History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: December, 1938 Vancouver Medical Association 1938

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 u
The BULLETIN
of the
VANCOUVER
MEDICALIASSOCIATION
SIr-Vol. XV.
DECEMBER.  1938
No. 3
With Which Is Incorporated
Transactions of the
Victoria Medical Society
the
Vancouver General Hospital
end the
St Paul's Hospital
In This Issue:
NEWS AND NOTES
PROBLEMS OF CONTRACT PRACTICE
THE (ESOPHAGUS
PROVINCIAL MEDICAL ASSOCIATIONS BULKETTS
(With Cascara and Bile Salts)
. . FOR . .
Chronic  Habitual
Constipation
BULKETTS POSSESS ENORMOUS BULK
PRODUCING PROPERTIES AND BEING
PROCESSED WITH CASCARA AND
BILE SALTS PRODUCE BULK WITH
MOTILITY.
WE WILL BE PLEASED TO PROVIDE
ORIGINAL CONTAINERS FOR TRIAL
ON REQUEST.
Western Wholesale Drug
(1928) Limited
456 BROADWAY WEST
VANCOUVER   -   BRITISH COLUMBIA
(Or at all Vancouver Drug Co. Stores) THE    VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical 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. XV.
DECEMBER, 1938
No. 3
OFFICERS  1938-1939
•Dr. Lavell H. Leeson Dr. A. M. Agnew
President Vice-President
Dr. W. T. Lockhart
Hon. Treasurer
Dr. G. H. Clement
Past President
Dr. D. F. Busteed
Hon. Secretary
Additional Members of Executive: Dr. J. P. Bllodeau, Dr. J. W. Arbuckle.
Dr. F. Brodie
TRUSTEES:
Dr. J. A. Gillespie
Historian: Dr. W. D. Keith
Auditors: Messrs. Shaw, Salter & Plommer
Dr. Neil McDougall
SECTIONS
Clinical Section
Dr. W. W. Simpson Chairman     Dr. F. Turnbull.— Secretary
Eye, Ear, Nose and Throat
Dr. S. G. Elliott Chairman     Dr. W. M. Paton Secretary
Pediatric Section
Dr. G. A. Lamont Chairman     Dr. J. R. Davies Secretary
Cancer Section
Dr. B. J. Harrison Chairman     Dr. Roy Huggard Secretary
STANDING COMMITTEES
Library:
Dr. A. W. Bagnall, Dr. H. A. Rawlings, Dr. D. E. H. Cleveland,
Dr. R. Palmer, Dr. F. J. Buller, Dr. J. R Davies.
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. Murray Baird.
Summer School:
Dr. A. B. Schinbein, Dr. A. Y. McNair, Dr. T. H. Lennie,
Dr. Frank Turnbull, Dr. W. W. Simpson, Dr. Karl Haig.
Credentials:
Dr. A. B. Schinbein, Dr. D. M. Meekison, Dr. F. J. Buller.
V. 0. N. Advisory Board:
Dr. I. Day, Dr. G. A. Lamont, Dr. Keith Burwell.
Metropolitan Health Board Advisory Committee:
Dr. W. T. Ewing, Dr. H. A. Spohn, Dr. F. J. Buller.
Greater Vancouver Health League Representatives:
Dr. W. W. Simpson, Dr. W. N. Paton.
Representative to B. C. Medical Association: Dr. G. H. Clement.
Sickness and Benevolent Fund: The President—The Trustees. IB
Protection Against Typhoid
Typhoid and Typhoid-Paratyphoid Vaccines
Although not epidemic in Canada, typhoid and paratyphoid infections remain a serious menace—particularly
in rural and unorganized areas. This is borne out by the
fact that during the years 1931-1935 there were reported,
in the Dominion, 12,073 cases and 1,616 deaths due to
these infections.
The preventive values of typhoid vaccine and typhoid-
paratyphoid vaccine have been well established by military and civil experience. In order to ensure that these
values be maximum, it is essential that the vaccines be
prepared in accordance with the findings of recent laboratory studies concerning strains, cultural conditions and
dosage. This essential is observed in production of the
vaccines which are available from, the Connaught
Laboratories.
Residents of areas where danger of typhoid exists and
any one planning vacations or travel should have their
attention directed to the protection afforded by vaccination.
Information and prices relating to Typhoid Vaccine and to
Typhoid-Paratyphoid Vaccine will be supplied
gladly upon request.
CONNAUGHT LABORATORIES
UNIVERSITY   OF   TORONTO
Toronto 5
Canada
Defot for British Columbia
macdonald's Prescriptions Limited
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. VANCOUVER HEALTH DEPARTMENT
STATISTICS, SEPTEMBER, 1938.
Total Population—estimated    259,987
Japanese Population—estimated : •_       i 8^685
Chinese Population—estimated .  7 808
Hindu Population—estima ted _  '335
Number
Total Deaths .    214
Japanese Deaths        6
Chinese Deaths      10
Deaths—Residents only    182
BIRTH REGISTRATIONS—
Male, 197; Female, 192.
389
INFANTILE MORTALITY—
Deaths under one year of age	
Death rate—per 1,000 births	
Stillbirths (not included in above)
Oct., 1938
8
_     20.6
6
Rate per 1,000
Population
9.2
8.1
15.1
8.2
17.6
Oct., 1937
10
37.0
6
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
September, 1938
Cases Deaths
Scarlet Fever    20 0
Diphtheria      2 1
Chicken Pox  19 0
Measles         1 0
Rubella .      0 0
Mumps       6 0
Whooping Cough  28 0
Typhoid Fever      1 0
Undulant Fever      0 0
Poliomyelitis      1 0
Tuberculosis   36 17
Erysipelas          1 0
Ep. Cerebrospinal Meningitis      0 0
October, 1938
Cases  Deaths
November 1st
to 15th, 1938
Cases  Deaths
22
0
27
2
3
6
19
3
0
0
20
4
0
0
0
0
0
0
0
0
0
0
0
15
0
0
16
0
29
2
2
0
14
1
0
0
16
0
0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL.
Burnaby
Syphilis    0
Gonorrhoea        1
West
North
Vancr.
Hospitals,
/ancr.
Richmond   Vancr.
Clinic
PrivnteDrs.
0
0               0
42
34
1
1               0
102
25
0
0
0
0
0
0
0
0
0
0
0
0
Totals
76
130
HYPERTHYROIDISM
USE BIOGLAN "C"
I HYPERTENSION
USE BIOGLAN "H"
The most effective therapy available.
A Product of the Bioglan Laboratories, Hertford, England.
STANLEY    N.   BAYNE
REPRESENTATIVE
1432 MEDICAL-DENTAL BUILDING
ff Ask the Doctor Who Is Using It"
Phone: SEYMOUR 4239 VANCOUVER, B. C.
P age 56 OBESITY contributes to many diseases.
Overweight predisposes to*such serious afflictions as diabetes, hypertension, arterio-sclerosis, heart disease, disorders of the kidneys and blood
vessels and lowered resistance.
Efficient reduction without drastic dieting or excessive exercise can be
accomplished with IODOBESIN, a potent combination of many glandular
substances.
IODOBESIN
For sustained pluriglandular reduction
Literature and samples from:
ANGLO-FRENCH DRUG CO.      - MONTREAL, QUE. VANCOUVER MEDICAL ASSOCIATION
Founded 1898    ::    Incorporated 1906.
GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month at 8 p.m.
Place of meeting will appear on the Agenda.
General meetings will conform to the following order:
8 P.M.—Business as per Agenda.
9 p.m.—Papers of the evening.
Programme of the 41st Annual Session.
1938
October 4th—GENERAL MEETING.
Dr. Frank Turnbull: "Pituitary and Para-Pituitary Tumours."
October 18th—CLINICAL MEETING.
November 1st—GENERAL MEETING.
Dr. J. Ross Davidson: "Some Aspects of Contract Practice."
November 15 th—CLINICAL MEETING.
December 6th—GENERAL MEETING.
Dr. Karl Haig: "Diagnosis of Congenital Dislocation of the Tip and Treatment
of Those Which Are Reducible."
December 20th—CLINICAL MEETING.
1939
January 3rd—GENERAL MEETING.
Dr. G. E. Kidd: "Points in Physical Anthropology."
January 17th—CLINICAL MEETING.
February 7th—GENERAL MEETING.
Dr. Murray McC. Baird: "Some Remarks About Rheumatism."
February 21st—CLINICAL MEETING.
March 7th—OSLER LECTURE: Dr. J. H. MacDermot.
March 21st—CLINICAL MEETING.
April 4th—GENERAL MEETING.
Dr. H. A. DesBrisay: Subject to be announced later.
April 18th—CLINICAL MEETING.
April 25 th—ANNUAL MEETING.
Page 57 EDITOR'S PAGE
In this issue we publish the paper read by Dr. J. Ross Davidson at the regular meeting
of the Vancouver Medical Association, entitled "Problems of Contract Practice." This
paper might well come into the "Medical Economics" Section of the Buletin, and it is
really a contribution to our thought on this subject.
Dr. Davidson speaks from an experience of contract practice: not a very long one, but
long enough to impress him with the importance, not only to himself, but to the profession
at large, of the problems which Contract Practice presents. He is really much more concerned with the wider application of the question than with its more personal effects; and
this, of course, is what makes his paper worth while.
The discussion that it evoked was noteworthy; it was free, and many took part in it,
and many new angles were suggested. The fact is that contract practice is not an ideal
way of practising medicine. It is sometimes the only practical method in a given area,
but it is a question whether it is as universally necessary as it has been held to be. It is a
"pis aller," as the French say—a compromise with circumstances.
Dr. Davidson urged a better control and more careful selection of those who are to
take contracts, and he also urged a more definitely unified and uniform stand by the
medical profession as to terms of contracts, etc. With these suggestions, we need hardly
say, we cordially agree—but there are certain lions in the path. The weaknesses of contract
practice, and the failure of the medical profession to secure adequate control of the
situation, so that as an organised body we can lay down minimum standards of salary,
conditions of work, terms of contract and so on, are due, in a measure at least, to factors
of which we may lose sight.
Each year every university turns out of its medical department so many men. Their
education has been a long and costly one, and it is vital for most of them that they begin
earning money at the earliest possible opportunity. To start practice in a city or even a
good-sized town is a slow and tedious process, and to many a practical impossibility. So
to these men contract practice has a very great appeal—and the fact that they will be
busy, gaining experience, and actually practising their profession, is often more important
than the actual size of the salary. As in a case quoted by one of those discussing the paper,
a salary of $200 a month looked like big money. This is one of the main reasons, we feel,
why the men taking the contracts so often are lacking in the experience that Dr. Davidson
rightly feels is necessary.
There is in existence a Medical Economics Committee of the B. C. College of Physicians
and Surgeons, and they are studying this whole question, and will be better prepared to
offer suggestions than we can be. But we feel that no amount of discussion, no good resolutions, no far-sighted advice from older, sadder and wiser men, will be of much use till
this gap between graduation and the earning of an adequate income has been in some way
bridged. Again we ask ourselves: Why cannot some scheme be worked out whereby the
doctor who needs practice and an income, and the poor and needy who need doctors and
medical care, can be brought together on a satisfactory basis? The day must arrive sometime when the State will recognize its obligation to provide for these people on a sound
economic basis: and doctors will be paid for their work. When this comes, the economic
hunger for work on the part of the man beginning practice will be capable of satisfaction
in the right way. He will not be compelled to grasp at any work he can get; the medical
profession as an organised body will be able to regulate the filling of positions in some such
way of Dr. Davidson suggests, and this will be all to the advantage of the consumer, i.e.,
the patients involved. Exploitation of the doctor, and inadequate care for the patient, will
then be preventable.
Till then, all that can be done should be done, by surveys of existing contracts, by
measures calculated to aid the men who hold these, and to protect them against unfair
competition, by education of the doctor, and advice by those who contemplate taking
contract work. Very much can be done this way, and many of the serious evils mitigated
or removed. We are grateful to Dr. Davidson for his frank and timely speech on the subject, and feel that much good will come out of the whole discussion of the subject.
Page 58 NEWS and NOTES
We are glad to hear that Dr. Maurice Fox, who has been in St. Paul's Hospital for
nine weeks, will soon be well enough to return to his home.
Latest reports concerning Dr. T. V. Curtin, who is also ill in St. Paul's Hospital, say
that he is "doing fairly well."
Dr. Draeseke, who was ill in hospital for some weeks, is now well enough to be back at
his office.
Drs. R. L. Pedlow, A. J. MacLachlan, P. McLellan, Lee Smith, F. Brodie and H. W.
Riggs attended the meeting of the Pacific Coast Surgical Association in Spokane.
Dr. G. E. Gillies and Dr. A. B. Schinbein have returned from New York, where they
attended the Annual Meeting of the American College of Surgeons.
The following were elected as members of the Vancouver Medical Association at the
regular General Meeting, held on November 1st: Drs. J. Ross Davidson, A. C. Gardner
Frost, A. Leigh Hunt, A. J. McDonald, S. A. McFetridge, B. B. Moscovich, E. E. Saunders, Neil A. Stewart.
Drs. W. F. Drysdale and S. L. Williams of Nanaimo were elected as Associate members of the Vancouver Medical Association on November 1st.
Dr. L. H. Appleby is enjoying a vacation in Southern California.
News comes from Victoria of the appointment of Dr. Andrew Turnbull as Radiologist at St. Joseph's Hospital in that city. Dr. Turnbull is a graduate of the University of
Manitoba Medical School. He did general practice in Athabasca, Alberta, for four years
and spent three years on a Fellowship in Radiology at the Mayo Clinic. He is a Diplomate
of the American College of Radiology and practised radiology in Durham, North Carolina,
prior to coming to Victoria.
Drs. Gordon Kenning, A. B. Nash and W. Allan Fraser attended the recent meeting
of the American College of Surgeons in New York. Drs. Nsah and Fraser were initiated
as Fellows of the College.
Drs. G. A. McCurdy and D. B. Roxburgh, pathologists at the Royal Jubilee Hosptial
and St. Joseph's Hospital, respectively, attended the meeting of the Pacific North-West
Society of Pathologists, held recently in Tacoma.
Dr. T. W. Walker, superintendent of the Royal Jubilee Hospital, attended a meeting
of hospital superintendents, recently held at Dallas, Texas.
The Board of Directors of the Jubilee Hospital were hosts to the staff of the Jubilee
Hospital at a dinner held in the Union Club on Tuesday, November 15 th.
Dr. H. E. Ridewood has just returned to Victoria after a five-weeks' holiday in California.
Dr. C. A. Watson attended the Annual Meeting of the Defense Medical Association
in Ottawa as the British Columbia representative.
Major-General Sir Ernest Walker, K.C.I.E., who has retired from the office of
Director-General of the Indian Medical Services and who is now living on the Island, has
accepted honorary membership in the Victoria Medical Society.
Page 59 Dr. D. W. MacKay of Nelson has just been elected president of the British Col
Amateur Hockey Association.  Hockey is a grand sport in the Kootenays.
umbia
Dr. W. Laishley of Nelson, the energetic secretary of the West Kootenay Medical
Association, called at the office and attended the Annual Dinner of the Vancouver Medical
Association.
Dr. H. Cantor has left for Mayo, Yukon Territory, to relieve Dr. E. W. T. Nash
during six months while Dr. Nash is absent on post-graduate study and a well-earned
vacation.
Dr. H. Winter is now at McBride during the absence of Dr. L. M. Greene on holiday.
Dr. G. W. Meyer has taken up the practice at Telegraph Creek.
