History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: January, 1953 Vancouver Medical Association Jan 31, 1953

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b|u lletin
The Vancouver Medical Association
dr. j. h. MacDermot
Publisher and Advertising Manager
Dr. D. S. Munroe
OFFICERS 1952-53
Dr. E. G. McCoy
Dr. George Langley
Hon. Treasurer
Additional Members of Executive:
Dr. G. R. F. Elliot Dr. F. S. Hobbs
Dr. G. H. Clement Dr. A. C. Frost Dr. Murray Blair
Auditors: Messrs. Plommer, Whiting & Co.
Dr. J. C. Grimson
Past President
Dr. J. H. Black
Hon. Secretary
Eye, Ear, Nose and Throat
Dr. J. A. Irving Chairman Dr. W. M. G. Wilson Secretary
Dr. J. H. B. Grant Chairman Dr. W. H. S. Stockton Secretary
Orthopaedic and Traumatic Surgery
Dr. A. S. McConkey Chairman Dr. W. H. Fahrni Ji|~ Secretary
Neurology and Psychiatry
Dr. B. Bryson Chairman Dr. A. J. Warren Secretary
Dr.  J.  S. Madill.__J1l_- Chairman Dr. H. Brooke Secretary
Dr. J. L. Parnell, Chairman; Dr. D. W. Moffat, Secretary;
Dr. A. F. Hardyment ; Dr. W. F. Bie ; Dr. R. J. Cowan ; Dr. C. E. G. Gould
Co-ordination of Medical Meetings  Committee
Dr. W. M. G. Wilson Chairman Dr. B. T. Shallard Secretary
Summer School
Dr. S. L. Williams, Chairman; Dr. J. A. Elliot,  Secretary;
Dr. J. A. Irvine ; Dr. E. A. Jones ; Dr. Max Frost ; Dr. E. F. Word
Medical Economics
Dr. E. A. Jones, Chairman; Dr. G. H. Clement, Dr. W. Fowler,
Dr. F. W. Hurlburt, Dr. R. Langston, Dr. Robert Stanley, Dr. F. B. Thomson
Dr. W. J. Dorrance, Dr. Henry Scott, Dr. J. C. Grimson
V.O.N. Advisory Committee SI
Dr. Isabel Day, Dr. D. M. Whitelaw, Dr. R. Whitman
Representative to the Vancouver Board of Trade: Dr. D. S. Munroe
Representative to the Greater Vancouver Health League: Dr. W. H. Cockcroft
— ■ 	
Published   monthly  at  Vancouver,  Canada.     Authorized  as  second   class   mail,   Post  Office  Department,
Ottawa, Ont.
Page 151 Dihydrostreptomycin Sulfate
Numerous studies by leading clinicians
confirm that Dihydrosteptomycin Sulfate
is as effective as streptomycin, minimizes
'pain and swelling at the site of injection,
and may be used even in some patients
allergic to streptomycin. Furthermore,
extensive comparative investigations have
proved Dihydrosteptomycin Sulfate
Merck less toxic to the vestibular system.
In addition to the dry form, this
preferred product is available also in a
convenient, ready-to-inject form as
Dihydrostreptomycin Sulfate Solution
MERCK (PAS), when used in combination with Dihydrostreptomycin Sulfate
Merck, prolongs the effective period of
antibiotic therapy by inhibiting or delaying the development of bacterial resistance.
A drug of Choice
in Tuberculosis
(9 days prior to Dihydrostreptomycin
therapy) Diffuse lobular tuberculous
pneumonia, lower half of left lung; thin-
walled cavity above hilus ($ x 3.5 cm.).
(2 days after discontinuance of Dihydrostreptomycin) Considerable clearing of
acute exudative process in the diseased
lung; cavity smaller and wall thinner.
MERCK &  CO. Limited
Manufacturing Chemists
Page 152 i
Founded 1898; Incorporated 1906
Regular Weekly Fixtures in the Lecture Hall
iMonday, 8:00 a.m.—Orthopaedic Clinic.
Monday, 12:15 p.m.—Surgical Clinic.
Tuesday—9:00 a.m.—Obstetrics and Gynaecology Conference,
j Wednesday, 9:00 a.m.—Clinicopathological Conference.
Thursday, 9:00 a.m.—Medical Clinic.
12:00 noon—Clinicopathological Conference on Newborns.
[Friday, 9:00 a.m.—Paediatric Clinic.
Saturday, 9:00 a.m.—Neurosurgery Clinic.
