27c a pound and we have cut the
amount used in half.  On the cotton we have saved annually $3 50.
We used to buy our ink in quart bottles at $3.60 per gallon and then we
bought it in kegs, filled our own bottles and distributed it to the wards at
a considerable saving. We next obtained a formula for making our own ink
which now costs us 3 5c a gallon. The ink is certainly not as good as the
product we used to buy, but is giving fair satisfaction.
We had a yearly consumption of 80 gross of pen nibs. Our average
price two years ago was $1.60 per gross and was high because in trying to
please everyone we bought a variety of nibs. Now we buy two standards,
Bank of Montreal and Bank of England, and get them for 50c a gross,
saving $88 annually.
Throughout the hospital we use an average of 230,000 paper handkerchiefs per year. The size of these was formerly 7 inches by 7 inches and the
cost 60c per 1000. We found out accidentally that we could buy a serviette
of the same material 13 5/? by 13 l/z for the same money. We therefore
bought the latter, cut them two ways in our printing department, which
gave us a handkerchief 6% inches square for 15c per 1000, representing
$ 10 3 5 saving annually.
In buying soap we find it cheaper to go outside the city. Our annual
consumption was 300 gross of 1-oz. bars and the best price we could get in
Vancouver was $2.50 per gross. We are now bringing it in from the East
at $1.40 ">er gross, an annual saving of $3 30.
The hospital uses 144 dozen of robber gloves per year. These, at one
time, were obtained from the East at $3.81 per dozen, but we can now
obtain just as satisfactory an article made locally for $3.00 per dozen,
savin'* $116.
Our mustard, bought locallv through a jobber, cost 43c per pound. By
Page 207 going direct to the manufacturer we oct it for 18c, so that on 1500 pounds
there is a saving of $375 during the year.
Our interne uniforms used to be made locally bv a manufacturer in
random sizes, large, medium and small, at $5 per suit. We now buy
material, have it washed and shrunk in our own laundr"". and when the
internes arrive send them to our own tailor for measurement. The suits cost
us $2.10 each complete. With 3 5 internes with 4 suits each, we save during
the year $406.
The hospital pen holders used to be rather fancy, with rubber finger
grips, and cost us; 70c per dozen. We now use a very plain holder at 30c
a dozen which, on our annual consumption saves us $15.
Sputum cups were imported, through eastern jobbers, at $5.15 per
1000. We can now obtain them locally at $4 per 1000 and, on our annual
consumption of 100,000, we save $115.
The above noted savings have been mentioned merely to show that an
actual saving hasi been accomplished, and do not begin to include all of the
economies effected by the purchasing department.
In the surgical supply department the economies practiced have, if anything, shown more ingenuity than elsewhere and some of them deserve
mention.
In place of buying five-yard bandages at 36c, 10-yard lengths are now
being bought at 46c per dozen. We therefore get our bandages at a much
cheaper rate and there are only half as many ends to be wasted.
In the use of rubber gloves in the main wards and the various buildings,
the surgical supply department effected a marked saving by taking charge
of all the gloves used in the hospital with the exception of those in the
operating rooms. These gloves are cleaned, repaired, sterilized and mended
in the S.S.R. and are issued to the wards on' requisition. In the event that
they are not used within two or three days they must be returned to the
S.S.R. Formerly, each ward was responsible for the cleaning of its own,
with the result that they all had from 12 to 18 pairs of gloves which stood
idle sometimes a month without being used, and consequently they often
deteriorated very rapidly. The saving here, then, is twofold, as fewer
gloves are in general use and they are worn out and not allowed to deteriorate.
In the same way, a saving has been effected by the S.S.R. setting up
various types of trays which can be loaned to any ward when necessary;
i.e., head tray, dressing tray, douche tray, anaesthetic tray, enema tray,
breast tray, hypo tray, etc. The possession of these trays, which are kept
constantly ready for use, does away with the necessity of so much equipment on each ward.
A system has been introduced in the Surgical Supply Room whereby
doctors wishing to obtain hospital supplies on loan or to use in their private
practice are charged a moderate fee. The results have been quite surprising.