Dr. Paul Ewert of Golden called at the office. He is on a month's vacation. He will
visit Dr. Carl Ewert of Prince George during two weeks.
Dr. W. J. Elliot is at Golden during Dr. Ewert's absence.
Dr. E. K. Hough is now at Woodfibre.
Dr. and Mrs. W. J. Knox of Kelowna are spending two months in the East. While
in New York, Dr. Knox will attend the convention of the American College of Surgeons.
Dr. O. O. Lyons of Powell River visited the office last week.
Dr. Allan B. Hall of Nanaimo was in Vancouver on November 18 th and attended the
Annual Dinner of the Vancouver Medical Association. He brought greetings as representative of the Upper Island Medical Association.
Out-of-town members of the Board of Directors of the British Columbia Medical
Association who attended the regular meeting held November 9th, following dinner at
the Hotel Georgia, included Drs. Stewart A. Wallace of Kamloops, C. T. Hilton of Port
Alberni, George T. Wilson and W. A. Clarke of New Westminster, A. C. Nash of West
Vancouver, Gordon C. Kenning, P. A. C. Cousland and W. Allan Fraser of Victoria.
The North Shore Medical Society took on this new name at its annual meeting held
on November 8th, when the election of officers resulted as follows:
President: Dr. A. C. Nash, West Vancouver; Vice-President: Dr. R. V. McCarley,
North Vancouver; Hon. Secretary-Treasurer: Dr. D. J. Millar, North Vancouver.
Dr. A. C. McCurrach is at Blue River doing the practice formerly carried on at that
point on the C.N.R. by Dr. Bramley-Moore.
Dr. D. J. Bell of Vancouver was honored by the residents of Vancouver Heights and
Capitol Hill when about two hundred persons gathered in the Masonic Hall and a presentation was made to this beloved practitioner by the people he has served during twenty-
five years. Dr. George Pringle paid eloquent tribute to Dr. Bell and was able to refer intimately to his fine service in the Yukon. Drs. H. H. Planche, C. M. Eaton and K. L. Craig
were present and participated in this fine tribute to Dr. Bell on the conclusion of fifty
years in Medicine.
Dr. and Mrs. H. A. L. Mooney of Courtenay are being warmly congratulated on the
birth of a daughter, November 14th.
Page 60 LIBRARY NOTES
Recent Additions to the Library
Method of Anatomy, 1937.  By J. C. B. Grant.
Clinical Atlas of Blood Diseases.  4th ed., 1938.  By A. Piney and S. Wyard.
Practcial Bacteriology.  9th ed., 1938.  By E. R. Stitt and P. W. Clough.
Endocrine Therapy.  1938. By E. L. Sevringhaus.
Injection Treatment of Varicose Veins.    1938.   By H.  O. McPheeters  and J. K.
Anderson.
Textbook of Pathology.   3rd ed.  By Wm. Boyd.
Surgical Pathology.  4th ed.  By Wm. Bflyd.
Obstetrics.  7th ed., 1938.  By J. K. DeLee.
Electrocardiography.   2nd ed., 1938.   By C. C. Maher.
1937 Year Book.   Supplement to Encyclopaedia Brtiannica.
Monograph on Veins, translated by K. J. Franklin.   193 8.
Cancer.   1938.  Published by Canadian Medical Association.
From the Nicholson Fund
On Thought in Medicine. By H. von Helmholtz.   1938.
Horse and Buggy Doctor.  By A. E. Hertzler.   1938.
Life of Chevalier Jackson.  An Autobiography.   1938.
Items From the Journals
Cold Vaccines—An evaluation based on a Controlled Study. By H. S. Diehl, A. B.
Baker and D. W. Cowan. J.A.M.A., Sept. 14, 1938.
Local Urinary Antiseptics. By H. W. E. Walther. J.A.M.A., October 15, 1938.
Surgical Treatment of Obstructive Jaundice in Pancreatic Disease. By Sir John Fraser.
Brit. Jl. Surgery, October, 1938.
Present Status of Treatment in Chronic Gastritis: Gastroscopic Observations. By W.
Rudolf Schindler.   S.G.O., November, 1938. I
The Role of Gastroscopy in the Recognition and Identification of Gastric Lesions. By
A. Swalm and Lester M. Morrison. Am. Jl. Dig. Diseases, October, 1938.
Development and Healing of Gastric Ulcer—A Clinical, Gastroscopic and Roentgenologic Study. By W. L. Palmer and R. Schindler. Am. Jl. Dig. Diseases, October, 1938.
A bulletin, published by the Lahey Clinic, has lately been received in the Library. Dr.
Lahey, in the Introduction, states this bulletin will be published at irregular intervals,
and only as material deemed worth while presents itself.
Surgical Clinics of North America, August, 1938.
Mayo Clinic Number
Diagnosis and Treatment of Vascular Disorders of the Limbs.   By W. McK. Craig
and B. T. Horton.
Deep Infections of the Neck.  By G. B. New and J. B. Eich.
Management of Head Injuries.   By J. Grafton Love.
Complications and Sequelae of Head Injuries.  By J. Grafton Love.
Recent Trends in Genito-Urinary Surgery.  By H. Cabot and J. L. Emmett.
Treatment of Tumors of the Bladder.  By H. Cabot and G. J. Thompson.
Surgery of the Biliary Tract.  By W. Dalters and M. W. Comfort.
Page 61 V
ancouver
Medical   Association
At the regular meeting of the Association to be held on December 6th, Dr. Karl Haig
will be the speaker of the evening. The title of his paper will be Diagnosis of Congenital
Dislocation of the Hip, ivith treatment of those which are reducible.
ANNUAL DUES
Members are reminded that the nanfes of those whose dues are unpaid on
December 31st will be posted in the Library on the second day of January, 1939.
THE ANNUAL DINNER
Prologue.
As we write this, the pleasant clink of cocktail glasses, yet afar off but ever drawing
nearer, begins to reach our ears, and in dreamy anticipation we distinguish the pleasant
aroma of the dry Martini, or the fragrant Old-fashioned, as it tickles (at least we hope it
will) our nostrils and delights our watering palate. For the Annual Dinner is in view—
tonight is most emphatically the night—and away with care! and begone! dull melancholy:
for Luke Sawbones is out on the tiles tonight—has forgotten vitamin "B" and tonsillectomies and intestinal flu and Brucella abortus, and is off to enjoy a few hours' surcease from
the ills of others, while he accumulates a headache on his own account.
And we hear that there is to be entertainment of a very refined nature—pure and
wholesome—and though we cannot, by coaxing, innuendo or direct questioning, get any
lead on the programme at all, yet the presonnel of the Dinner Committee is very reassuring. In view of the rather paternalistic, not to say busybody, rules on libel, as laid
down by the society in which we live, move and have our being, we shall not mention
any names, nor impute any motives—in fact, we will say no more. After the ball we
may have a few further remarks to make.
Epilogue.
We were quite right—it was a good dinner. Some hundred and sixty-five men were
present—and there would have been many more—but apparently all the Surgical Associations, and Medical Associations, and Staff Meetings, and special meeting of all kinds,
in the Western Hemisphere, were busy on the night of the Annual Dinner of the Vancouver Medical Association, and there were many men who could not be present. We
received telegrams from them, and that is all very well, but we lamented their absence.
There were some newly vacant seats, too, which will remain vacant, and as the list
of departed members was read, all present stood in reverent silcence. We shall miss them,
good fellows all. But they leave a good name, and did good work. Many of them died in
harness—a happy ending for any man.
The new recipient of the P.G.F. degree was Charles H. Vrooman, best known as
"Charlie". The secret of his selection has been well kept and Charlie was completely
taken by surprise. He well deserves the honour: he has been long a devoted worker in the
Association and has, too, all the other qualifications as laid down in solemn Latin in
the diploma.
The entertainment was well received and our congratulations are due to the Dinner
Committee that worked hard and long to provide a programme, and to ensure the smooth
functioning of the dinner. Our last impression of the dinner was the sight of Dr. Freeze
counting huge stacks of currency all by himself in Peacock Alley. Unless we were seeing
double (and we really did not have enough for that) he had most of the doctors' incomes
for the current week in his possession. That's what it is to be trusted. Leaving him in
this pleasant atmosphere of wealth and luxury, we hurried out to see a malade imaginaire,
as our French colleagues would say, and thereby to earn a more or less honest dollar wherewith to buy a ticket for next year's dinner.
Till then, au revohrl
Page 62 PROBLEMS OF CONTRACT PRACTICE
J. Ross Davidson, M.D.
This paper is not presented as the studied opinion of any committee on Medical Economics, nor is any claim put forward that it will even contain the main problems of
Contract Practice. It is my intention to mention only a few of the problems facing a
medical practitioner under such a scheme, in the hope that those of you who have had no
experience in this type of work will give it your careful thought, from which will arise
some concrete suggestions which can be moulded into a form that will benefit the medical
fraternity as a whole.
Contract practice had its origin in necessity, for which reason a group of individuals
or some industrial concern contracted with a medical man for certain services. These communities were usually lying in some distant part of the province not sufficiently populated
to offer any inducement to a doctor to undertake private practice, tt became necessary,
then, to guarantee to some medical man a certain emolument monthly in return for certain services. This form of barter between the public and the members of the medical profession is not in itself unethical, but a recognized and highly commendable form of business
transaction in the economic world of today, of which we find ourselves a part, but it has,
in its fundamental aspects, some features that should be controlled, and which, if left
unchecked, will not only bring the profession into disrepute but seriously undermine the
health of the community, whose duty it is ours to protect.
In the earlier days, most contracts were entered into between a doctor and the management of some company. Before the advent of the Workmen's Compensation Act, most
companies felt some moral obligation to those of their employees who were either sick or
injured, and as a result often made considerable material contributions to the contract and
exercised control of the hiring of medical men. As a result of economic conditions, cutthroat competition and a mass of governmental social legislation, the companies found
themselves in a position whereby they had to shift the responsibility to those pedple who
were recieving the benefits. This move, I might add, was also activated by the fact that
the general public, the legal profession, or both, found out that medical men were fair
game for malpractice suits, and the companies found themselves as co-defendants in such
suits. To overcome this difficulty the various hospital and sickness societies were incorporated to handle all matters pertaining to medical care.
One can readily see that out of the arrangement would come a heterogeneous variety
of plans and contracts. With organized medicine, as represented by the various local and
provincial associations, frowning for the large part on contract practice and refusing to
recognize it as a vital part of their programme, there was no attempt made to regulate the
terms of any plan, and the individual doctor concerned was left to his own resources in
framing a contract for some place which, in a number of cases, he had never seen. As a
result he often fell prey to those better versed than himself in the completion of business
transactions, which, once entered into, proved difficult to change. Without any positive
guide to the formation of contracts, and with only negative help from organized medicine,
it is easy to see the utter confusion and multiplicity, of forms that made up the present-
day contract practice, for there are at the present time some hundred and fifty contracts in
British Columbia, not two of which bear any great similarity to each other, even in their
basic principles. It is obvious that local conditions will influence each individual contract
and present peculiar problems that must be handled in an individual manner, but there
should be, however, some supervision of the fundamentals.
What, then, are those basic principles and what do they involve? Contract Practice
is defined by the Judicial Council of the American Medical Association, as applied to
medicine, as: "The carrying out of an agreement between a physician, or a group of
physicians, as principals or agents and a corporation, or individual, to furnish partial or
full medical services to a group or class of individuals for a definite sum or for a fixed rate
per capita." Such services may include medical and surgical care, obstetrics, hospitalization, drugs, specialists'* care, and the individual plan may include all or any of these
features, either for employees alone or for employees and their dependents.
Let us analyze for a short time each of these features:—
The cardinal question in all contracts is just what constitutes "adequate medical and
Page 63 surgical care." In this age of specialization it is obvious that one medical man serving a
thousand people or less cannot by any stretch of the imagination give them a specialist's
service in all branches of the healing art. He not only lacks the experience, but even if
he had it, the necessary equipment is wanting. There is, I believe, only one contract in
British Columbia that embraces a sufficient number of subscribers to employ enough doctors
who can divide the work in such a manner that each may enjoy at least some specialty.
Where a general practitioner's ability is to end is a moot question that I do not intend even
to open for discussion, but I can assure you it is a live issue in the relationship of the two
parties to a contract practice. At this point may I make a plea for those men practicing
their profession in isolated districts and ask you to exercise some forbearance with them in
their diagnosis and treatment. Their laboratory usually consists of an alcohol lamp and
a bottle of Benedict's solution. They are their own X-ray technicians with no portable
equipment, and for an anaesthetist they usually have a nurse or a lay man pouring ether,
necessitating artificial respiration at least twice during the course of a simple appendectomy.
I think that in these contracts, all that can be expected is the service of a medical man
with average training. In this regard, if it is to be the policy of the Medical Association to
protect the medical man by defining the terms he is to expect under such a contract, then
I feel it should likewise be their duty to protect the public he is to serve by stipulating
that any man undertaking such a contract should have certain requirements of training.
To demand from society a salary that we consider fitting for a medical man and then fill
the position with a recent graduate having no postgraduate training is to my mind neither
protecting the public nor the medical profession. That man is often placed where there
are no consultants and he can get no assistance. The impression he leaves with his patients
will be the impression that that community will have of the medical profession as a whole.
There is no place in the practice of medicine for "the public be damned" attitude, and I
can assure you that one has only to live in one of these communities to realize that hospital
and medical attention is the dominant factor of their existence.
Hospitalization is always a bone of contention in all contract practice, and I feel that
no medical man should associate himself with any guarantee to provide such for any
patients under his contract. He is courting financial disaster to undertake such an agreement, for all of you are aware of the ever-changing demands of modern hospitalization and
equipment. The old axiom of a man not being able to serve two masters is still true, and,
after all, running a hospital for financial gain is not one phase of the healing art. The
ever-prevailing chance of an epidemic hangs over his head to ruin him, and in the majority
of these places there is a large proportion of the population living in bunk houses who
require hospitalization for conditions which in larger centres would not be considered as
such. This type of man demands hospitalization if he is under contract, because he probably not only finds it inconvenient to carry out treatment in his bunk, but while in the
hospital he is saving his board bill. There is in addition considerable responsibility resting
on the shoulders of any docotr who has refused to hospitalize a simple influenza case when
this is demanded, when the patient later develops broncho-pneumonia and dies. The harmonious relationship between patient and physician is, as wou are all aware, one that is
subject to considerable variations. An even more dangerous tension exists under Contract
Practice when the doctor is financially interested in providing the service of hospitalization.
The question of supplying drugs is perhaps the most controversial point that will crop
up in the creation of any contract, and it will in all probability be the one stumbling block
of an otherwise smooth relationship. Some contracts call for free medicines, some for
medicines to a limited degree, while others will require patients to pay some part of the
cost. Perhaps the clause which will give the greatest difficulty is the system under which
free drugs are limited. In other words, the contract will read that drugs are limited to those
in the British Pharmacopceie, or it may be drugs exclusive of biologicals. The most vicious
clause of them all is one that reads: "Drugs as prescribed by the local doctor." The pitfalls
of such a system are obvious. Anything that is free is gathered in large quantities and
stored away in some cupboard against any and every possible emergency. Under a contract
that supplies free medicines yet allows a fee charge against dependents, any too close
enquiry into the reason for such drugs will cause only the feeling that the doctor is seeking
a consultation for a fee.   I might mention just a few of these—something for a burn;
Page 64 something for my son's tummy ache (it cannot be appendicitis); something for a cut that
is infected.  Each in itself may be trivial but has possibilities of serious consequences.