Regular Weekly Fixtures
2nd Monday of each month—2 p.m Tumour Clinic
Tuesday—9-10 a.m y Paediatric Conference
Wednesday—9-10 a.m . Medical Clinic
Wednesday—11-12 a.m Obstetrics and Gynaecology Clinic
Alternate Wednesdays—12 noon Orthopaedic Clinic
Alernate Thursdays—11 a.m Pathological Conference (Specimens and Discussion)
Friday—8  a.m. Clinico-Pathological Conference
(Alternating with Surgery)
Alternate Fridays—8 a.m. Surgical Conference
Friday—9 a.m Dr. Appleby's Surgery Clinic
Friday—11  a.m Interesting Films Shown in X-ray Department
Regular Weekly Fixtures
Tuesday, 8:30 a.m.—Dermatology.
Wednesday, 10:45 a.m.—General Medicine.
Wednesday, 12:30 p.m.—Pathology.
Monday, 11:00 a.m.—Psychiatry.
Friday, 8:30 a.m.—Chest Conference.
Friday, 1:15 p.m.—Surgery.
685 West Eleventh Avenue,
Vancouver 9, B.C.
Monday—9 a.m. - 10 a.m Ear, Nose and Throat Clinic
Tuesday—9 a.m. - 10 a.m Weekly Clinical Meeting of Attending Medical Staff
Tuesday—10:30 a.m. - 11:30 a.m ± Lymphoma Clinic
Daily—11:45 a.m. -  12:15 p.m JgL Therapy Conference
Spring meeting—April 25th, 26th, 1952.
Page 153 A
jl "eftodSt"
W 7^^%
Tablet No. 445 "fFcijt"
Each tablet contains:
Pentobarbital sodium 65 mg. (1 gr.)
(in outer shell)
*Nocfinal (in the core) 50 mg. (% gr.)
*Butabarbital sodium N.N.R.
DOSE: One tablet before retiring.
MODE OF ISSUE: Bottles of 100.
Brand of Pentobarbital-"Noctinai" Compound
• induces sleep promptly;
• provides refreshing, all-night
rest . . . without 'hangover'.
Chalk* $.&kx>6dSceo.
Page 154
Rapidly soluble outer coating.
Pentobarbital sodium for prompt
Inner coating dissolves
approximately when effect of
pentobarbital wears off.
"Noctinal" provides further
!?:;*S h
[Total population (census) ] 344,833
[Chinese population       7,117
November, 1952
Rate per
Number 1000 pop.
Total deaths   (by occurrence) +    377 13.1
Chinese   deaths 1 i       24 40.5
Deaths, residents only ; .     314 10.9
Birth Registrations—residents and non-residents  (includes late registrations)
November, 1952
[Male     385
Female   j :     3 64
749 26.1
\Infant Mortality—residents only
November, 1952
Deaths under 1 year of age         6
Death rate per 1000 live births ~       11.1
Stillbirths   (not included in above item)         4
Scarlet Fever
Diphtheria   _.
Diphtheria Carriers
Chicken Pox	
Whooping Cough ^_
Typhoid Fever	
Typhoid Fever Carriers
Undulant Fever	
Meningitis  (meningococcic)
Infectious   Jaundice	
Salmonellosis Carriers	
Dysentery I	
Dysentery Carriers 	
Cancer   (Reportable  Resident)
November, 1952
Cases '        Deaths
28 —
November, 1951
Cases Deaths
112 —
•     46
Page 157
Concentrated and Irradiated Human Serum
Human serum prepared from the blood of healthy adults so as to
involve a pooling from a large number of persons provides an economical
and effective agent for the modification or prevention of measles.
Modification is often preferable since it reduces to a
minimum the illness and hazards associated with measles,
but does not interfere with the acquiring of the active and
lasting immunity which is conferred by an attack of the
disease. On the other hand, complete prevention of an
attack of measles is frequently desirable, and can be
accomplished provided that an ample quantity of serum is
administered within five days of exposure to the disease.
Serum supplied by the Connaught Medical Research
Laboratories is concentrated to one-third the volume of
normal adult serum and is irradiated so as to minimize the
occurrence of homologous serum jaundice.
Irradiated Anti-Measles Serum, pooled
and concentrated, is distributed by the
Laboratories in 5-cc. rubber-stoppered
University of Toronto Toronto, Canada
Established la 1914 for Public Service through Medical Research and the development
of Products for Prevention or Treatment of Disease.
Page 158 Many of our readers will have seen the article in Saturday night contributed by
Mr. Stu Keate, taking the medical profession to task for unwillingness to cooperate with
the press or other media of publicity. Mr. Keate gave this as an address, it will be
remembered, at the Annual Meeting of the B.C. Division in Victoria last September.