Saline, distilled water, glucose solutions, etc., were at one time bought from
the hospital in large quantities. A charge was made at that time only sufficient to cover the cost of the solution, the idea being that the doctor would
return the flask. We found that the flasks were returned very infrequently.
The cost to the hospital for this service was considerable. The system practiced by the S.S.R. now is such that a doctor getting a solution from the
hospital gets a receipt from the cashier's office which he tenders to the S.S.R.
where he receives the material. This receipt is kept until the flask is returned, and if it is not returned they get in touch with the doctor or charge
Page 208 IfiteEE
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it up to him. In the same way there is now a charge against the splints,
crutches, plaster shears, intravenous sets, etc., which are taken from the
hospital. For splints and crutches we make a charge covering the cost of
the article and when it is returned a refund is made of all but 2 5c or 5 0c.
The saving here, especially in the time of our splint man, has been remarkable, as our loss of splints which we used to lend to patients was very high.
Our intravenous sets cost $22.15 for the equipment alone and we charge
$5.00 for anyone wishing to use them outside the hospital. This includes
two flasks of solution, and when you consider the labour of preparing them,
cleaning and sharpening of needles, sterilization, etc., you see the charge is
quite moderate. It has resulted in very few of them leaving the hospital,
whereas formerly when no charge was made we prepared a considerable
number for outside use.
We now insist that nurses who break hospital equipment such as syringes,
thermometers, etc., pay for them. This action has reduced our consumption
astonishingly. In 1932 we used 30 gross of thermometers, in 1933 15 gross.
There has been a corresponding decrease in the breakage of china, to which
the same rule applies. The employee is charged just enough to cover the cost
of the thermometer, and in the case of china and crockery they are charged
50% of the cost. In 193 3 the S.S.D. collected $409 from graduate nurses
and $395 from student nurses to cover the cost of breakages. The saving
to the hospital, of course, lies not only in the $800 which was recovered but
in the fact that if we had not charged for these breakages consumption
would probably have been twice what it was.
Up until recently patients were not charged for dressings, but for the
last two years if they use more than an average amount of dressings they
are assessed for the additional amount. In 193 3, in the Main Building, we
collected $345, and in the Private Ward Pavilion $1032, a total of almost
$1400, for dressings which we formerly included in the daily charge. Our
charges for the dressings are moderate and include the actual cost of the
materials and the labour of their manufacture. For example, a bag of gauze
swabs including 30 pieces costs 2 5 c, 12 pieces of four gauze 3 5c. A prostatectomy dressing costs $1.00, which includes two packages of four-gauze,
two extra large dressings and two large dressings. An extra large dressing
costs 8c, an ordinary large dressing 4c. A tin of absorbent swabs, 30 pieces,
20c. Amputation dressings 40c. Perineal dressings cost lc each. These
prices include sterilization. The cost to the hospital of dressings can be
clearly shown when I state that our high tension surgical unit cost us $650
and our saving in prostatectomy dressings paid for this machine within a
period of two months. The foregoing is only part of the economies effected.
The head of the S.S.D. has striven very hard to standardize and economize in
the surgical dressings used in the hospital and in her work is sometimes a
trifle dogmatic and stubborn, but her energies are so whole-heartedly devoted
to the hospital that her shortcomings in this way can be overlooked.
Another type of economy that we have tried to practice in the hospital
of late has been that in which capital expenditure has been necessary in order
to save money. For example, during 1931 and 1932 the hospital orinting
cost in the neighbourhood of eight to nine thousand dollars. At the commencement of this year the hospital installed its own printing deoartment
in the form of a Multilith and Multieraph which does practically all the
printing required in the hdspital with the exception of large books and financial statements. This year our printing will cost us not more than $6000,
so that inside of two years at the most the machine, which cost originally
Page 209 $2400, will have been completely paid for and our annual saving in our
printing department from then on will be over $1000 a year. In addition
to the saving, we have more creative work being asked for from the various
departments of the hospitaji, and are able to change our forms, as conditions
require, more cheaply than we could formerly.