Recent years have seen such advances in endocrine and biological therapy that they now
form a great part of the general practitioner's armamentarium, but the cost of these
products is still almost prohibitive, especially so under contracts drawn up before their
advent. To prescribe these products is courting bankruptcy, yet it is the patients' right
that they should receive any benefit of recent therapeutic advances. There is nothing to be
gained by arguing with a patient that the only drug that will cure him is not in the B. P.
or is a biological product, hence he will have to pay for it. They are only aware of the fact
that they have so much money deducted from their pay cheques for sickness and drugs,
and if the doctor prescribes it, it must be a drug. Those fortunate individuals who could
afford a trip to town for a specialist check-up would return and present a prescription
bearing the latest in trade names. Not only would the local doctor not carry it but would
not even know what it was. These people will not even tolerate a change in the vehicle of
a prescription for triple bromide that they have paid twenty-five dollars to get, and the
poor local doctor is in wrong again. "He is obstructing the march of progress, not keeping
up with the times, and it is time he was fired." Making a patient pay for a portion of all
drugs has its beneficial side, but unless the community is big enough to support a druggist,
is also has its drawbacks. It puts the local doctor in the business of bookkeeping, and it is
almost impossible for him to figure out the cost of individual prescriptions, especially if
he is busy practicing medicine.
The question of obstetrics is relatively a simple one. If the contract calls for service to
dependents as well as employees, then the inclusion of midwifery should be part of the
service. To the lay mind there is no logical reason why it should not be classed as a sickness, and its exemption only leads to dissatisfaction. Mention of exemptions brings to mind
the one great contentious point of Contract Practice. In practically every contract there
is a clause which states that free service will not be given to pre-existing diseases. In most
large industrial plants each employee is examined prior to being taken on the payroll and a
record kept of that examination. It is surprising the number of prospective employees that
have some physical defect, which does not at all impair their ability to work and in the
majority of cases has caused the applicant no discomfort or symptoms. Yet if the doctor
is to protect the company or association against future medical and hospital expenses, these
must be excluded. Such cases include chronic infected tonsils, sinusitis, chronic ears,
bronchitis, hernia, enlarged inguinal rings giving an impulse on coughing, varicose veins,
haemorrhoids, fallen arches, presence of cardiac murmurs with or without some degree of
hypertension. Each of these cases represents a potential patient with resultant expenditure
of drugs, hospitalization and doctor' services. If one is to accept these cases as employees
and they report sick two years later, it is difficult to convince them that they should pay
for any service rendered, for they feel that having contributed for two years they are
entitled to free medical care. What are you going to do with these cases that deny at the
time of examination any gastric symptoms, yet when they appear with symptoms of peptic
ulcer will, on questioning, admit attacks dating back several years prior to employment?
It is easily said that you should force them to pay for treatment, but remember that after
all these men are members of an association that is paying your salary and it is very easy
to start a whispering campaign against the doctor that gathers momentum until the original
cause of the dissension has been lost sight of in the gross charges that follow. It is perhaps
often better to handle these cases without comment when first seen.
There is no denying the fact that the general public today is specialist-conscious and
small isolated communities are no exception. A specialist, in their case, is any medical man
outside their own community who puts on a different type of splint or uses heat where the
local doctor prescribes cold. Human nature being what it is, you will always find a certain
percentage of people without confidence in the medical man to whom they are forced to
go by virtue of a contract. They are the ones who on the slightest provocation demand
the service of one whom they choose to call a specialist. In drawing up all contracts the
need in certain cases of a specialist is foreseen and the provision is written into the contract
to cover such cases in somewhat the following manner: "The doctor or society (as the case
might be) agrees to furnish the services of a specialist where required." All of you can at
Page 65 once see the difficulties that arise from this clause. Where cost of transportation, hospitalization and specialist fees are guaranteed the situation is aggravated. Even Workmen's Compensation Board cases come under this provision when working under what is
termed the Approved Plan. For those of you not familiar with this scheme I will merely
say in passing that the Workmen's Compensation Board allows certain companies or societies
that have their own hospitals and doctors to forego any payment for medical service to the
Board and they in turn do not have to pay either the doctor's fees or hospitalization. Thus
any case sent out for a specialist's care is a direct charge against the society at the local
community. A conservative estimate, I believe, would be that every case sent to one of the
large centres for a specialist's care costs the local society an average of over two hundred
dollars. There are always a few people who desire the service of certain medical men who
enjoy the public favor at the time and this desire becomes acute if they themselves do not
have to pay for it. The trip to Vancouver at no added cost is also an inducement, and these
people, immediately on getting hurt or becoming ill, demand through themselves or friends
that they be sent to a specialist. At this point the local doctor is literally "on the spot." If
he insists that the patient does not need a specialist and any complications arise, he was
wrong. If the patient gets better he is annoyed at the doctor for not giving him the benefit
of a holiday for which he would not have to pay. In either case the doctor's lot is not a
happy one. Here, I may honestly say, I have slightly exaggerated the conditions, and it is
only rarely that one is faced with such a problem, yet it does arise, and when it does, disturbs the relationship that should exist between the doctor and his patient. Insert into any
contract the stipulation that all or part of specialist fees must be borne by the patient and
a great deal of this unpleasantness will disappear. The free transportation feature, at least,
should never be included, for this item alone, if made a responsibility of the patient, will act
as a deterrent to a great many of the specialist-minded people.
I realize that in addressing these remarks to the medical men of Vancouver I am treading on dangerous ground when I offer as one of the problems of Contract Practice the
relationship between yourselves and those medical men in general practice in remote places.
It is obvious that a certain number of patients will be referred or come down to the large
centres of their own free will to consult you regarding conditions that have baffled the
local doctor or under whom treatment has been unsatisfactory. I ask you to remember that
it lies in your power to make or break the reputation and even the livelihood of the doctor
in that community from whence the patient comes. Merely by suggestion alone, you can
give that patient an idea that he possibly exaggerates, and which by the time it is retold
with embellishments of his own imagination, will be sufficient to prove to the populace at
home that the doctor is incompetent. Try and place yourself in the position of one of these
men who is working seven days a week, with no afternoon off for golf, seeing thirty or more
patients a day, of all kinds, and with very little in his laboratory as an aid to diagnosis, and
ask yourself if you could have done any better. It is perhaps easy to criticize the position
of a fractured femur after you have had the opinion of an X-ray specialist, but could the
fracture under your hands have been any better with adhesive for traction and no check-up
by X-ray possible?
I am sure that when any false impressions are left with patients who have consulted
you, it is not with any intent to harm but a result of thoughtlessness, yet it is difficult for
the small-town doctor to view them with equanimity when, by the next boat after his
patient returns, he receives a letter from the parent Medical Association asking him to sign
a form committing him to abide by any arrangements that a committee will make on his
behalf, when he might find on that committee the names of one or two men who have by
their actions already jeopardized his standing in that community. Was it not Iago in
Othello who said:
"Who steals my purse steals trash, 'tis something, nothing,
'Twas mine, 'tis his, and has been slave to thousands,
But he that filches from me my good name
Robs me of that which naught enriches <faim,
And. makes me poor indeed."
I have up to this point made no mention of what should be a proper remuneration to
any medical man participating in Contract Practice, nor do I intend to fix as a basic any
Page 66 salary that should be regarded as a minimum., yet I do wish to point out a few of the
problems under these schemes. There is apparently a widespread opinion held, not only
by the public but by the remainder of the profession, that men receiving a salary under
some contracts are well off. Granted they are well off for the time being, but you must
realize that at any time they are subject to the whims of those peoples or societies that
employ them, and are apt to find themselves relieved of their jobs with absolutely no private
practice to depend on. They are forced to spend any savings they might have in establishing
a practice in another community. Apart from this lack of economic security the problem
arises of post-graduate work. It is hardly conceivable that any man who has worked many
years of his life and saved a certain sum of money for the education of his children or his
old age is going to spend that in post-graduate work unless he can see where it will bring
him returns in later life. I throw this out as a challenge to any committee dealing in Contract Practice. The basic rate of remuneration to any doctor who is willing to devote his
energies to practice in distant parts of this province, with all its attendant discomforts and
drawbacks, should be sufficiently large to enable him to take post-graduate courses at least
every three years, or else it should be written in the contract that the employers of the
doctor, be it company or society, provide for such post-graduate study. Only in making
provision for some type of refresher course can you protect the public from a doctor who
is willing to become merely a pill dispenser, and protect the doctor from a public who will
accuse him of hanging on to a soft job and making no effort to keep abreast of advancing
medical knowledge.
I feel that the system of Approved Plans, as far as the Workmen's Compensation Board
is concerned, should be done away with. Under this scheme the doctor received no added
remuneration for work done on compensation cases. In those industries where employment is seasonal, this amount of work is apt to be considerable and many contracts which
in their inception cared only for five hundred men, now might find a thousand under the
scheme with no increase in remuneration to the doctors participating. There are several
contracts in British Columbia which have the doctor on salary and he, in return, is required to turn over to his employer his cheque for any work done under the Workmen's
Compensation Act. This, of course, is a ridiculous state of affairs, and remuneration for
all Workmen's Compensation work should be quite apart from the contract and rightfully
belongs to the doctor performing the service.
What then is the solution of some of these problems of Contract Practice? I do not
want to leave the impression that it has not its brighter side. This is self-evident in those
periods of which we have come to know as "business recessions," yet, like all contracts
involving Servants and Masters, it must be controlled.
We have in our British Columbia Medical Association a committee that, I believe, is
called the Economic Committee. It should fall to the lot of that committee, or a special
committee constituted for the purpose, to study all contracts at present in force; to pass
on all new contracts that are anticipated, and before any plan can come into effect it should
bear their approval. One of the members most familiar with contracts, preferably your
secretary, could visit the location, study the peculiar local conditions and then, with the
available data, in collaboration with his committee, draw up a contract which would not
only protect the medical man involved but provide some measure of protection for the
public he is to serve, for after studying the situation, the committee should be in a position
to judge which of the available men would be best suited to fill the contract. It is just as
important that, for the good of the profession, the public be protected from the doctor
as for the doctor to be protected from the public. A committee of medical men who have
served, or are serving time in Contract Practice, should be able to formulate some plan
that will procure the best for both the parties participating.
Contract Practice, whether or not we as a profession approve of it, has come to stay
and will in all probability continue to be a vital part of the medical whole. This fact
should be faced immediately. We must be cognizant of the changes that are taking place
in the economic conditions and the social ideas which have given rise to this problem. We
must attempt some constructive work in endeavoring to arrive at its solution. Unless we
make this attempt, others will do it for us and we shall find ourselves submerged under an
avalanche of social legislation in which we are "the thin, small voice crying in the
wilderness."
Pige 67 British  Columbia  Medical   Association
(Canadian Medical Association, British Columbia Division)
President Dr. D. E. H. Cleveland, Vancouver.
First Vice-President Dr. F. M. Auld, Nelson.
Second Vice-President ^ Dr. E. Murray Blair, Vancouver.
Honorary Secretary-Treasurer Dr. A. H. Spohn, Vancouver.
Immediate Past President— Dr. Gordon C. Kenning, Victoria.
Executive Secretary Dr. M. W. Thomas, Vancouver.
DIRECTORS-AT-LARGE:
Dr. P. A. C. Cousland, Victoria; Dr. Anson' C. Frost, Vancouver; Dr. Stewart A. Wallace,
Kamloops; Dr. George T. Wilson, New Westminster; Dr. Wallace Wilson, Vancouver.
DIRECTORS:
Dr. W. E. Ainley, Vancouver., , ™„Representative,
Dr. L. H. Appleby, Vancouver	
Dr. G. H. Clement, Vancouver	
Dr. W. Allan Fraser, Victoria	
Dr. F. R. G. Langston, New Westminster
Dr. D. P. Hanington, Ladysmith __ 	
Dr. C H. Hankinson, Prince Rupert	
Dr. R. B. Shaw, Nelson ;/'.'-- 	
Dr. F.'E. Coy, Invermere	
Dr. J. C. M. Willoughby, Kamploops	
Dr. A. C. Nash, West Vancouver	
College of Physicians & Surgeons of B. C.
College of Physicians & Surgeons of B. C.
Vancouver Medical Association.
Victoria Medical Society.
Fraser Valley Medical Association.
Upper Island Medical Association.
Prince Rupert Medical Association.
West Kootenay Medical Association.
East Kootenay Medical Association.
District No. 4 Medical Association.
North Shore Medical Society.
COMMITTEE CHAIRMEN:
Dr.  H. H. Milburn, Vancouver Chairman,
Dr. G. F. Strong, Vancouver	
Dr. G. C. Kenning, Victoria	
Dr. D. M. Meekison, Vancouver--	
Dr. M. McC. Baird, Vancouver	
Dr. C. T. Hilton, Port Alberni	
Dr. A. H. Spohn, Vancouver        '•'	
Dr. J. D. Moore, Chilliwack	
Dr. W. A. Clarke, New Westminster	
Dr. C. H. Vrooman, Vancouver	
Dr. W. S. Turnbull, Vancouver	
Dr. Roy Huggard, Vancouver™-.	
Dr. J. H. MacDermot, Vancouver	
Committee on Constitution and By-laws.
Programme and Finance.
Legislation.
Medical Education.
Archives.
Maternal Welfare.
Public Health.
Ethics and Credentials.
Economics.
Pharmacy.
Hospital Service.
Cancer.
Editorial Board.
The Board of Directors of the British Columbia Medical Association (Canadian
Medical Association, British Columbia Division) met following dinner at the Hotel Georgia
on Wednesday, November 9th.
Twenty-two members attended. Present Dr. D. E. H. Cleveland, President; Doctors
Gordon C. Kenning, P. A. C. Cousland, W. Allan Fraser of Victoria; W. A. Clarke and
George T. Wilson of New Westminster; J. D. Moore of Chilliwack; Stewart A. Wallace
of Kamloops; C. T. Hilton of Port Alberni; A. C. Nash of West Vancouver; Roy Huggard,
A. C. Frost, W. E. Ainley, Wallace Wilson, H. H. Mliburn, G. H. Clement, G. F. Strong,
Murray McC. Baird, J. H. MacDermot, W. S. Turnbull, A. H. Spohn and M. W. Thomas.
The Chairmen of Standing Committees were properly placed in office. Arising out of
the report of Dr. J. H. MacDermot, Chairman of the Editorial Board, it was decided that
papers presented at the Annual Meeting, by arrangement with the Bulletin, be published,
as was done last year, in the form of a special supplement.
The members of the Board of Directors who reside in Vancouver, New Westminster
and the North Shore will comprise the Executive Committee of the Association.
Page 68 Instructions were given providing for sending of minutes and proceedings to all members of the Board of Directors and especially to the representatives of District Associations
for the information of the local membership.
It was agreed that the Association should approve and co-operate in the plan for sending to all non-members of the Canadian Medical Association the special membership
December issue of the Journal of the Canadian Medical Association.
Dr. Wilburn reported that the Constitution and By-laws of the Association as amended
at the Annual Meeting had been registered and were now ready for printing and distributing, authorization for which was given.
Dr. Gordon C. Kenning, representative from British Columbia on the Executive Committee of the Canadian Medical Association, reported on the proceedings of the meeting of
the Executive held in Ottawa. Full notes on the report will be published when Dr. Kenning
has an opportunity to review the minutes.