He is Editor of the Victoria Daily Times, and is a seasoned and most capable newspaperman.   His opinions are well worth our careful consideration.
His subject is easily divided, like Gaul, into three parts. With one of them we
agree cordially—the other two do not impress us as much.
The first part deals with general publicity, showing forth the work that is being
done in hospitals, and in practice generally. Mr. Keate feels that there are hundreds of
stories available that would catch public interest—and feels that a knowledge of these
from time to time would be of advantage to us as well as the public, in showing what
modern medicine can do and is doing—it would improve public relations.
Somehow or another, this does not appeal to us very much, except under certain
circumstances. When a drive is being made for Community Chest Funds, Cancer Campaigns, and so on, great use is made of such dramatic material, and no doubt has some
value. But ordinarily, it seems in some way to cheapen things. It is like the difference
between a painting which depicts a woman sorrowing for the loss of a child, and a
photograph of that woman in similar circumstances. The former can be art, because
it is the conception of an artist in the abstract, and is universal in its appeal—the latter
is an invasion of privacy, which is unpardonable. And any exploitation, for a mere
passing appeal to the emotions, of the sufferings of humanity, through the press or any
other medium, would, we feel, be objectionable.
The second part deals with the relations of the medical profession, as an organized
body, with the public—and he makes a plea for greater frankness: and here we thoroughly agree with him. In matters of policy, dealing with such things as public health,
health insurance, Medical Acts, and so on, both we and the public have in the past
suffered from our unwillingness to explain our side of the case. Too often, and for
too long, the medical profession has tended to clam up—to retreat into its shell, or its
ivory tower, or its hospital wards, what you will—and with a mens conscia recti, to
ignore the clamour outside the door from those who wish to meet us, to make friends
perhaps, at least to bring us out into the open, where mutual problems can be aired
and perhaps solved by open discussion.
This attitude of ours has several dangers. One is that tensions without, which
might be eased by clearer understanding of both our problems and those of the public,
can mount to a dangerous and even explosive point. Another is, that hostilities and
prejudices can develop, which are entirely unnecessary and need never have arisen if
facts were honestly presented, and misunderstandings abolished by clearer knowledge.
Rising from these, is the danger that uninformed emotion and mere desire for relief,
may translate themselves over into the political field, and result in imperfectly explored
legislation. This is a very real danger. There is no doubt that this sort of thing has
occurred, and to the public detriment, as well as ours. Mr. Keate is perfectly right in
his contention that there should be closer liaison, more cooperation between ourselves
and the public we serve. It is very gratifying, in this respect, to think that we in
British Columbia, as Mr. Keate notes, have taken steps to remove some of the barriers,
and to come out frankly with our views, to acknowledge the existence of misunderstandings, and suspicions, and to do our best to face questions frankly, and answer
them honestly. ||§§
We need the press, just as the press needs us—we need a friendly and a cooperative
press.  And here we should like to interject a remark based on personal experience.   In
Page 159
V a good many years of meeting representatives of the press, we have come to realize that,
taken by and large, and in practically every instance, they can be trusted. They respect
any promise they make—they do their honest best to play fair—even if they do at
times put things in language that the public can understand. So we need have no fear
of trusting them, and relying on them to observe honourably any terms to which they
The third part of his address deals with our insistence, in the case of individual
men's work, on rules of procedure, on the limitations imposed by our Code of Ethics,
anonymity and so on.
When the medical profession shows its Code of Ethics, as a reason against giving
doctors' names under certain conditions, it is not merely being stuffy—nor is it a matter
of jealousy of the success or achievements of others, as Mr. Keate implies. It goes a
great deal deeper than that. Mr. Keate voices what we believe a good many people are
thinking, but he and they are wrong.
Medicine is an art, and not a science, though it is based on scientific principles.
In the practice of an art, each man to some extent develops his own particular techniques, some more successfully than others. The decision as to such superiority, or as
to the correctness of a man's work, can only be made by other physicians, not by the
public—and this is one reason why publicity attached to any one man's name is unwise,
and is objected to by the best minds in the profession.
Hippocrates' maxim "Experience is fallacious, and judgment difficult" is a very
wise one—and implies especially to an art such as medicine.
Results, in the long run, are what count. Each new discovery, each new technique,
must undergo rigorous and merciless testing by the whole profession, before it can be
accepted. Premature publication of such work is dangerous, and leads often to disappointment and actual damage. One has seen that so often, in the premature publicity
given to supposed cures, which looked so good to the discoverer, but which could not
stand up to the test of time and experiment.