Two years ago we bought a sanding machine for refinishing the floors,
for which we paid $365, and a power lawn mower for approximately $425.
Both of these machines have paid for themselves many times over in saving
of labour. The power lawn mower, for example, does the work of four men.
In the same way we have been able to do away with overtime in our laundry
by buying a new flat ironer at a cost of $12,000. The saving in this case is
very apparent. Thd laundry had been working at its utmost capacity and
for the months immediately preceding the purchase of this new equipment
we were forced to pay in the neighbourhood of three to four hundred dollars per month to an outside laundry for work that we could not handle.
Since buying the new equipment, we are able to do all our laundry and have
done away with overtime. It is apparent therefore that this expensive piece
of machinery will have paid for itself in a very few years.
With all of the economies practiced, the majority of which I have tried
to mention, we were able to save approximately $5 5,000. This was considered satisfactory, as a definite curtailment in service beyond the safety
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vitamins so important for our bodily vigor.
Of these vitamin A is perhaps the most important. The formation of this vitamin seems to be
restricted to the action of light upon green plants.
Animals consuming the plants are able to concentrate the vitamin.
Milk fat is the richest source of vitamin A in the
foods commonly used by children and most adults.
Milk is also an excellent source of vitamin G
and a good source of vitamin B.
Vitamins C, D, and E are normally present in
milk in much smaller quantities.
MILK FOR MINERALS
Milk is also a particularly important part of the
diet because it is perhaps our best source of mineral
matter, which is quite deficient in many otherwise
valuable food substances.
ASSOCIATED DAIRIES
LIMITED
DISTRIBUTING
RICH—SAFE—CLEAN—MILK
service phones:
Fairmont 1000     North 122     New Westminster 1445 A new type of bismuth salts has recently appeared in the field of therapeutics:
the oil-soluble salts for intramuscular injection. These constitute a class of
products which are rapidly absorbed due to the fact that the bismuth derivative
dissolves immediately in the lipoids and does not have to be transformed in situ.
Ever anxious to meet all the requirements of the Medical Profession, we are now
offering, under the trade name of NEOCARDYL, a compound representative of
this new form of liposoluble bismuth. NEOCARDYL has an additional decided
advantage over other compounds of its class in that it contains bivalent
sulphitr combined in its molecule.
NEOCARDYL
"POULENC"
Ampoules of 1.5 cc. equivalent to 0.075 Gm. of bismuth metal.
Boxes of 12, 50 and 100 ampoules; bottles of 30 cc.
LABORATORY POULENC FRERES
OF CANADA LIMITED
Distributors: ROUGIER FRERES, MONTREAL
A PRESCRIPTION SERVICE . . .
Conducted in accord with the ethics of  the Medical
Profession and maintained to the standard suggested by
our slogan:
Pharmaceutical Excellence
I MCG! 6 Ormo
FORT STREET (opp. Times)       Phone Garden 1196      VICTORIA, B. C
STEVENS' SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity for the bag or the office.  Supplied
in one yard, five yards and twenty-five yard packages.
B. C. STEVENS CO.
Phone Seymour 698
73 0 Richards St., Vancouver, B. C
Li; p) ANTIPHLOGISTINE
Is of material value in the treatment of subacute
and chronic inflammations of the pelvic organs.
Impregnated with glycerine and containing
boric and salicylic acids, compounds of iodine,
oils of gaultheria, eucalyptus and peppermint,
blended in judicious proportions in the finest
anhydrous silicate of aluminum, this Dressing,
when inserted as a tampon, will yield moist heat
and plastic support for many hours.
'T I
I      i
15?
Antiphlogistine is also a valuable adjunct
to other forms of therapy and an aid to
diathermy, the action of which it helps to
reinforce and sustain.
The Denver Chemical Mfg. Co.
153 Lagauchetiere Street W.
MONTREAL
,'*' 1
:
METRITIS
ADNEXAL INFLAMMATIONS
PARAMETRITIS
Made in Canada
V:
h
■\.< "Absolute Accuracy"
In filling the eye physician's prescription, nothing short
of absolute precision will satisfy us.