Dr. A. H. Spohn, Chairman of the Committee on Public Health, reported the activities
of that Committee and outlined several objectives set out for this year's programme—sustained pressure for compulsory pasteurization, preventive measures directed against prenatal syphilis, and a study of health problems and solution of them.
A resolution presented by the Committee on Public Health which was a forceful argument in favor of pasteurization of milk, was endorsed by the Board of Directors and
instruction given that it be forwarded to the Ministers of the departments of Government
involved.
Dr. C. T. Hilton of Port Alberni, Chairman of the Committee on Maternal Welfare,
and Dr. Murray McC. Baird, Chairman of the Committee on Archives, discussed the proposed approach to the work of these two committees.
District No. 4 Medical Association Annual Meeting
The Annual Meeting of District No. 4 Medical Association was held in Kelowna, at
the Royal Anne Hotel, on October 3rd.
The afternoon session opened at 3:00 p.m. with the president, Dr. J. S. Henderson, in
the chair. There were three speakers: Dr. Murray McC. Baird, Dr. Roy Huggard and
Mr. Allen Mail. The members of the Association are very grateful to these men for the
excellence of their papers, and the time they sacrificed to come to the meeting.
At 6:30 p.m., cocktails were served in the lounge to the doctors and their wives and
guests. Dinner was served in the main dining room, following which a business meeting
was held with Dr. Henderson in the chair.
It was decided that the next meeting would be held in Kamloops and/ the following
officers were elected:
President—Dr. J. C. M. Willoughby.
B. C. Medical Association Representative—Dr. Willoughby.
Secretary—Dr. J. A. Ireland.
Reporter—Dr. J. A. Ireland.
Dr. Thomas then spoke on the appointment of a man from the district to serve on
the Committee on Economics, explaining the duties of this body. Dr. R. J. Wride of
Princeton was elected to represent this district.
Following this, Dr. Thomas gave a brief outline of the work that has been done by
the British Columbia Medical Association and by the College of Physicians and Surgeons
■during the past year, and of what they plan for the future.
Dr. Huggard then spoke on the two organizations—the Committee on Cancer of the
British Columbia Medical Association and the Canadian Society for the Control of Cancer,
and outlined the activities and hope for the future of each.
Following this the meeting adjourned.
Those present were: Dr. M. W. Thomas, Vancouver; Dr. Murray McC. Baird, Vancouver; Dr. Roy Huggard, Vancouver; Dr. and Mrs. Osborne Morris, Vernon; Dr. and
Mrs. A. L. Jones, Revelstoke; Dr. and Mrs. J. C. M. Willoughby, Kamloops; Dr. G. F.
Kincade, Tranquille; Dr. and Mrs. R. Haugen, Enderby; Dr. and Mrs. J. A. Shotton,
Armstrong; Dr. and Mrs. A. W. Vanderburgh, Summerland, Dr. F. P. McNamee, Kamloops; Dr. R. P. Borden, Penticton; Dr. and Mrs. L. F. Brogden, Penticton; Dr. P. S.
Page 69 Tennant, Kamloops; Dr. and Mrs. V. E. Latimer, Penticton; Dr. and Mrs. J. R. Parmley,
Penticton; Dr. N. McGregor, Penticton; Dr. and Mrs. R. J. Wride, Princeton; Dr. and
Mrs. N. J. Ball, Oliver; Dr. Roy P. Walker, Penticton; Dr. deB. F. Boyce, Kelowna; Dr.
and Mrs. W. J. Knox, Kelownaj Dr. and Mrs. A. S. Underhill, Kelowna; Dr. and Mrs.
L. A. C. Panton, Kelowna; Dr. and Mrs. G. A. Ootmar, Kelowna; Dr. and Mrs. J. S. Henderson, Kelowna; Dr. W. F. Anderson, Kelowna; and Dr. Reba E. Willits, Kelowna.
Reba E. Willits,
Retiring Secretary.
West Kootenay Medical Association Annual Meeting
The Annual Meeting of the West Kootenay Medical Association was held in Trail, on
October 5th, 1938, with a total attendance of twenty-seven doctors.
In the afternoon, papers were read by Dr. Roy Huggard of Vancouver on Cancer of
the Breast, and by Dr. Murray McC. Baird of Vancouver on Medical Emergencies, and
by Mr. Allan Mail, Entomologist of the Dominion Government, on Ticks, and the Diseases
Caused by Them.
Before the Annual Banquet the members were entertained at the home of Dr. M. R.
Basted.  The election of officers took place after the banquet and resulted as follows:
Honorary President—Dr. C. M. Kingston, Grand Forks.
President—Dr. R. B. Shaw, Nelson.
Vice-President—Dr. J. V. Murray, Creston.
Secretary-Treasurer—Dr. W. Laishley, Nelson.
Reporter—Dr. Stuart Daly, Trail.
Representative on Committee on Economics  of  the British Columbia
Medical Association—Dr. D. J. M. Crawford, Trail.
Representatives on Committee on Cancer of the British Columbia Medical
Association—Dr. F. M. Auld, Nelson and Dr. M. R. Basted, Trail.
W. Laishley,
Honorary Secretary-Treasurer.
The meeting was largely attended, those present being: Doctors M. R. Basted of Trail,
president; W. Laishley of Nelson, honorary secretary; J. Bain Thom, W. A. Coghlin, L. N.
Beckwith, J. Stuart Daly, W. J. Endicott, N. D. C. MacKinnon, D. J. M. Crawford, J.
W. Leonard, M. E. Krause, F. L. Wilson of Trail, E. E. Topliff, H. R. Christie, and
Leonard B. Wrinch of Rossland; F. M. Auld, H. H. MacKenzie, F. P. Sparks, W. K. Blair
of Nelson, J. Vernon Murray of Creston, N. E. Morrison of Salmo, V. B. Goresky of
Castlegar, F. O. R. Garner of Nelson; Doctors Baird and Huggard of Vancouver, and Dr.
M. W. Thomas, executive secretary.
East Kootenay Medical Association Annual Meeting
On October 7th the East Kootenay Medical Association had the pleasure of welcoming Doctors M. W. Thomas, Murray McC. Baird and Roy Huggard, who were on a lecture
tour of the Lower Mainland. The meeting was held in Cranbrook and the district was
represented by Doctors F. E. Coy of Inveremere, J. F. Haszard, D. W. Davies of Kim-
berley, G. E. L. MacKinnon, W. O. Green of Cranbrook, W. Workman of Coal Creek,
H. P. Asselstine of Ferrrie, G. C. Johnston of Michel and D. A. Campbell of Creston.
A luncheon was held in the Cranbrook Hotel, following which a business meeting
was conducted for the election of officers for the coming year. Dr. G. E. L. MacKinnon
of Cranbrook was elected president with Dr. W. O. Green, vice-president. It was decided
that Dr. J. F.. Haszard continue his position as honorary secretary of the Association. Dr.
F. E. Coy was elected representative on the Board of Directors of the British Columbia
Medical Association.
Following this meeting, lectures were given in the lecture room of the St. Eugene
Hospital Nurses' Home. Dr. Baird spoke on Medical Emergencies and Rheumatic Conditions. Dr. Huggard: Carcinoma of the Breast and The Treatment of Gall-Bladder
Disease. The lectures were most practical and instructive.
Page 70 The Association hopes that again they will have the opportunity of entertaining a
similar lecture tour in this district.
W. O. Green,6
Vtee-President.
UPPER VANCOUVER ISLAND DISTRICT MEDICAL
ASSOCIATION
The Annual Meeting of the Upper Vancouver Island District Medical Association,
held at Qualicum, November 10th, was well attended despite the cold weather.
A highlight of the evening was the presentation to Dr. W. A. Richardson of Campbell
River, by the District Association, of an engraved cigarette case as a memento of his fifty
years in practice in British Columbia. Dr. W. F. Drysdale of Nanaimo officiated. This
event is reported in full elsewhere.
Dr. A. H. Meneely, the retiring President, was Chairman, and passed over the Chair to
the new President, Dr. P. L. Straith.
Election of officers.for the ensuing year resulted as follows:
Dr. P. L. Straith, President; Dr. Campbell Davidson, Vice-President; Dr. T. A. Briggs,
Hon. Secretary-Treasurer; Dr. S. L. Williams, Representative to Committee on Cancer;
Dr. D. P. Hanington, Representative on Board of Directors; Dr. C. T. Hilton, remaining
on Board of Directors as Chairman, Committee on Maternal Welfare; Dr. H. A. L. Mooney,
Reporter.
Dr. J. A. Leroux gave a short report on the work of the Division of Venereal Disease
Control on the Upper Island.
The speakers of the evening were Dr. J. R. Naden and Dr. Roy Huggard, both of
Vancouver. Dr. Naden spoke on "Epiphyseal Separation in the Upper Extremity, Its
Recognition and Treatment." A concise paper, well rendered and illustrated with slides,
it gave a clear picture of what might be expected as to functional result. In conclusion,
Dr. Naden spoke reassuringly to the general practitioner on the results obtainable, stressed
the necessity for clinical as well as radiological examination, and said that comparative films
of the good arm should always be taken when in doubt.
Dr. Huggard gave a well condensed paper on "The Diagnosis and Treatment of Breast
Carcinoma, which was received with great interest. Following a short discussion of the
anatomy and the lymphatic drainage of the breast area, he outlined "a regime of treatment
applicable to all breast tumours.
Dr. M. W. Thomas then spoke briefly about the Old-timers in the profession in this
Province, and appealed for greater solidarity of the Profession as a whole.
The meeting then adjourned.
H. A. L. Mooney, Reporter.
PRESENTATION TO DOCTOR W. A. RICHARDSON
As a mark of recognition from the Upper Vancouver Island Medical Association, Dr.
W. A. Richardson of Campbell River was presented with a suitably engraved cigarette
case on the occasion of his fiftieth year in practice in British Columbia.
The presentation was made by Dr. W. F. Drysdale of Nanaimo.
Dr. Richardson registered in British Columbia in 1888, fofllowing his graduation in
1886 from Toronto. He was the first Medical Superintendent of the Royal Jubilee Hospital
in Victoria, and also served as Pathologist at that Institution for seven years.
In 1897 he went to the Klondyke and served as Medical Officer during the railroad
construction days. Overseas in 1914, and a post-war practice at Fort Norman until 1923,
when he moved to Campbell River, where he has since practised with an experience in work
and usefulness seldom equalled by anyone.
Still remarkably active and healthy, Dr. Richardson deserves richly the best wishes of
the Association for many more years of active life and practice.
Page 71 CANCER ORGANIZATION and ACTIVITIES
Dr. A. Y. McNair.
On October 31st and November 1st I had the pleasure and privilege of attending, in
Toronto, as your representative, two important meetings on cancer activities. The first,
the Department of Cancer Control of the Canadian Medical Association, composed of an
executive committee and the chairmen of the nine provincial Cancer Study Committees;
the second, the meeting of Grand Council of the Canadian Society for the Control of
•Cancer. I was accompanied by Mr. Duncan Bell-Irving, who is the lay Grand Councillor
for British Columbia. Both these meetings were the first full meetings held snice organization in 1937. It was very stimulating to anyone interested in the problem, to listen to,
and take part in, the discussion of the various activities of the Department of Cancer
Control from a national point of view. I must say that the cancer problem has become
a very important and difficult one to attack and, while a great deal of ground work has
been already done, we are only just starting at the task.
Historical Background.
For those members who do not know the history of the development of the Department of Cancer Control and its activities, I will outline them briefly.
In 1937 the Cancer Study Committee of the Canadian Medical Association drew up a
plan of cancer organization for Canada and submitted it to the Board of Directors of the
Bessborough Fund or King George V Silver Jubilee Cancer Fund for Canada. This plan
was approved by them and they asked the Canadian Medical Association to do two things.
In return for this, or to make it possible, the sum of $14,000 a year for at least two years
was given to the Association to be used in cancer organization. The two things were two
big jobs—one, the organization.of a Department of Cancer Control, whose work is largely
the education of the doctor in many phases of the cancer problem by organizing hospital
cancer study groups, lectures, addresses, clinics and post-graduate studies, etc.; the second,
the initiation and organization of a lay-medical group, the Canadian Society for Control
of Cancer, whose activities are largely the dissemination of knowledge, among the laity,
of the early signs and symptoms of cancer, in a special effort to get cancer cases for treatment or diagnosis at a much earlier period; secondly, to gather funds for cancer research,
and thirdly, to correlate cancer activities so that the attack on cancer would be much
more effectual. Both of these organizations have been set up and have held their first full
meeting of their members.
While cancer organization is absolutely essential and the policy laid down must be
followed, it is most important that your provincial committee and its chairman have the
sympathy and support of the doctors of the province. Your help and co-operation has
been much appreciated in the past. I ask it for my successor, Dr. Roy Huggard, who is
the present chairman of your provincial cancer study committee. On him has fallen the
arduous task of carrying out the plan of attack of the Department of Cancer Control.
Many of us will be approached and asked to serve on various committees. I hope that we
will all make a sincere endeavor to give of our time and/ effort, even in a small measure,
so that the sum total may add up to a very splendid showing as our conrtibution to the
control of this disease.
Hospital Study Groups in Hospitals of 100 Beds and Over.
1. As a means of getting accurate information on cancer case records, the Department
of Cancer Control has deemed it advisable to organize, in each hospital of 100 beds and
over, Cancer Study Groups, which will undertake the supervision of these records as to
completeness, and to analyze these for the purpose of tabulation of statistics. To give
short talks at staff meetings on early signs and symptoms of cancer in various parts of
the body.
2. To compile the various facts and report them at definite stated intervals on special
summary forms which will be supplied by the Department of Canacer Control, the forms
to be analyzed by a statistical department and the results published, if deemed advisable
by the Board of Directors. The responsibility for initiating, organizing and putting this
work into operation is placed on the chaiman of the provincial committees. The success
of this work will be far-reaching. It will be of great value to the local groups as a teaching
Page 72 medium and to the national body as a statistical basis fori study.  The help of your committee will be very gladly given in this effort and it is hoped we can all co-operate.
Medical Publicity.
The department has distributed a very large number of volumes on the handbook on
cancer to the medical profession of Canada. This has been a difficult task. The Authorship
Committee, under the chairmanship of Dr. Roscoe Graham, are to be congratulated, and
our thanks are due to those who gave so liberally of their time and effort which made the
completed work possible. It is hoped that that committee will continue its work in the
preparation of skeleton or complete addresses, suitable for lay audiences, so that this information will be correct and of an authoritative nature. This is so important in our
support to the Canadian Society for Control of Cancer, who draw their speakers from the
medical profession, many of whom have not the time or material available for preparation
of such addresses. In this regard, we have already set up a Speakers' Bureau in British
Columbia.
It is hoped that before long, at many of our medical association meetings, Dominion,
provincial or district, that "Cancer" will find a place on the programmes.
Cancer Forms.
Your committee decided that after a long study of the problem of forms for recording
cancer cases, the idea was not practicable. They felt that, for the time being at least, no
national form can be adopted. The only form adopted will be the "summary" form to
be used by the hospital study groups to summarize the information on the case records.
Perhaps at a later date it may be possible to adopt a form to be used throughout the
province as a purely provincial record form. This is under consideration at the present
time. *       *       *       *
The report of Dr. McNair of the meeting of the Canadian Society for the Control of
Cancer has been received by the Editor and will be published in next month's issue.
BRITISH COLUMBIA MEDICAL ASSOCIATION
Lecture Team Visits Annual Meetings
Doctors Murray McC. Baird and Roy Huggard
The lecture team arranged by Dr. G. F. Strong, chairman of the Committee on Programme of the British Columbia Medical Association moved out of Vancouver on September 30th. Dr. Thomas, with whom they travelled, wished to avoid any possible delay
in securing an early start on October 1st.