The practice of medicine is a matter of teamwork—not of inq^viduals. Every man
who has something new, something good, to offer for inspection and testing, can be
sure if it passes this test, he will get full credit and acclaim. And the public, on the
other hand, may rest assured that no technique, no drug, no operative procedure, will
be allowed to come into general use, till it has received this trial, by medicine as a whole.
And this is another reason why we shun premature publicity, and the attachment
of an individual's name to work that is in process of testing. To quote the Code of
Ethics of the Canadian Medical Association: "No advance or discovery . . . made by a
physician should ever be capitalized ... by him in any way for his personal gain. Such
advance or discovery should be made common for the advantage of the whole profession,
and for the progress of science. There are well recognized methods by which physicians
can place their work and discoveries before those who are fitted by education and experience to judge them. The lay press is not the proper medium for the first announcement
of a physician's work or discoveries."
With this the medical profession is in unanimous accord.
Kipling put the matter in a nutshell, as he so often does:—"The game is more
than the players of the game, and the ship more than the crew."
And there are many ways in which we can open our treasures to the public, and give
them the knowledge and information they seek, and to which they feel they have a
right. The organizations which represent us legally or from an economic or other
standpoint, may present the case of medicine, or men of ''established position and
authority", acting under the aegis of the organized profession, can speak.
There is a great deal more in Mr. Keate's fascinating address to which we should
like to do justice—but time will not permit. The differences between his viewpoint and
ours are not fundamental—they are differences of emphasis, of technique, and fundamentally we can easily come into agreement. "For he is right, and We are right, and all
is7 right as right can be," as the song in the Mikado has it.
Page 160 r
We are all for greater frankness and the improved public relations which can only
come from such frankness—and we rejoice to see that, no matter how slowly and
reluctantly it does so, the medical profession is beginning to realize its responsibilities
in this matter. But it must be done with due regard to the ethical rules which through
the ages have been evolved and laid down by the medical profession—as a result of long
and sometimes bitter experience. Meantime, we owe a debt of gratitude to such men as
Mr. Keate, who, in obvious sincerity and amity, hold out a hand of friendship to us.
Monday to Friday | 9:00 a.m.—9:30 p.m.
Saturday : 9:00 a.m.—1:00 p.m.
Recent Accessions: MM
Zimmerman, B. Endocrine Functions of the Pancreas.
Grulee, C. and Eley, R. C, The Child in Health and Disease.
Ayre, J. E., Cancer Cytology of the Uterus.
Kayne, G. G., Pagel, W. and O'Shaughnessy, L., Pulmonary Tuberculosis.
Graybiel, A., White, P. and Wheeler, L., and Williams, C., Electrocardiography
in Practice.
Gilford's Textbook of Ophthalmology.
Feiling, A., Modern Trends in Neurology.
Daneshek, W. & Taylor, F. H. L., Symposium on Haematology.
Daley, R. & Miller, H. G., Progress in Clinical Medicine.
Bourne, A. W. & Williams, L. H. W., Recent Advances in Obstetrics
|    and Gynecology.
Brenneman's Practice of Paediatrics.
Journal of Laboratory and Clinical Medicine, volume 38, 1951.
Archives of Internal Medicine, volume 87, 1951.
Circulation, January, 1952.
The rest of the Library's (Journal)  holdings in general and special Medicine are
listed below.    The first half were published in the December Bulletin.
Journal of the History of Medicine and Allied Sciences.
Journal of Laboratory and Clinical Medicine.
Journal Lancet.
Journal of Physiology.
Journal of Pharmacology and Experimental Therapeutics.
Jornal de Medicine de Lyon.
Page 161 The Lancet.
Manitoba Medical Review.
Medical Annals of the District of Columbia. md
Medical Arts and Sciences
Medical Journal of Australia.
Medicme. ||1|
Minnesota Medicine.
Modern Concepts of Cardiovascular Diseases.
New England Journal of Medicine.
New York State Journal of Medicine.
* Northwest Medicine.
Nova Scotia Medical Bulletin.
Ohio Medical Review.
Ontario Medical Review.
Physiological Reviews.
Postgraduate Medicine.
The Practitioner.
Proceedings of the Royal Society of Medicine.
Proceedings of the Staff Meetings of the Mayo Clinic.
Quarterly Journal of Medicine.
Revista Medical de Cordoba. mm ^$:
Stanford Medical Bulletin.
Texas Cancer Bulletin.
Texas Reports on Biology and Medicine.
U.S. Armed Forces Medical Journal.
Yale Journal of Biology and Medicine.
Next  month  a  list  of   the  surgical   journals   received  in   the  Library  will   be
There has been a slight change in the International Sanitary Regulations whicltq
involves persons planning to travel to foreign countries.