We take a pride in maintaining
Guild standards to the utmost.
OPTICAL CO. LTD.
Dispensing Opticians
631  Birks Bldg., Vancouver, B. C.
Nit tin $c (Hfjomaon
2559 Cambie Street
V
ancouver
, B. C.
REST  HAVEN
A Medical Institution for the restoration of health, situated eighteen
miles from Victoria, overlooking the Gulf of Georgia.
Modern facilities for the treatment of all classes of patients with the
exception of those suffering from mental or contagious diseases. Hydrotherapy, electrotherapy, massage, and diet, under medical supervision.
Physicians referring patients or convalescents for treatment are requested
to send such reports and suggestions as may assist in their treatment.
REST HAVEN SANITARIUM and HOSPITAL
SIDNEY, B. C.
S. BOWELL & SON
DISTINCTIVE FUNERAL
SERVICE
Phone 993
66 SIXTH STREET
NEW WESTMINSTER, B. C. Nupercainal "Cilia
A Non-Narcotic Analgesic Ointment
for the relief of pain or itching in affections of
the mucous membranes or skin.
»»
Nupercainal has been found to be highly effective to secure
prompt and prolonged relief from discomfort in:
SUNBURN - BURNS - HAEMORRHOIDS - DRY
ECZEMA - ULCERS - DECUBITUS - PRURITUS ANI
and VULVAE - ANAL FISSURES, Etc.
Issued in one ounce tubes with a rectal applicator.
CIBA COMPANY LIMITED
MONTREAL
1 !•! J.
iii
flfcount pleasant "Unbertaking Co. Xtb.
KINGSWAY oMlth AVE. Telephone Fairmont 58 VANCOUVER, B. C.
R. F. HARRISON W. R. REYNOLDS
——^ The Continental Breakfast
growing
In far too many homes, a breakfast of a roll and a cup of coffee is the fare for children as well as adult*]
Woefully deficient in vitamins and minerals, such a meal furnishes little more than a small amount«
calories. A dish of Pablum and milk, however, is just as easily prepared as a "continental breakfast,  W
furnishes a variety of minerals (calcium, phosphorus, iron, and copper) and vitamins (A, B, G, and h) n°
found so abundantly in any other cereal or breadstuff. The addition of a glass of orange juice and o§|
Mead's Capsule of Viosterol in Halibut Liver Oil can easily build up this simple breakfast into a nouns]
ing meal for the children of the family as well as the adult members. It is within the physician's proviBH
to inquire into and advise upon such matters, especially since Mead Products are never advertised to u!
public. Servarnus Fidem, "We Are Keeping the Faith."
Pablum (Mead's Cereal pre-cooked) is a palatable cereal enriched with vitamin- and mmeral-conteini|
foods, consisting of wheatmeal, oatmeal, cornmeal, wheat embryo, alfalfa leaf, beef bone, brewers y688^
iron salt, sodium chloride.
of Canada. Ltd., Belleville, Ont., when requesting i
enting their reaching unauthorized persons.
:ooperate kiffti
7 I
J 5     11
I'JJ
Announcing Reduction in Price
THEELIN and THEEOL
(PARKE DAVIS & CO.)
Old Price    New Price
6 amps
THEELIN    6 suppos
6 amps (in oil)
THEEOL        Kapsealsin20's
$4.60      $2.70
$4.95       $3.25
These prices subject to 20% professional discount
?SEYIOSO
OPtNAU
NIGHT
OPEN
ALL
NIGHT
GEORGIA PHARMACY
SEYMOUR
1050
W. GEORGIA
STREET
(Eimtpr $c %wxtm 10ft.
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.    Powell River, B. C.
Published monthly at Vancouver, b. C by ROY wrigley LTD., 300 West Pender Street
»
i, I
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sssgasssssg^^
I     'IMI
ll    I'
;«
lll!5
% H" Ll
I Ik.
1
III
a r?- >:
il.   I
H;!1.
Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
UK
S^5^SSSSSSSS5SS^SSS5SSSSS

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