So, by arrangement with Dr. Robert McCaffrey of Chilliwack, who is president of
the Chilliwack Medical Society and a maestro at dinners, Doctors Murray McC. Baird,
internist, and Roy Huggard, surgeon, presented two papers to the profession at that centre:
Treatment of Medical Emergencies and Carcinoma of the Breast, respectively. The team
was off to a good start, as evidenced by Dr. McCaffrey's letter of thanks and appreciation to Dr. Cleveland, president of the Association. There were questions and a discussion
which Dr. J. D. Moore, the vice-president, rounded off by proposing thanks to the team.
The next day was October the first and Roy Huggard picked apples at Choate Lodge,
where luncheon broke their fast. This proved to be the commencement of Dr. Thomas'
troubles in providing meals to two doctors who were not on a diet.
Lytton was the next stop, and here Dr. Jack Ellis had rounded up the whole countryside to hear Dr. Roy Huggard expatiate on the necessity of the populace becoming
cancer-conscious and doing something about it. Dr. Huggard had just accepted the
chairmanship of the Committee on Cancer of the British Columbia Medical Association
and with considerable cogency impressed the need of action. Lay citizens were greatly
impressed by his invitation to join with organized Medicine in a frontal attack on cancer
as a common enemy.
Dr. E. J. Lyon of Prince George, who was accompanied by his wife, attended the
meeting and was inspired to develop, as Dr. Ellis has done, a unit in the British Columbia
Branch of the Canadian Society for the Control of Cancer. To meet Dr. and Mrs. Lyon
at Lytton was very fortuitous.
On October 2nd, being Sunday, the party moved off through Ashcroft to find Dr.
Drummond busy with Dr. Lynch on C.P.R. business. We had bid farewell to Dr. Lyon.
He had gone but, no! Eddie had changed his mind, or rather his wife's, and he was going
to Kelowna to see Dr. Knox and Dr. Panton, who was a classmate in 1904 at Toronto.
(Toronto again) Roy Huggard comes from Toronto. Baird came from Scotland. However, Dr. Eddie Lyon took Dr.   (Mc) Huggard in his car and hastened by the dusty
Page 7>
— short-cut to Vernon and on to Kelowna. Doctors (Mc) Baird and (Mc) Thomas (Doctors
Huggard and Thomas had lost their Irish and Welsh character and had fallen under the
influence of the Scot) had Dr. (Mc)Huggard's toothbrush with them. They took the
other route via Chase and Salmon Arm, Enderby and Armstrong—no dust and all the
beauty of that road.
At Chase they stopped to visit Dr. and Mrs. Scatchard and, as anticipated, Dr. Baird,
too, was captured by the charm of England at Chase and a visit with a doctor who had
received a degree in 1882 at the Rotunda, and to meet Mrs. Scatchard. It is only a year
since these dear people celebrated their fifty years of marriage. Enough for now. If you
have never visited the Scatchards at Chase, you should.
Kelowna was reached late that night and Dr. Huggard was sitting up sleepily and
impatiently awaiting the arrival of his sleeping suit. Doctors Eddie Lyon and Leonard
Panton were talking about Toronto.
The next day, October 3rd, saw the arrival of doctors and wives from Revelstoke,
Princeton, Oliver, Summerland, Vernon, Armstrong, Enderby, Kamloops, and the Annual Meeting of the No. 4 District Medical Association began. It is not important that
the entertainment began at the canning plant and led the party on to the "Calona" Winery.
The samples were good and one can get a real kick out of Kelowna. (Inserted without
prejudice to the Liquor Control Board). There was much visiting and fraternizing at
luncheon at the Royal Anne Hotel, which housed the visitors and the meeting. The
arrangements were planned by Dr. and Mrs. J. S. Henderson and Dr. Reba E. Willits, the
secretary. The whole party prepared for the dinner in the lounge and repaired to the
banquet hall, where covers were laid for fifty-seven. The ladies attended the dinner and
thus a group of twenty-eight doctors produced a large gathering. A charming feature of
the dinner was the delightful address of Dr. G. A. Ootmar, who came to the district about
twenty years ago, as he thanked the doctors for the kindly reception accorded Mrs. Ootmar
and himself on their arrival from Europe and during these many years.
Dr. Huggard left that night for Penticton in company with Doctors McGregor and
Borden. He was able to help with an operation on Tuesday morning and when Doctors
JBaird and Thomas arrived he addressed a largely attended public luncheon and assisted
the local doctors in the organization of Penticton Unit of the Canadian Society for the
Control of Cancer.
Luncheon over and a puncture repaired, the party of three filled up with gas and set
out for Grand Forks via Oliver, Rock Creek and Greenwood.  At Grand Forks, which
was much interested in mining and a dinner to the Honourable Mr. Asselstine, Minister
of Mines, Dr. Windsor Truax and Dr. C. M. Kingston visited the party in the Annex
(with the red door) of the hotel.
Safely out of Grand Forks on the morning of the 5 th of October, the heavy rains
made the Washington roads more passable, so the approach to Rossland and Trail was
made by the American route. The Annual Meeting of the West Kootenay Medical Association and Doctors Basted and Laishley awaited the arrival of the party.
On October 6th the party reached Nelson via Castlegar in time for a large lay-medical
luncheon arranged by the doctors in support of their cancer membership effort. Doctors
Huggard, Baird and Thomas were through in time for the ferry to reach Creston for
dinner with Doctors Vernon Murray and D. A. Campbell, and then on to the church,
where Dr. Huggard addressed a large lay audience, and then on to Cranbrook by midnight.
Dr. Thomas had some trouble at this point in that the two lecturers were tired. However, he gave ear to their protests. As they had two papers each to present at the Annual
Meeting of the East Kootenay Medical Association on the following day, October 7th,
they were allowed to sleep in, while Dr. Thomas met the early train and Dr. J. Bain Thorn,
the member of the Council for that district. Together they drove to Kimberley to visit
T)r. D. W. Davis and Dr. J. F. Haszard. Dr. Huckvale was away on vacation.
The same happy atmosphere which welcomed the team at Chilliwack, Kelowna and
Trail was found at Cranbrook. There was frost in the air but there were warm hearts to
meet and greet the visitors. (Continued on page 80)
Page 74 Victoria Medical  Society
Officers, 1938-39.
President , Dr. P. A. C. Cousland
Vice-President Dr. W. Allan Fraser
Hon. Secretary—. Dr. W. H. Moore
Hon. Treasurer Dr. C. A. Watson
On November 7th, His Honor Lieutenant-Governor E. W. Hamber officiated at
the opening the new X-Ray Department of St. Joseph's Hospital, Victoria.
St. Joseph's Hospital has recently replaced its x-ray equipment with new x-ray apparatus, the major part of which was made in Canada by the Ferranti Electric Company of
Toronto. This new apparatus includes a 400,000-volt x-ray therapy equipment and is
the fifth supravoltage installation in Canada. There is also a three-phase transformer for
diagnostic work which is the first of its kind in Canada.
The equipment includes numerous modern improvements, making the department
one of the most thoroughly equipped in Canada.
CLINICAL CONFERENCE
A Clinical Conference was held at the Royal Jubilee Hospital on Friday, November
4th, 1938, at 12 noon, under the chairmanship of Dr. H. H. Murphy.
Dr. R. Scott-Moncrieff was introduced to the meeting and presented a paper on
The Oesophagus.
On opening the subject, Dr. Scott-Moncrieff stated that the time being brief he could
only hit the high spots of his address on the oesophagus.
"Since the cesophagoscope plays such an essential part in the diagnosis and treatment
of the vast majority of diseases of the oesophagus, I am going to begin by reading the
opening paragraphs on the section of cesophagoscopy in Recent Advances in Laryngology
and Ootology, Stevenson, 1935. It is typical of the opening paragraphs of all such works."
ff fOesophagoscopy: As in the case of bronchoscopy, cesophagoscopy has today advanced
far beyond the mere passage of an cesophagoscope to remove an impacted foreign body,
though not all hospitals have yet attained the range of Chevalier Jackson's clinic, where
every patient complaining of persistent abnormal sensation or disturbance of function of
the oesophagus has an cesophagoscope passed as a routine, and not all physicians and general
practitioners have yet realized that cesophagoscopy can be a painless proceduare, safe in
the hands of an expert and capable of yielding valuable information in many obscure cases.
Dysphagia may be due not only to a foreign body in the pharynx, oesophagus, larynx, or
trachea, but also to benign or malignant neoplasm or abcess in these regions; to spasmodic,
cicatrical or other strictures; to tuberculosis, syphilis, or diphetheria; to oesophagitis, ulceration or erosion; to varicosity or diverticulum of the oesophagus, or aneurysm, to aero-
phagia or hysteria, or to other minor causes. In the past the diagnosis of hysteria has in
many cases prevented the recognition of serious disease of the oesophagus in its early stages,
and organic disease cannot-be excluded without cesophagoscopy—nearly every patient
with post-cricoid carcinoma has had symptoms of swallowing neurosis dating back many
years and has been called a case of globus hystericus. As the function of deglutination can
best be studied by observing the swallowing of a barium or other opaque mixture with
the fluoroscope, Chevalier Jackson advises that cesophagoscopy for general physical examination (including the mouth, pharynx and larynx) and the Wasserman test should be
further routine preliminaries.
" 'Mosher has recently made an important statement about the alleged dangers of cesophagoscopy. For years he has maintained that every examination of the oesophagus, even
the simple passage of a bougie, is a possible tragedy, and he has had a few tragedies with
both procedures.   He states that the general impression among the medical staff of his
Page 75 hospital is that cesophagoscopy is too dangerous a procedure, and they do not feel safe in
referring cases for oesophageal examination. Those of them, however, who are doing oesophageal work have known all along that the percentage of tragedies is low. During the
past twelve years there have been 938 oesophageal examinations with the cesophagoscope.
There were nineteen mortalities associated with this examination, and probably due to it.
This makes a mortality rate of a little over 1.50 per cent. The cases of stricture of the
oesophagus numbered 294, with six mortalities reported in this group. Webs of the oesophagus numbered 79, with one mortality; carcinoma of the oesophagus numbered 247,
with nine mortalities; foreign bodies of the oesophagus including all kinds, simple and the
most difficult, numbered 285, with two mortalities; cases of cardiospasm numbered 33,
with one mortality.
'Oesophagoscops is contraindicated (except for urgent reasons, such as an impacted
foreign body) in the presence of aneurysm, advanced organic disease, extensive varicosities
of the oesophagus, and in acute necrotic oesophagitis and acute oesophagitis with sloughing
from swallowing caustics—in the last it should be deferred until the healing process is
well advanced.'
"Because the hypopharynx is the funnel-shaped entrance to the oesophagus proper, it
should be briefly dealt with first. Anteriorly the hypopharynx is bounded by the posterior
wall of the larynx, in the upper part of which lie the arytenoids. Thus many conditions
which are primarily laryngeal spread posteriorly to the hypopharynx. The two which immediately spring to mind are tuberculosis and malignant growths.
"From the diagnostic point of view the following conditions of the hypopharynx
must be considered.  They are the same as in the case of the oesophagus:
1. Dilation.
2. Diverticulum.
3. Stenosis — congenital, spasmodic,
inflammatory (acute and cronic),
cicatricial or stenosis from compression.
4. Abscess.
5. Tuberculosis.
6. Syphilis.
7. 'Non-specific' inflammation.
8. Ulceration or erosion.
9. Neoplasm—benign or malignant.
10. Paralysis—functional or organic.
11. Foreign body, etc., etc.
"The symptoms, except in severe traumatic or acute conditions, are in the early stages
of hypopharyngeal disease generally slight, vague and poorly localized sensations, either
spontaneous or on swallowing, and it is due to this very fact of the patient's inability accurately to place and describe his symptoms that the diagnosis of globus hystericus is so
often forced upon him. This symptom, when it occurs in hysterical patients, is due to
spasmodic contraction of the inferior constructor muscle in part or whole. But, as
Chevalier Jackson so well puts it, globus hystericus is more often cancerous than hysterical.
"In the later stages of most diseases of this region the symptoms are mainly referable
to the act of swallowing, there being either pain or difficulty in swallowing, or both. There
may also be spontaneous pain, either local or, as is often the case, referred to the ear. There
may often be local tenderness, but this generally located in the regional lymph glands.
"While on the subject of referred otalgia, I should like to remind you of that well-
known saying to the effect that, in an apparently healthy male, with a hoarse voice and
a wad of absorbent cotton in one ear an immediate diagnosis of carcinoma of the larynx
is very often correct.
"Inflammation, ulceration, erosion and stricture of the hypopharynx are usually
secondary to trauma, such as foreign body, instrumentation -or the swallowing of some
caustic substance such as lye or acid.
"Traumatic perforation as from the blind passage of a bougie is generally followed by
cervical emphysema and cellulitis, which very apt to spread downwards to the mediastinum
and a fatal ending.
"Abscess is usually the result of a retropharyngeal abscess, which has worked down
from above. Its chief causes are adenoid or tonsillar infection, disease of one or more
vertebrae (as for instance in cervical Pott's disease), suppurative adenitis, foreign body
or perforation.
"In children the finger will give the diagnosis, but it should be remembered that this
procedure is not without risk, especially in the very young.
Page 76 "Paralysis of the hypopharynx is paralysis of the interior constrictor in part or whole.
The patient being unable to swallow will rapidly die of thirst if not fed by artificial means.
Gravity has almost no effect on the descent of either liquids or solids from mouth to
stomach.
"Diverticulum of the hypopharynx affects the oesophagus more than the hypopharynx
and so will be mentioned later in this connection.
"Inferential methods of diagnosing hypopharyngeal disease cannot be relied upon. It
is upon objective methods that diagnosis should depend.   These are:
1. Palpatation of the lower part of the neck, particularly deep under the sternomas-
toids.
2. X-ray, first without and then with an opaque mixture.
3. Direct inspection. The mirror will.seldom suffice, and for absolute certainty the
area must be examined by direct inspection through a laryngoscope or oesophageal
spatula.
4. A biopsy, when necessary, can be taken with great ease and certainty when done
thus under direct vision.
"As regard the oesophagus proper, a few anatomical and physiological facts should be
mentioned.
"The oesophagus, like the gut, has two muscular coats, an outer longitudinal and an
inner circular. The latter is a continuation downwards of the inferior constrictor, while
the longitudinal fibres are attached to the back of the cricoid cartilage, which lies wholly
in front of the oesophagus. The muscle spreads down and round the sides of this organ
from its attachment. In reaching the posterior oesophageal wall a V-shaped space, about
one inch long, is left at its upper and posterior extremity where the circular fibres lack
the support of the longitudinal. This the weak spot of the oesophagus where herniation
may take place in the formation of a diverticulum. Between the muscle layers lie the
plexuses of Meisner and Auerbach, the latter supplying vagal control.
"Within the muscular tunnel is the glandular layer with its covering of pavement
epithelium.
"The total thickness of the wall measures no more than 3-4 mm. This must be kept
constantly in mind by anyone who passes an cesophagoscope, and as bacteria are always
present, surgical procedures are associated with the risk of infection.
'The anterior wall of the oesophagus is, in part of its length, shared with the trachea.
It is in this party wall that are situated the lymphatics draining the posterior portion of the
larynx, and it is largely by this route that posteriorly situated malignancies of the larynx
early spread to the mediastinum.