The following is an excerpt from a letter dated November 26th, 1952 received
from the Department of Health at Ottawa:—
"The International Sanitary Regulations of the World Health Organization require
that certificates of vaccination bear an approved stamp in a form prescribed by the
health administration of the territory in which the vaccination is performed. The purpose of the stamp is to verify that the signature of the vaccinator on the cerificate is
that of a qualified practitioner, it being understood that the vaccination has been performed by him or under his immediate supervision."
In other words, even though a doctor has his nurse or technician do the actual
vaccination, it is he who takes the responsibility and his signature should be on the
It will save time both at the doctors' offices and at the Health Department, as
well as lessen the amount of annoyance to the prospective traveller, if this plan is
regularly observed.
Senior Medical Health Officer
J. D. ALEXANDER, M.D., F.R.C.S. (c)
The management of discharge from the non lactating mammary nipple continues
to be a difficult diagnostic and therapeutic problem and few clinical lesions present
such a wide divergence of opinion. Especially controversial is the treatment of patients
with nipple discharge without a palpable tumour, and opinions vary from that of
Stowers stating "the surgical procedure of choice is mastectomy", to that of Bartlett
stating "bleeding is a positive sign of benignancy and the treatment is always local".
A fairly well standardized attitude prevails toward abnormal discharge from other body
orifices, particularly bloody discharge. No such agreement exists with regard to nipple
discharge. This communication is to stress the importance of nipple discharge as a
sign which should make the observer search for an actual cancer or a precancerous lesion
in the affected breast. In many cases neither will be found but only in this way is
the patient adequately safeguarded.
Review of the Literature
Collins Warren recommended that surgical attack on papillary lesions be limited
to local excision, as he believed they were benign in character, although earlier observers
had regarded these as malignant. In 1916 Dean Lewis in discussing the bleeding nipple
| emphasized that discharge is usually indicative of benign intraductal papilloma and not
! of carcinoma. He advised operative search for and excision of the papilloma even when
no tumour was palpable. In 1917 Judd of Mayo Clinic reported 57% of 100 cases
| with serous or bloody discharge were found to have carcinoma, but all of these cases
I with carcinoma had a palpable breast tumour. This led him to use the presence of a
tumour as a distinguishing feature between nipple discharge due to carcinoma and that
due to duct papilloma, as none of his cases of duct papilloma formed a palpable tumour.
J He advocated mastectomy for patients with discharge and a palpable tumour but
conservative treatment for those in whom no tumour could be detected. Bloodgood in
1922 expressed the opinion that "bleeding is only a symptom and without a palpable
j tumour does not demand treatment" and further he did not feel that a patient with such
a symptom ran a greater risk of developing cancer. However, in spite of this statement he did search for the cause of the discharge and excised papillomata when found.
In 1923 Miller and Dean Lewis found in reviewing 40 cases with a serous or bloody
discharge that it was due to benign duct papilloma in 32% and to carcinoma in 68%.
This led Lewis to take a more serious view of nipple discharge than previously. He
emphasized the discharge was evidence of a lesion which must be searched for and
identified. In 1927 Hart in reviewing Johns Hopkins' data concerning 119 intracystic
papillary tumours found 48% of the benign lesions had nipple discharge which in
many cases had been present for years and in 20% of these no tumour was palpable,
local excision sufficed to cure these lesions. 12% of his malignant cases had discharge,
the duration of the symptoms was short and tumour was present in every case. In only
one instance did he feel a benign lesion had become malignant. In 1930 Adair presented
a very different point of view. He reviewed 108 cases of sanguineous discharge from
the nipple. He did not however state how many he had to review to obtain this
number. In 47% the symptom was due to malignant and in 53% to benign lesions.
He concluded bloody discharge signified the presence of a carcinoma as often as it did
a benign lesion and that benign papillary cystadenoma eventually developed into
papillary adenacarcinoma. In 1931 Cheatle and Cutler presented histological data in
support of their belief that benign papillomata may evolve into carcinoma and advocated
simple mastectomy as the proper treatment. In 1941 Gray and Wood again reviewed
the Mayo Clinic material regarding nipple discharge. 88 patients were found to have
benign papilloma and all had simple mastectomy. In 87 other cases, a diagnosis of
malignant papilloma was made and 60% of this group had no palpable tumour.    Some
Presented at montly Staff Clinical Meeting, Vancouver, General Hospital, April 22, 1952.
Page 163 authorities however feel that many of these cases were actually benign lesions. Estes and
Phillips in 1948 in reviewing 87 cases of duct papilloma concluded simple mastectomy
was the proper treatment although none of their cases treated by local excision subsequently developed cancer. Campbell, Haagenson and Stoutt, Slaughter and Peterson
and Fitts feel simple mastectomy is too radical in most cases of discharge with no
palpable tumour and prefer excision locally. Donelly and Hinckey are inclined to be
more in favor of mastectomy but emphasize the necessity of carefully weighing each
individual case after thorough investigation.
This report is based on the study of 701 of the cases with disease of the breast
admitted to the Vancouver General Hospital from 1948-51. 518 of these were benign
and 183 malignant lesions. 84 or 11.9% of these patients had discharge from the
nipple. All types of discharge were included because there is tendency to focus
attention on bloody discharge only. (Table I shows the various lesions found with
the number showing discharge). This compares with 9.6% in 219 cases in Donnelly's
series, 9.3% in 1048 cases in Fitts series and 6.3% in 2917 cases, 4% in 2390 malignant
lesions reported by Geschickter. Of the 84 cases in this series 7% had bilateral discharge. Only 2 male patients were encountered and only 1 of these had nipple i
discharge. The age incidence was found to vary with the type of lesion being 45
years for duct papilloma, 46 for chronic cystic mastitis and comedo mastitis and 54
for carcinoma.
Types of Discbarge
Breast lesions involving the duct and secretory systems produce a variety of
abnormal discharges. The breast is not a static organ but is constantly undergoing
hyperplasia and involution. A disturbance of these processes usually as a result of
ovarian hormone inbalance may produce either excessive hyperplasia or delayed involution or both with hyperplasia of the duct lining, or dilation of the ducts with stasis
and accumulation of normal exfoliative products in them. Thus, a discharge may be
due to hyperplasia and tend to be serous and sanguineous or to stagnation and stasis
with accumulation of normal products and be creamy, green or brown. Concern over
a sanguineous discharge should not blind the surgeon to the importance of a non
sanguineous one as the presence of carcinoma cannot be excluded because the discharge
is free from blood. A dark coloured discharge if it contains blood may be due to the
fact that the tumour is situated further from the nipple and the blood has changed in
character by the time it reaches the nipple. Usually 50% of the chronic cystic mastitis
cases that have discharge show the type associated with stasis. In this series it was
about 33%. Galactocele shows a characteristic milky discharge. Table II shows the
incidence of type of nipple discharge.
Etiology of Discharge.
Observations by others show that duct papilloma, chronic cystic mastitis and
carcinoma are responsible for about 75% of the instances of nipple discharge. This
study, however, shows these 3 lesions to account for about 90% of the cases. This-is
about identical with Donnelly's series of 219 cases. Tables III and IV show the lesions
producing all types of discharge in the 84 cases. Of the 48 cases with bloody discharge
60.4% were due to duct papilloma, 22.9% to chronic cystic mastitis, 6% to comedo
mastitis and 10.4% to carcinoma. The latter figure was 53% in Donnelly's series and
47% in Adair's while Geschickter in a large series found only 4%. The occurrence of
discharge in cancer depends on the number of papillary types of cancer in the series
and in the situation of the lesion in the breast. Centrally placed lesions are more
likely to have discharge. 70% of the cases of cancer with discharge in this series were
found to have a non sanguineous discharge. This shows the fallacy of placing too
much emphasis on a sanguineous discharge. However, it is important in regard to
benign lesions, that bloody or serous discharge is very suggestive of a hyperplastic
Page 164 lesion. In this series, age did not seem to influence whether or not a sanguineous
discharge was present, as it occurred as early as 31 years both in malignant and cystic
mastitis cases.
Other causes of discharge reported but not encountered in this series are traumatic
lesions, hormonal dysfunction, sarcoma and chronic inflammatory lesions. Fitts found
the latter as a cause of discharge in 13% of his cases.
The vascular character of duct papillomata is responsible for the symptom of
bleeding shown commonly in these tumours. It is due either to rupture of a friable
vessel or to minor trauma. The tumour is commonly present within 2 cms. from the
areola but may occur in any portion of the duct system, the ones closer to the nipple
being more likely to show bleeding. They occur in normal breasts or in those showing
pathological changes. The lesions may be single or multiple. Quoted figures show
the latter to vary from 17 to 80%. This series showed 60% to be multiple and 43.6%
to show a discharge, of the latter these 53% had associated hyperplasia. Duct
papillomata are frequently impalpable and of the cases with discharge 56% had no
palpable tumour. In cases with bloody discharge 62% had no tumour and 57%
showed multiple lesions. Excision of a grossly recognizable lesion may leave others present
in the breast tissue, and for this reason there is a predisposition to subsequent development of cancer in a breast from which such a lesion has been excised. Geschickter cited
54 cases in which excision was carried out and 3 of these subsequently developed
cancer. Haagenson and Stoutt believe these lesions to be essentially benign and
recommend only local excision but emphasize the importance of excising the whole
lobule feeding the involved duct. Warner states that this lesion is more apt to predispose to the development of cancer than any other encountered in the breast. Two
out of 97 in this series showed adenomatous changes, two showed premalignant changes
and 3 showed carcinoma. Adair estimates the development of cancer required 10-12
years and by this time there is usually a palpable mass. There are many cases reported,
however, where the transformation to malignancy had already occurred yet its only
evidence was discharge from the nipple and this was of short duration.