"The average length of the oesophagus at different age periods is shown in the table
(B. and E., p. 68). These are not hard and fast measurements, they are averages. It is
not uncommon to find in a long-trunked adult that the cardia is 45 cms. or more from
the incisors. In one patient with whom I had dealings the 60 cm. cesophagoscope was
necessary to look beyond the hiatus.
"Note the anatomical constrictions. Four can be demonstrated with the cesophagoscope. A fifth is often demonstrated by foreign bodies but not easily by cesophagoscopy.
This is the point at which occurs the narrowing at the upper opening of the thorax, and
seems to be due to the crowding into a narrow, circumscribed space of the many organs,
which here enter and leave the thoracic cage. It is, however, a fact that foreign bodies
will stick here more often than anywhere else in the oesophagus.
"The cricopharyngeal pinch-cock, as Jackson terms it, is produced by the tonic contraction of the orbicular band of fibres at the lower end of the inferior constrctor. In the
normal oesophagus it is at this point that the greatest difficulty is experienced in passing an
cesophagoscope from pharynx to stomach. In health it relaxes only on the approach of a
bolus of food—its momentary relaxation being timed to coincide with the contraction of
the inferior constrictor above. Saliva in small amounts will pass this point, but a slight
excess necessitates the act of deglutition.
"The cricopharyngeus is attached to the flat posterior surface of the cricoid cartilage
and closes the mouth of the oesophagus with an extraordinary powerful forward pull. Between the horizontal fibres of the cricopharyngeus and the more or less diagonal fibres of
Page 77 the inferior constrictor, is a weak triangular area on each side. This is the site at which
herniation occurs to form a hypopharyngeal pouche.
"Near the distal end of the oesophagus is the 'hiatal pinch-cock'. Here again the lumen
is kept closed by the constricting action of a muscle outside the oesophagus—in this case
the crura of the diaphragm. The function here, of course, is to allow food to pass downwards and to prevent regurgitation of gastric contents.
"There is no constriction at the cardia.  This is an important point.
"Congenital anomalies may exist in various forms. The oesophagus may be double. It
may open into the trachea, its lower part being absent. There may be a fistula between
the oesophagus and the trachea and annular strictures have been found. Congenital diverticula have never been reported.
"The term 'cardiospasm' is a relic of the days before the oesophagus was examined by
sight. Jackson and the Philadelphia groups have long maintained that the site of cardiospasm is at the hiatus and not the cardia—and further, that it is caused not by spasm of
the diaphragmatic pinch-cock so much as lack of co-ordination whereby the approach of
a bolus of food fails to produce its normal effect of opening at the right momeint the
door to the stomach.
"Mosher of Boston lays particular stress upon the more or less tunnel of liver through
which the abdominal oesophagus passes, so that hepatic abnormality in this area greatly influences the passage of food. He also maintains that a web or stricture at the level of the
liver tunnel is a frequent cause of cardiospasm, especially when associated with an exaggeration of the bend or twist of the lower end of the oesophagus, a condition which to some
extent is present in the normal.
"Recent, Hurst, Brown, Kelly and others have found in post mortem examinations
of a number of cases of cardiospasm inflammatory and degenerative changes in the ganglia
of Auerback's plexus, whose function is to contract the oesophageal musculature and relax
the hiatal pinch-cock. This lesion then explains the neuro-muscular incoordination whose
presence was deduced by Jackson from oesophagoscopic observation.
"The symptoms all result from the inability of food to pass out of the lower end of
the oesophagus. There is a feeling of fullness of the organ and perhaps of pressure behind
the lower end of the sternum. If the condition is mild, the symptoms will pass off as the
food gradually enters the stomach. This may be aided by the taking of a warm drink. A
cold one will tend to have the opposite effect. As the closure of the hiatus progresses, the
diet becomes more and more restricted, and more and more liquid. Vomiting of retained
food now occurs with increasing frequency and there is increasing loss of weight. A sudden blockage of the lumen may at any time precipitate a surgical emergency. The onset
is generally after 3 5 years of age, and the symptoms have generally been slowly progressing
for years when the patient seeks medical advice. I had to do with a patient who had been
unable to swallow anything more than softs for over 20 years.
"As regards treatment, there are two main types. One is some form of gradual dilation.
Many techniques have been devised and in general the results are good. The other methods
are surgical. An anastomsis with the stomach may be necessary, in cases where there is
firm fibrotic closure. G. C. Knight, among others, has obtained good results in cases where
there is no hypertrophic stenosis, firm adhesions, by doing a left gastric sympathectomy.
The idea of this is to control the autonomic imbalance, and therefore incoordination,
which was mentioned above.
"The patient whom I mentioned, as having had symptoms for over 20 years, was
operated upon thus. The operation was entirely and dramatically successful, but the
patient died.
"Diverticulum. There are two types. The first and commoner is due to a herniation
of the mucous membrane through the lower part of the inferior constrictor or through
the weak triangular space where, at the upper end of oesophagus, the longitudinal fibres
leave the circular fibres unsupported. These so-called pulsion diverticula generally lie
on the postero-lateral wall of the oesophagus—most often on the left.
"Many cases have been specified, but none proved. However, it would seem likely that
at least in some cases the anatomical weak areas are caused to bulge outwards due to the
abnormal pressure effects of late or inadequate opening of the cricopharyngeus.
Page 78 "The chief symptom is obstruction to the passage of food through the oesophagus—
the degree of this being dependent upon the size of the full sac which compresses the oesophagus. If the pouch is large, food tends to enter this more readily than the oesophagus,
and the patient lives on the overflow from the diverticulum. When he takes food he is
never sure of retaining it. Lying down to sleep may be impossible because overflow from
the pouch is apt to enter the larynx and cause sever spasms of choking and coughing.
"In making an examination with any instrument it must be remembered that the
walls of a diverticulum are no thicker or stronger than the single layer of mucous membrane of which they are formed. Even in quite small sacs, it may be difficult to find by
direct vision through an cesophagoscope the noimal passageway of the gullet, so that the
blind passage of a bougie is nothing short of recklessness.
"Diagnosis by means of fluoroscopy and x-ray with a barium drink can be quqite exact.
The larynx should be included in the x-rays so as to place the diverticulum.
"As regards treatment, dilatation through the cesophagoscope has been used with a fair
measure of success. For every large diverticula, various operations have been devised for
obliteration of the sac. Obliteration has been accomplished endoscopic ally, but the operation of choice is generally the two-stage external one. The sac is first mobilized through
an external incision and fixed with the mouth down. If deemed necessary the sac is later
removed in a manner which is roughly similar to that used for the removal of the appendix.
"The second type is called the traction diverticulum. It occurs almost always at the
bifurcation of the trachea. Turner has shown from post mortem records that practically
all of these are of tuberculous origin. Their formation is due to an adjacent tuberculous
gland, which suppurated and then healed. The resultant contraction of scar tissue attached
to the oesophagus pulled out a part of the wall to form a pouch. These seldom cause
symptoms and do not enlarge to the extent of the first type, which may extend to below
the clavicle.
"Carcinoma, At the present time the oesophagus is an unusually fatal site for the development of a cancer. This is so for two reasons. Firstly, the condition is seldom even
suspected, far less recognized, as such until the growth is far advanced. Secondly, the
relations and general situation of the oesophagus throughout the greater part of its length
makes for great difficulty in the treatment of this condition. It should, however, be
stressed that until the tumour has reached quite an advanced! stage, it remains localized,
tending to spread along the submucosal lymphatics rather than to metastasize. This does
not occur until the muscular coats of the organ have been broken through.
"Oesophageal malignancies are nearly always squamous cell carcinoma. Occasionally,
adeno-carcinoma is found at its lower end.  Other malignant growths are rare.
"The region of the crossing of the left bronchus is the favorite site, the post-cricoid
area being next in frequency in general, though the commonest site for this condition is
in women.
"The symptoms cannot be anything but vague to begin with. There is very often a
history of many months and sometimes a couple of years. Prior to actual obstruction of
the oesophagus the symptoms range from an indefinite feeling of abnormality behind the
sternum to actual dysphagia, the result of oesophageal irritation and spasm at one or both
of the pinch-cocks.
"There is a gradual increase in the severity of the symptoms with eventual slow starvation, except in the event of mechanical sudden obstruction.
"In treating the condition, the overcoming of this state of starvation is of prime importance, no matter what other form of treatment is used. Even with no treatment, other
than keeping up the nutrition, there are cases on record of patients who lived for as long
as two years, after establishment of the diagnosis. Malnutrition must be considered a
serious complication. It is treated generally by the making of a gastrostomy or by the
insertion, in the oesophagus at the site of the growth, of some sort of tube for maintaining
the necessary lumen. Repeated dilatation of the region of the growth has been abandoned
as being both dangerous and not very satisfactory.
"As regards eradication of the tumour, the multiplicity of methods speaks for their
general lack of success.
Page 79 "Radium or deep x-ray therapy has given many good palliative results, and a few cures
have been reported.
"Due to the technical difficulties involved, as well as to the advanced state of nearly
all growths when diagnosed, surgery has not been a success to date. However, a few cures
have been reported as resulting from resection in the early stages.
"I may say there is a good summary of this condition in the Handbook on Cancer,
which has recently been issued by the Canadian Medical Association—it ends with this
statmeent: 'When there is difficulty in swallowing, try an cesophagoscope and barium with
x-ray .
Pictures were shown on the screen at different intervals during the address:
1st—Diagram of oesophagus from incisor teeth to cardia. Four constrictions were
demonstrated as with the cesophagoscope at the aorta, left bronchus, hiatus and cardia.
2nd—Diagram showed the danger of passing a bougie blindly into the oesophagus.
3rd—Sixteen normal and abnormal views of the oesophagus as seen through the cesophagoscope.
4th—Illustrated peptic ulcers at lower end of oesophagus.
5 th—Showed lye burns—acute stage, healed scar, lumen blocked by scar, etc.
6th—Showed malignant growths of different forms of the oesophagus.
Diagrams were drawn on the blackboard demonstrating the weak spots in the oesophagus.
Mr. Murphy thanked Dr. Scott-Moncrieff for his very interesting presentation of the
subject of the oesophagus.
Dr. Murphy then showed a number of films demonstrating lesions of the oesophagus
that Dr. Scott-Moncrieff had spoken of. These films were taken from cases that had
recently passed through the Radiographic Department.
B. C. MEDICAL ASSOCIATION LECTURE TEAMS
(Continued from page 74)
All happiness has some sorrow and so it was that Dr. (Mc) Baird was put on the early
train en route to Rochester and Doctors (Mc) Huggard and (Mc) Thomas lost a good
driver and a really merry travelling companion. It was a case of home via Creston, Gray's
Creek to Fraser's Landing to Kaslo and along the road to New Denver and on to Nakusp
that night.
The next morning to Fauquiers and by ferry to Needles and over the Monashee to
Vernon. Sunday evening was spent by the fireside of Dr. and Mrs. Osborne Morris and
two tired trippers enjoyed the comforts of home that night. A cheery send-off saw them
safely on their way to Revelstoke, where a Thanksgiving dinner awaited them at the
home of Dr. and Mrs. Llewelyn Jones. After dinner all went to the Hospital where the
citizenry had met in spite of a deluge of rain and Thanksgiving Day. A large meeting
heard Dr. Huggard's address on cancer and the unit at that point was formed.
The next morning saw Doctors Huggard and Thomas on the way to Sicamous and
Salmon Arm, where Doctors Beech and Harry Baker were seen, and then on to Kamloops
and on and on towards Vancouver without hitting but one rock in a> pluvial slide near
Boston Bar.
The lecture team had done well and left warm friends and open doors and hearts all
along the route. Doctors Baird and Huggard made a splendid contribution and deserve
the thanks of us all.
Penticton Unit No. 31 of the Canadian Society for the Control of Cancer is now well
organized and an active drive for membership is under way. All organizations are cooperating fully.
Page 80 Preventive  Medi
cine
Secti
SYPHILIS IN PREGNANCY
I.   A Pregnant Syphilitic Woman has a 16 per cent Chance of a Healthy Living Baby.
The Birth of Syphilitic Babies is Preventable.
The Public Health responsibility for eradication of Prenatal Syphilis lies largely on
the shoulders of the physician.
II.   The Diagnosis of Syphilis in Pregnancy can be made only by Routine* Serodiagnostic
Tests because:
1. Few pregnant syphilitic women have lesions. Pregnancy has an ameliorative
influence on the infection, reducing the clinical evidences of it.
2. Syphilis run a milder course in women than in men. It is difficult, therefore*
to get a history of primary or secondary manifestations.
3. A routine blood Kahn should be taken early in every pregnancy, preferably
before the fifth month. (Although the existing facilities of the Division of
Laboratories, Provincial Board of Health, are greatly overtaxed, Dr. Dolman
recognizing the importance of use of the routine Kahn in pregnancy has permitted the Division of V. D. Control to recommend this procedure routinely
throughout the province.)
III. The Treatment of Syphilis in Pregnancy:
1. It must be instituted early, preferably before the fifth month.
2. It must be continuous throughout, at weekly intervals.
3. The pregnant woman tolerates arsentcals and heavy metal well and may be
given full doses for her weight.
4. A woman who has had syphilis, even though apparently cured, must have
treatment throughout every subsequqent pregnancy to avoid the possibility
of birth of syphilitic baby.
5. Therapeutic abortion is not indicated. Pregnancy has a beneficial effect on
the mother's infection. Adequate treatment gives the baby a reasonable
chance of being healthy and non-syphilitic.
6. Outline of Prenatal Treatment:
(a) Third and Fourth months—Ten neoarsphenamine, eight bismuth, ten
neoarsphenamine.
(b) Fifth and Sixth months—Eight neoarsphenamine, eight bismuth, eight
neoarsphemine.
(c) Seventh to Nine months—Concurrent treatment with neoarsphenamine
and bismuth, that is one injection of each weekly.
7. Outline of Postnatal Management:
(a) Mother—continue treatment as for non-pregnant women.
(b) Baby—no treatment till diagnosis made.
(i) Take cord blood—if positive it may mean syphilitic infection of
the baby or passive transfer of anti-bodies from mother's blood to
baby's without syphilitic infection of the latter.
(ii) Repeat blood Kahn at two weeks and thereafter monthly for six
months and every six months for two years. If the Kahn remains
negative throughout or if the cord blood is positive at birth but
becomes negative by the third month and remains so, the baby may
be considered non-syphilitic.
(iii)  X-ray the infant's long bones at two weeks.
(iv) If blood Kahn is persistently positive after the third month, or
x-ray reveals evidence of syphilitic epiphysitis, or ciinical evidence
of syphilis ensues, start routine treatment for prenatal syphilis.
IV. The Birth of Syphilitic Babies can be Prevented by:
1. Premarital examination for syphilis.
2. Routine blood kahn taken early in every pregnancy.
3. Institution of continuous weekly treatment before the fifth month in every
pregnancy of every known syphilitic or apparently cured syphilitic woman.
Page 81 V
ancouver
G
enera
H os pita
Case: Intestinal Obstruction—Dr. W. L. Graham.
At the request of the Vancouver Medical Association I have been asked to present some
cases from my service at the Vancouver General Hospital. At first I wish to offer my
appreciation to Dr. Seldon, the Chief of the Surgical Service, for permission to publish
these cases. We are presenting three cases which we think will be of some interest to the
profession. The case histories will necessarily be short, but we hope that they will give
you a picture of the case as we see it and our ideas of treatment. These cases offer divergence
from those usually seen in the ordinary surgical practice. These cases were shown at a
Staff Clinical Meeting of the Vancouver General Hospital, and the conclusions ond observations will be summarized.