Discharge in chronic cystic mastitis is not common, only 23 of 347 cases showing
it, 11 of these had bloody discharge and 12 had no palpable tumour. 66%. of the
latter had bloody discharge.    Many of these cases show duct hyperplasia and 4 of the
i 23 had associated duct papilloma.    The one male case with discharge was 82 years old
j wit hno palpable tumour and a serosanguineous discharge. Warren states that since
there is no way on external examination of distinguishing between these forms of
chronic cystic mastitis which show little or no epithelial activity and those which
show marked hyperplasia, the disease must be considered precancerous.    He found that
[patients between 30-49 years of age, having chronic cystic mastitis, showed 11.7 times
as much cancer of the breast as the Massachusetts female population of comparable
age. Women over 50, when hormonal activity is less or absent, showed 2.5 times as much
cancer. In the whole group the rate was 4.5 times that of normal. He lays down the
following rule—if chronic cystic mastitis be localized and the patient under 50 years
; of age or particularly desirous of keeping her breasts, no further therapy beyond local
excision is immediately indicated, but the patient must be followed every 6 months and
if further masses develop, either simple or radical mastectomy should be done, depending
on the pathological findings. However, if on examination, there is found to be
definite evidence of precancerous hyperplasia, a simple mastectomy should be done on
the affected side. Since the lesion is often bilateral, the logical procedure would be to
amputate both breasts, but the risk is not sufficient to warrant this. Geschickter now
is reported to agree with Warren's feeling that clinical cystic mastitis is precancerous.
13 of 183 cases of cancer showed discharge. As noted above 70% had no
sanguineous discharge. Only 2 cases had no palpable tumour. One, age 41, had yellow
discharge for 2J4 years and a nodular breast. The other, age 80, had bleeding for some
months then developed a tumour.    She had had the opposite breast removed 1 year
Page 165 previously for duct cancer. As Geschickter points out, the incidence of bleeding is
low in^infiltrating scirrhous cancer and highest in the more highly differentiated forms.
Duct cancers showed discharge in about 20*4 of his cases and Paget's Disease of the
nipple in 38%. He found cancer to occur in approximately 9% of cases with bleeding
from the nipple without a palpable tumour. Table V lists lesions showing discharge
but no palpable tumour.
The patient with nipple discharge requires a thorough study to determine the
nature of the underlying lesion.   As well as a careful history and physical examination,
a microscopic smear should be made from the discharge to demonstrate the presence
of blood and a positive chemical test shows further confirmation.    Papilloma stains
will on occasion show malignant epithelial cells and give a clue to the underlying lesion j
but while this method of examination is an aid it should by no means supplant biopsy or i
the other diagnostic means.    In cases without a palpable tumour three aids may help i
locate the source of the bleeding:
(1) Transillumination—It is easily applied and often of help if sufficient blood is
present in the duct to outline a papilloma. However, it is often, most
(2) Mammography by injecting thorotrast into the suspicious duct has been
recommended by Hickens, but serious tissue reactions plus the possibility of
error ininimize its value.
(3) Pressure tests have proven most valuable. Point pressure over various segments of the areola will usually indicate which duct shows the discharge.
Frequent examinations every 2 weeks with instruction to the patient to
refrain from examining the breast in the interval will often show a swelling
where the discharge has accumulated in the dilated duct. Haagensen and
Stoutt in this way feel they can find the involved duct in nearly all cases.
Aspiration of a palpable tumour has been recommended.
Haagensen and Stoutt strongly advise against relying on frozen sections in
questionable cases, and do only a biopsy, waiting for the report on the study of paraffin
sections. before carrying out more radical surgery. Their experiences and the findings
in this survey show examples of radical surgery having been done only to find on
further pathological study that the lesion was not malignant. This mistake is a serious
one, especially in a young woman, and the small risk of a second operation is amply
justified if a breast may be saved.