The first case presented is one of a partial intestinal obstruction due to post-operative
adhesions. He was a young man of 34, who was admitted to hospital on May 3, 193 8. He
complained of recurrent atatcks of nausea and pain in the abdomen for the past six and a
half years. He gave a history of having his appendix removed seven years previously.
Whether it was acute or chronic we do not know. His convalescence was prolonged with
periods of nausea and vomiting. Since then he had has nine abdominal operations. Five
operations were for adhesions and four for intestinal obstruction. Since October, 1937,
this man has been a patient in the Vancouver General Hospital on six occasions. His hospitalization has been from one to four days, and he has been relieved by enemata and
pituitrin. At other times he has presented himself to the Emergency Department for relief
of abdominal cramps which enemas have relieved. He has repeatedly come into the
Emergency asking for a hypodermic. The family history is negative. His past illnesses
include encephalitis in 1920, and he now presents a Parkinsonian syndrome. This man has
periodically worked in the Occupational Therapy Department and has been reported as
being industrious and efficient.
The physical examination of this patient apart from the abdomen and the associated
encephalitis is essentially negative. The abdomen presents numerous abdominal incisions
on the righ half of the abdomen. During acute attacks of pain visible peristalsis can be
observed beneath the scars. He was admitted on May 3, 1938, and the previous history
reviewed. On October 1, 1937, a barium enema was negative. Just previous to admission
a gastro-intestinal series showed suggestion of some obstruction to the lower small bowel.
After consideration of this case it was decided that some form of operative treatment
might be of value to the patient, either multiple anastomosis or a block resection of the
involved bowel.
On May 14th a left rectus incision was made and the terminal five feet of the small
bowel was found to be involved in dense adhesions. The remainder of the small bowel was
free. A resection was done of the lower five feet of the terminal ileum and an anastomosis
from the proximal end of the resection to the small bowel proximal to the cascum.
Recovery in this case was uneventful and he was discharged from the Hospital on
June 26, 1938.
Since discharge the patient has been working and has enjoyed good health. He has been
married within the last month and has been readmitted to Hospital with a fracture and
laceration of the nose [! ? Ed.] but no symptoms referable to his digestive tract. His subsequent blood count will be carefully followed.
His pathological report was a section of the small bowel superficially hemorrhagic and
patchily congested showing many fibrous tags. There is no evidence of any specific process
such as tuberculosis or malignant lesion.
Remarks.—Since 1932 this man has had at least nine operations for intestinal adhesions
and intestinal obstruction. He suffered tremendous pain in the last three months. He did
have peristalsis and did have distention. He would appear in Emergency every other night
for an enema.
Page 82 Operated on May 13th. The right abdomen was a mass of scar tissue, so we went in
on the left side and found the last five feet of bowel involved in this granular adhesive type
of plastic peritonitis. It looked almost acute. We did think of doing multiple anastomosis
to relieve the obstruction, but felt that it probably would be only temporary relief. I took
out the last five feet of ileum and did an end-to-end anastomosis. One wonders what the
future will be. He has been surprisingly well and is very grateful for relief of pain. This
man has a Parkinsonian syndrome as well. He is age 34. In this case an anastomosis was
done over a tube.
STAFF CLINICAL MEETING
I.—GASTRIC LUES VERSUS INOPERABLE CARCINOMA
OF THE STOMACH.
The first case—Gastric Lues versus Inoperable Carcinoma of the Stomach—was presented by Dr. J. E. Walker.
This patient complained of pain two hours after eating. He came to Outpatient Department in the
spring, and at that time showed 2800 red blood cells, 3 8% haemoglobin, plus one small cell and plus one large.
He was admitted to hospital at that time. Apart from a rasping cough, the physical examination showed
nothing of importance. Blood pressure was 140/72. An x-ray showed no enlargement of the liver. The heart
was slightly enlarged. Blood Kahn was plus one. The Throat Department diagnosed his hoarseness as "chronic
laryngitis." Examination of the thorax showed no specific reason for this. The patient was given anti-syphilitic
treatment. Cough mixture was given for his cough. No cause was demonstrated for his anaemia. He then
left hospital in June and went up north, where his diet gave him some trouble. As a result of eating fried
foods, etc., he began to have indigestion. The patient states that this was his first attack since 1930. He was
re-admitted to hospital on July 17th, and was in until September 9h. The pain in the epigastrium is recent.
It came on after eating and was relieved by eating. After a while the pain was present all the time and was not
relieved by anything. By the time he came to hospital it was present all the time. On examination he was
found to have no true rigidity; there was some tenderness above the umbilicus. The Surgical staff said that he
had a mass, but the Medical staff never found that mass. An x-ray taken after the administration of barium
meal showed the stomach to be empty after five hours. The pyloric end showed marked definite irregularity.
The duodenum was spastic. Blood count showed 2,300,000 R.B.C. and 25% haemoglobin; colour index .5. On
admission showed plus 2 blood in stool and in the next showed plus 4. He was started on iron and a month
after coming to hospital his blood count was up. Due to the fact that he was looking and feeling so much
better another x-ray was taken. Five hours after the ingestion of a barium meal the stomach was empty. The
stomach showed no evidence of irregularity.
Discussion.
A doctor enquired how long after the first x-ray was the second x-ray taken. Dr.
Walker replied: "Exactly one month."
The patient was discharged on August 9th and was referred to the Outpatient Department. He was admitted again a couple of days ago because of cough. The Nose and Throat
Department still diagnoses his condition as "chronic laryngitis."
In reply to a question about the patient's weight, Dr. Walker said that the patient
claims to have lost about 20 pounds while up north, but he is putting it all back on again.
On April 6th, the patient had a plus one Kahn;; on April 27th, plus 1; on July 22nd
it was negative and on October 21st doubtful. Colloidal gold was negative. No dilatation
of the aorta. The nervous system shows no signs of syphilis. Dr. Walker said that he looked
up some facts on syphilis of the stomach. This man, he said, does not seem to fit into it.
Haemorrhage is rare. This man shows a one or two plus blood on gastric analysis; there
was blood in his stools. His stomach contents are within normal limits and he has a cough.
Dr. Harrison says this is a case of gastric hypertrophy. "On physical examination at
present," said Dr. Walker, "I do not think there is much to find."
At this point the patient was brought in and questioned by Dr. Walker. He said that
he had pain after eating every day, but that it is much better than it was two months ago.
His laryngitis is also improved.
In reply to a question, Dr. Harrison said that x-ray diagnosis of hypertrophy of the
gastric mucosa is not very common.
Dr. Hodgins said that gastric hypertrophy is much more common than gastric syphihs,
which is a very rare disease. Gastric hypertrophy can have many forms. It is caused by
poor food, alcohol and exposure.  It can occur in any situation, of any extent, and can
Page 8} come and go in the matter of a month or two at will. It comes and goes without treatment. The x-ray may show it to be in the greater curvature. After washing out the
stomach for a month or two it will be completely gone. It may go through the pyloric
ring and take the form of a polypus. Dr. Hodgins asked whether there was pressure on
the stomach, and Dr. Harrison said that there was not. Dr. Hodgins said that he did not
think the patient could have syphilis of the stomach. Good food and rest cured him. Gastritis is very uncommon without hypertrophy; it is relatively common with hypertrophy.
Dr. Hatfield asked whether it is impossible to make a direct examination of the stomach.
He said that in a case of this type a direct examination would give some idea of the diagnosis
and asked whether it would not be possible to develop this work on the staff.
Dr. Graham remarked that the man may have two concurrent diseases, but that the
two must be related in some way. He suggested that the Nose and Throat might investigate the cause of the patient's laryngitis further.
Dr. Davidson asked whether they should continue with the anti-syphilitic treatment.
Dr. Walker said that they were more concerned with the stomach trouble at that time.
As far as treating for syphilis goes, Dr. Walker said that he did not think it was doing the
patient much harm. It did not matter a great deal whether anything was done for the
syphilis—his blood Kahn is certainly very weak.
The case was then discussed by Dr. Harrison. The lesion of this man was rare and
interesting, as it did not follow the type usually seen. ''There were several large plaques
protruding into the lumen of the stomach associated with some constriction which is quite
different to the picture of mucous membrane which one sees in cases of hypertrophy gastric
mucosa. The first picture did not suggest hypertrophy. There is, however, no reason why
a hypertrophy cannot be complicated. This man, according to the history, had evidence
of gastric tenderness. Assuming that he had a gastritis to start with, the original picture
can be accounted for by rupture of the mucosa with gastric inflammation. In the ordinary
case of hypertrophy of the mucous membrane there is not necessarily any superficial
erosion of any great size. There are frequently some small superficial erosions." Dr. Harrison said that he is not quite satisfied with this case. He has seen malignant cases of that
degree of severity improve within a few months. This patient still has a certain amount
of rigidity. "This is, I think, one of the types of cases in which the correlation of radiology
and gastroscopy is essential to a full diagnosis, and, since the invention of the flexible gastro-
scope, I see no reason why we cannot have it in the V. G. H." Dr. Harrison concluded by
saying that it is his present opinion that neither radiography nor gastroscopy is enough
7 ltSe f" II.—A CASE FOR DIAGNOSIS.
Dr. Lyle Hodgins.
Dr. Hodgins' case was presented by Dr. Munroe.
The patient was a young man of 24 years, admitted to hospital on the 24th of September. He had a
history of diarrhoea, nose bleeds and vomiting. The patient said that he was in good health until 17 days ago,
when he developed a cough and sore throat. Towards the end of the week he had several nose bleeds, vomiting
and diarrhoea after meals. Towards the second week of his illness—before admission—the diarrhoea stopped.
Vomiting occurred ten or twelve times a day. There was no blood in the stools or vomitus. On examination
the patient was found to be a well nourished young adult male, extremely hydrated. B.P. 120/80; T. 100;
P. 60; respirations 20. He had no pain, the only symptom being vomiting. The abdomen was scaphoid—
negative except for a possible enlarged spleen. Two days after admission the spleen was easily palpable. The
dehydration was slightly overcome but he was still vomiting. He did not complain of nausea. For the first
seven or eight days he was vomiting 70 to 80 ounces per day. He was given atropine, grs. 100, for six days
with no effect. Dr. Carder at this time considered that the possibility of typhoid had been eliminated. He
was given intravenous two a day at first, and; later three a day. On admission, leucocytes 15,900; four days
later, 10,800; today about 6000. A spinal puncture was done; pressure was 16 and was reduced to 9. The
laboratory work was entirely negative.  Cultures were negative for typhoid.  Sinuses negative.
This case, therefore, is one of acute upper respiratory infection follewed by diarrhoea
for one week, after which there was a week of obstinate constipation. The patient ran a
slow pulse. On Saturday last he was seen by Dr. F. Turnbull, who stated that there was a
slight papillcedema and slight mystagmus of the lateral fields on both sides. He was also
seen by the surgical Staff. At the present time the spleen is no longer palpable.
Dr. Hodgins said that he has no idea of the nature of the infection. The patient is
improving now.
Page 84 Dr. Palmer stated that he saw the patient on the 16th or 17th day of his illness. The
case was very suggestive of typhoid fever. His temperature was never very high, but he
has a surprisingly slow pulse. He had a little bit of headache, but was rather inclined to
be a little drowsy. Dr. Palmer thought he could feel the spleen. The desquamation of the
hands and feet ws very marked—as in scarlet fever. The most probable diagnosis is typhoid
fever. While it is true that in most cases of typhoid fever—something over 95%—the
blood agglutination is positive, there are a few cases that do not follow the rule, particularly if the patient is seen after the first week. However, the diagnosis is much more likely
to be that which Dr. Hodgins suggested—a marked generalized response to the severe upper
respiratory infection. Dr. Palmer concluded by saying that he still feels that it would be
well to do a blood agglutination test.
Dr. Turnbull said that the neurological examination showed nothing apart from that
reported above and he did not consider the case primarily neurological.
Dr. Williams asked how they had ruled out scarlet fever, as it is not uncommon to find
a palpable spleen in cases of scarlet fever.
Dr. Gillies said that he is quite interested in this case, as he had seen another case of
upper respiratory infection about three weeks ago in which the patient had a slow pulse
very much like the present case. However, the patient was a woman of about 60 years of
age, and it is just possible that there was a certain amount of myocardial involvement which
would account for the slowness of the pulse, which was around 44 to 58. She was too ill
to be removed to the Heart Station, so the portable machine was transferred to her room.
However, there was too much static and she could not register properly. It would be interesting to explain why there was desquamation. It is extremely unlikely that a case of
scarlet fever should run a slow pulse—it is never seen. The usual association with scarlet
fever is a rapid pulse, more often out of proportion to the temperature. In typhoid fever
we often see a slow pulse not in proportion to the temperature, and associated with a very
low leucocyte count. Dr. Gillies said he could not put a label to it, but, if anything, the
case seems to be in the typhoid group.
Dr. Harrison remarked that one point had not been emphasized—what is the cause of
the vomiting?
With regard to the x-ray history, Dr. Harrison pointed out that while the patient was
on his back they could not get the food around through the duodenal pool, but as soon as
he was turned over on his side or face it went straight on.
SIR DAVID WILKIE—1882-193 8
The news of the death of Sir David Wilkie, on August 28th of this year, came as a
great shock to the medical profession, especially in England. He had been a speaker at
the Annual Meeting of the British Medical Association at Plymouth in July.
Born at Kirriemuir, in Scotland, the "Thrums" of Sir J. M. Barrie, 56 years ago, he
graduated from the University of Edinburgh. He became a Fellow of the Royal College
of Surgeons of Edinburgh in 1907, and of the Royal College of Surgeons of England in
1918. He was made an Honorary Fellow of the American College of Surgeons in 1926.
He was a brilliant surgeon and held many important appointments. His genius as a
teacher was outstanding. It was in the operating theatre, however, that he was seen at
his best. There, with a technique which was faultless, with a dexterity that was equally
complete, he operated and demonstrated in a manner that called forth sincere admiration.
He was a personal and close friend of Sir James Barrie. Indeed, he seems to have had
a great capacity for friendship, as evidenced by the warm tributes paid to him in the
October number of the British Journal of Surgery, and the British Medical Journal for
September 10th, 1938.
Drs. White, Parmley and (Bill) White have moved into their new offices, which they
share with Dr. F. Parmley, dentist, who is a brother of Dr. J. R. Parmley.
Page 85 St.   Paul s   Hospita
MEDICAL STAFF MEETING
Doctor Lynch presented three cases of carcinoma of the stomach, and he opened his
remarks with the following quotation: "Where there is everything to lose, one must dare
much." This, he went on to point out, is nowhere so true as in dealing with cases of cancer
of the stomach. When one realizes that cancer of the stomach has the melancholy distinction of holding first place as a cause of death of all cancers that afflict the human body, one
realizes the necessity for drastic action. Death from cancer of the stomach comprises about
one-third of the total from all forms of cancer and 2.6% of the deaths from all causes
combined. In other words, out of every hundred thousand individuals 28.8 will develop
cancer of the stomach.
The operation for cancer of the stomach must of necessity be a radical one and never
less than three-quarters of the stomach and gastro-colic and great omentum must be
removed. Even in high circles it has been so usual of late to bemoan or even decry the
results of operative treatment of malignant disease that many members of the profession
are deterred from advising surgical interference. As Gray Turner says, "There is a real risk
of a generation of medical men arising who are ignorant of what surgery can offer in the
treatment of cancer. At the present time we are living through one of those periods in
which the medical profession and the general public is being encouraged to grasp at remedies which hold out hope of cure or alleviation without mutilation, and it was never more
necessary to have in our ranks bold gastric surgeons with wide experience and balanced
judgment, who can determine which cases can reasonably be selected for such conservative
treatment and which must be treated by thorough and not half-hearted surgical methods.
The history of surgery of malignant disease is neither so discouraging nor so discreditable
as many would have you believe."
Dr. Lynch's own personal experience convinces him that there is no place for pessimism
in the treatment of early cancer by surgery. Therefore, in dealing with cancer one must
ever be bold, remembering the inevitable mortality if surgery fails, and with courage do
what one feels to be right.
Cancer at its inception is always a localized disease, hence early diagnosis is of the
utmost importance. It is discouraging to the gastric surgeon to find that 50% of the cases
referred to him are inoperable and of the 50% remaining only one-half are really resectable
and come into the five-year cures. All patients between the ages of 40 and 60 complaining
of vague gastric symptoms should be carefully studied from the radiological standpoint
and a complete gastric analysis for free and combined hydrochloric acidl should be done.
"Some things are hard to say," went on Dr. Lynch, "and it is often easier and pleasanter
to leave them unsaid, but, in my opinion, radium has no place in the treatment of malignant
disease of the stomach, and for that matter of the alimentary tract, and deep x-ray therapy
of the upper abdomen for advanced inoperable cancer is only a therapeutic straw and causes
irreparable damage to the normal tissues of the alimentary tract and frequently to the
abdominal parietes as well. Cancer of the stomach must be recognized early if the percentage of our five-year cures is to be increased. The operative risk in the majority of cases
will be from 30 to 35% and the five-yeat cures range from 10 to 25%."
Doctor Lynch gave it as his opinion that gastroenterostomy as a palliative operation in
dealing with advanced cancer of the stomach has no place in surgery. The operative mortality in such cases is over 24% and the longevity of the patient is increased only 2.8
months. As W. J. Mayo said many years ago, "it merely enables the patient to live longer
and suffer more." This palliative operation for advanced carcinoma of the stomach only
brings disrepute on gastric surgery and is largely responsible for the present fatalistic attitude not only of the laity but also among many members of the profession as well.
Page 86 "In operating on cases of cancer of the stomach," said Dr. Lynch, "I never allow myself
to think of a radical cure and I am always satisfied if these patients are alive and well five
years after the resection. Cancer of the stomach is undoubtedly of a high grade of malignancy and survival from three to five years is about as long as we dare to expect." In a
series of over two hundred gastric resections, most of which were done for carcinoma of the
stomach, the speaker admitted a mortality of 32%, and a five-year cure of not more than
11.3%. Starving to death is extremely unpleasant, but thirsting to death is intolerable.
Therefore, most cases of cancer of the stomach which can be resected ought to be attempted.
The patient has everything to gain and nothing whatever to lose. The vast majority of
cases who survive extensive resections for malignancy of the stomach will live on the
average four years and nine months, and those who have recurrence within that time die
of metastases, usually in the liver, a comparatively speaking painless death compared to
death from starvation and thirst.
(Several pre-operative and post-operative slides were shown, some of cases surviving
eight years, one five years and one two years.)
In the speaker's experience all cases of carcinoma of the stomach which the pathologist
reported as Grade 4 will be dead within eighteen months to two years from the date of
resection. The speaker pointed out that a careful rectal examination should be made before
planning any gastric resection in a case of cancer of the stomach to eliminate a rectal shelf.
Also the umbilicus must be carefully palpated and the Virchow Mikulicz gland felt for in
the left supra-clavicular fossa. Any or all of these are absolute contraindications for
surgery.
There are no classical symptoms of early cancer of the stomach, and a more careful,
painstaking history is of great importance, and the physician consulted should be always
suspicious of the possibility of a cancer being responsible for the symptoms complained of
and take appropriate steps to eliminate this possibility.
Dr. Lynch paid a tribute to the roentgenologists as giving an 8 5 % absolutely correct
diagnosis in cancer of the stomach. In his opinion, in reading the plates, stomachs that lie
largely to the left and low in position are resectable. Radiograms showing high-placed
stomachs with carcinomatous involvement indicate metastases in the lesser omentum and
are frequently found to be inoperable. Gastrectomy, even when not permanently successful, is a very satisfactory palliative for cancer of the stomach.
Dr. J. Stuart Daly of Trail has been visiting in Vancouver and is back at practice
after a deserved vacation. Dr. Daly was re-appointed reporter of the West Kootenay
Medical Association.
Dr. H. F. Tyerman of Nakusp visited Vancouver in October. He missed seeing Drs.
Huggard and Thomas.
Dr. Arnold Francis of New Denver visited Nakusp daily in Dr. Tyerman's absence.
Dr. G. A. B. Hall of Nanaimo is at Carmi, near Penticton, on his annual hunting trip.
He will visit Nelson before his holiday is ended.
Dr. J. R. Parmley and family are leaving for Montreal. They will spend a month at
Mrs. Parmley's home. Dr. Parmley will db some special work at the Royal Victoria
Hospital.
The newly formed Penticton Medical Association elected the following officers at the
first meeting:
Honorary President—Dr. R. B. White.
President—Dr. H. McGregor.
Honorary Secretary-Treasurer—Dr. W. R. Walker.
The Penticton profession felt that it required to deal with some of its problems in a
united way and to speak as one voice.
Page 87 MEMBERS of THE GUILD
Wt       of PRESCRIPTION OPTICIANS of AMERICA
Always Maintain the
Tithical   Principles   of
the Medical Profession
Guilder aft Opticians
430 Birks Bid?.        Phone Sey. 9000
Vancouver, Canada.
ADEQUATE
I   IRON
for HYPOCHROMIC ANEMIA
Excellent hemoglobin response results
in most cases front the daily dose of
three Hematinic Flastules Plain. This
provides 15 grains of ferrous iron.
Small dosage, easy assimilation and
toleration favor the use of Hematinic
Flastules for hypochromic anemia, because they produce maximal results,
at low cost, without discomfort or
inconvenience to the patient.   .
Hematinic Flastules provide ferrous
iron and the vitamin B complex of
concentrated yeast, in soluble gelatin
capsules. They are issued in two
types—in bottles of fifty—Hematinic
Flastules Plain and Hematinic Flastules with Liver Concentrate.
JOHN WYETH
& BROTHER, Inc.
WALKERVILLE, ONTARIO
For Complete
BINDING
OF
THE   BULLETIN
A phone call will bring
immediate attention.
Sey. 6606
Roy   Wrigley   Printing
and Publishing Co. Ltd.
300 West Pender St.
Vancouver, B. C.
A PRESCRIPTION SERVICE . . .
Conducted in accord with the ethics of the Medical
Profession and maintained to the standard suggested by
our slogan:
Pharmaceutical Excellence
N\CG ftOfmo
LIMITED ^—'
FORT STREET (opp. Times)
Phone Garden 1196
VICTORIA, B. C. The New Synthetic Antispasmodic
Trasentin "Ciba"
(Diphenylacetyldiethylaminoethanolester-hydrochloride)
SUPPRESSES SPASMS OF THE GASTRO-INTESTINAL
TRACT, GENITO-URINARY SYSTEM AND
OTHER SMOOTH MUSCLE ORGANS
Tablets—bottles of 20 and 100. Ampoules—boxes of 5 and 20.
1 tablet or 1 ampoule contains 0.075 grm.
of the active substance.
CIBA COMPANY LIMITED
MONTREAL
SssasS*
Xwi*X*XC"SOOC«X"Xss*
13 th Ave. and Heather St.
Exclusive  Ambulance  Service
FAIRMONT 80
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
J. H. CRELLIN
W. L. BERTRAND THIAMIN CHLORIDE SQUIBB
Indicated in all degrees of Vitamin B1 deficiency, especially the more severe forms. Permits adequate dosage in small volume. Stable and convenient to use. Bottles of 50 tablets
in 2 potencies—300 (1mg.) and 1500 (5 mg.) International units per tablet. Boxes of 6x1-cc.
ampuls—each ampul containing 3000 I.U. (10 mg.) of the crystals in solution; also in 5-cc.
vials containing 3000 I.U. per cc.
SQUIBB VITAMIN B COMPLEX  SYRUP
For Patients Needing the Several Factors of the "B Complex"
The therapeutic usefulness of Squibb Vitamin B Complex Syrup depends upon the fact
that it supplies an abundance of naturally occurring Thiamin (Bj), Riboflavin (B£)> Vitamin B6, the filtrate factors and the pellagra-preventive factor (nicotinic acid). There is
also qualitative experimental evidence suggesting the presence of factor W and Vitamin B4.
INDICATIONS: Anorexia, Chronic gastro-intestinal mal-function, Constipation, Pregnancy
polyneuritis and vomiting, Lactation, Alcoholic polyneuritis, cardiovascular disturbances,
Retarded growth in infants, Retarded growth in older children, Infant feeding, Pellagra.
DOSAGE: Infants, V2 teaspoonful a day; children, 1 to 2 teaspoonfuls a day; adults, 2 to
4 teaspoonfuls a day.
Supplied in'3 and 6-oz. bottles and 12-oz. jars.
Vitamin Content as Shown by Multiple Physiologic Assays:
VITAMIN Bi—50 International units per 1 cc.
Thiamin, as it occurs naturally.
VITAMIN B2—10 gammas per 1 cc.
"Riboflavin" is the accepted ne w term for the artificial vitamin B2. In Vitamin B
Complex Syrup, riboflavin is present in naturally occurring form.
VITAMIN Bc—100 gammas per 1 cc.
This vitamin can be prepared in crystalline form; here it occurs in its natural form.
FILTRATE FACTORS—Jukes-Lepkovsky factor value of 27 per 1 cc.
PELLAGRA—Preventive Factor contains an abundance.
Recent literature refers to this factor as nicotinic acid.
For descriptive literature address Professional Service Department, 3 6 Caledonia Rd., Toronto, Ont.
ER: Squibb & Sons of Canada, Ltd.
MANUFACTURING   CHEMISTS   TO   THE    MEDICAL   PROFESSION   SINCE    1858 Doctors-
YOUR
PRESCRIPTION
AND
RECOMMENDATION
Is Our Guide
Always-
OUR
MECHANICAL
and
SCIENTIFIC
ORTHOPAEDIC
EQUIPMENT
Is At Your Service
Avail Yourselves
of  our   experience   in   last
making to aid correction in
Minor Foot Ailments.
PHONE
Pierre Paris
FOOT CLINIC
Sey. 3 778       51 W. Hastings
Colonic
Irrigation
Institute
Superintendent:
B. M. LEONARD, B.N.
Post Graduate Mayo Bros.
Up-to-date treatment rooms;
scientific care for cases such as
Colitis, Constipation, Worms.
Gastro-intestinal Disturbances,
Diarrhoea, Diverticulitis, Rheumatism, Arthritis, Acne.
Individual Treatment $ 2.50
Entire Course  $10.00
Medication (If necessary)
$1 to $3 Extra
631 BIRK8. BUILDING,
VANCOUVER, B. C.
Phone: Sey. 2443
506-7 CAMPBELL BUILDING
VICTORIA, B.C.
Phone: Empire 2721 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.
ESTABLISHED   NEARLY  A
B. C. STEVENS CO.
Phone Seymour 698
730 Richards St., Vancouver, B. C.
s.
BOWELL
&
SON
Distinctive   Funeral
Service
Phone 993
>
66 SIXTH STREET                                         1
*EW WESTMINSTER, B. C.
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea^ Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and stabilizing the tone of its
musculature. Controls the utero-ovarian
circulation and thereby encourages a
normal menstrual cycle.
• MARTIN H. SMITH COMPANY
Ik 1M IAFAYITTI STRUT.  NIW TOM, N. T.
Full formula and descriptive
literature on request
Dosage: 1 to 2 capsules
3 or 4 times daily. Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule  is  cut  in  half  at  seam. Because of the
difficulty encountered in obtaining
breast milk, all infants (in the Premature Department,
Cincinnati General
Hospital) are on a
formula of evaporated milk, water,
and beta lactose.
The results with this
feeding compare
most favorably with
those of the preceding years using
breast milk."—Proceedings: Meeting
of Region III, American Academy of Pediatrics; J. Pediat.,
710, May, 1937.
7?2
The success with which evaporated milk is employed in the feeding of premature infants is due
in large part to the soft-curd quality imparted by
O. BOOKLET FOR
PHYSICIANS
—You are invited to-
write for "Simplified
Infant Feeding," an
authoritative publication treating of
the use of Irradiated
Carnation Milk in
normal and difficult
feeding cases. . . .
Carnation Company, Ltd., Toronto,
Ontario.
the heat treatment of sterilization. .
mity of Irradiated Carnation Milk in
this respect is assured by exact control of sterilization time and temperature, and is one of the reasons why
this product has become the evaporated milk of choice with many
pediatricians.
The unifor-
IRRADIATED
C   arnation
^fc^^^^r    A CANADIAN PRODUCT — "from contented cows
Milk
// RADIO-MALT
(Standardised Vitamins A, B^ B2 and D)
In reporting on his experience with Radio-Malt, the medical officer of a
well-known residential college states: ". . . for years I have prescribed
Radio-Malt; I look on It as invaluable."
The administration of Radio-Malt builds up the body's resistance against
any attacks of invading organisms and maintains throughout the winter
months the vitality and robust health usually associated with summer
time.
Stocks of Radio-Malt are held by leading druggists throughout the
Dominion, and full particulars are obtainable from:
THE BRITISH DRUG HOUSES (CANADA) LTD.
Terminal Warehouse Toronto 2, Ont.
ZZZZZIZZZZZZZZIZZ^^ RM/Can/3812
flDount pleasant XHnbertakinQ Co. %tb.
KINGSWAY at 1 lth AVE. Telephone Fairmont 58 VANCOUVER, B. C
R. P. HARRISON W. R. REYNOLDS H
Antiphlogistine .. always indicated in
TONSILLITIS, PHARYNGITIS,
LARYNGITIS, BRONCHIOLITIS
"Write for sample and literature
THE  DENVER CHEMICAL MANUFACTURING CO.
153 Lagauchetiere St. W.
Montreal
Made in Canada. \        5
How Much Sun
Does the Infant
i
Really Get ♦
Not very much: (1) When
the baby is bundled to protect against weather or (2)
when shaded to protect
against glare or (3) when the
sun does not shine for days
at a time. Oleum Percomorphum offers protection against
rickets 365 % days in the year,
in measurable potency and in
controllable dosage. Use the
sun, too.
Oleum Percomorphum is an economical source of vitamins A and
D.  We purposefully selected a classic name which is unfamiliar
to the laity, or at least not easy to popularize.  Oleum Percomorphum is supplied without dosage directions. Samples are
furnished only to physicians.
Mead Johnson^ Co. of Canada,Ltd.,Belleville,Ont., does not advertise any of its products to the public. Pharmaceuticals-plus!
We have built up connections with sources of
supply during these last thirty years that enables us to offer you a most complete stock of
medicinals—and with these, seven trained,
experienced pharmacists to compound them
for you.
Open day and night—Seymour 2263
i—mm
GEORGIA PHARMACY
LIMITED
W. OIOROIA
STRBIT
Only One Store
(&mt?t $c ijMwa $tu
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.   Powell River, B. C. 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
ROY WRIGLEY PRINTING a^^^oft PUBLISHING CO. LTD.

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