In this study, excluding cases with a diagnosis of malignancy, 41 cases of duct
papilloma with discharge were operated on, 27% having excision, and 67% simple
mastectomy. This is much more radical treatment than that of Haagensen and Stoutt,
who had 70% excision and only 30% mastectomy in 108 cases. In the 23 cases of
chronic cystic mastitis, 25% had excision and 75% simple mastectomy.
In the cases without a palpable tumour, there were 23 duct papillomas, 40%
having biopsy and 60%, or 14 cases, simple mastectomy. Only 3 of these 14 cases
were below menopausal age, averaging 41 years. In the 12 cystic mastitis cases without
a tumour, 3 had excision and 9 had simple mastectomy, the youngest being 31 and 6
being menopausal age. In the comedo mastitis cases with discharge, 1 only had
excision and 5 simple mastectomy, one of the latter cases being only 28 years old and
having a bilateral simple mastectomy. This case strongly exemplifies the need of
adequate investigation and of waiting for the study of paraffin sections before finally
deciding on the course to follow.
This study does not include any data on follow-up. However, Estes and Phillips,
in 87 patients, had no cases of cancer develop where excision only was done, but 15%
required further operation.     Geschickter  found 4  cases of cancer develop in cystic
Page 166 disease following excision and 3 in adenosis. In 54 duct papillomas, 8 recurred and 3,
or 6%, developed cancer. None of Haagensen and Stoutt's cases (72) of duct
papilloma developed cancer ancf only 4 showed recurrence. Donnelly followed several
cases with discharge and no palpable tumour. All having mastectomies were well. One
with bleeding was followed without operation and developed Cancer 10 years later, of
7 with duct papillomas with excision only, 3 were well, one had recurrence and 3
developed cancer, and, in 5 with cystic mastitis showing hyperplasia, 3 developed
Even accepting the dogma that it is better that a woman lose her breast than
her life, the determination of the extent of the surgical procedure to be done in any
case is still not easy. To most women the loss of a breast is a tragedy and no one
has been able to determine the number of breasts which, with justification, may be
sacrificed to save a life. The group of cases in whom both tumour and discharge are
present arouse no controversy, the presence of the mass in itself being a definite indication for surgery. However, a bloody discharge^ should never stampede the surgeon
into performing a radical mastectomy.
The troublesome and dangerous problem is the discharging breast which shows
no palpable mass. No apology need be offered for performing many biopsies, or
mastectomies in border-line cases.
However, the psychic and cosmetic arguments against mastectomy are prominent
in the minds of patients and demand consideration.
Three general alternatives present themselves:
(1) Mastectomy as recommended by those believing the undiscovered source of
the discharge is probably a precancerous or even a malignant lesion.
(2) Observation as advised by Blood good and others. The great weakness of this
course is the great difficulty in getting patients to come for regular follow-up.
So often they are lost track of and only reappear when it is tod late for
successful treatment.
(3) Local excision or mastectomy. Many women will not consent to mastectomy
and in many cases it is a radical procedure. Local surgery may often and
should, if possible, supplant the less desirable alternative of observation.
There are 4 groups of patients with nipple discharge and no tumour, in which
the indications for surgery are definite. In consideration of the above results, and in
the light of personal experience, I would recommend the following:
(1) In cases with positive pressure tests or positive transillumination—excision of
the involved duct. In view of the possibility of multiple lesions existing, excision of
the involved duct should include removal en bloc of the involved segment right out
of the breast margin. Babcock's suggestion of inserting a blunt needle into the duct
identified and incising along it is a good one. At times mastectomy may be required,
depending on the extent of the lesion or the presence of precancerous hyperplasia.
(2) In nipple discharge with localized nodularity—A biopsy, or if. hyperplastic
I epithelium is found, either a quadrant excision or simple mastectomy.
(3) In nipple discharge in patients approaching or after the menopause—Simple
mastectomy. The cosmetic and psychic arguments' are so attenuated and the risk of
cancer so real, it is safer to adopt an arbitrary policy and do simple mastectomy unless
some definite local lesion can be found.
(4) In continued bleeding of • undetermined origin the whole breast should be
removed where the bleeding continues under observation for one month or more and
at this time no localized lesion can be identified.
Further aid in individualizing patients as to surgical treatment versus observation
may be received by consideration of the following factors:   (1)   Type of discharge.
[ (2) Duration of the discharge. (3) Age of the patient. (4) A family history of cancer.
(5) The size of the breast.  (6)  The psychology of the patient, and (7)  the question
of adequate follow-up which is essential to a programme of observation.
Page 167 Summary:
(1) 84 cases of nipple discharge are reported, 57% showed blood in the discharge
and 15% were malignant.
(2) Non-sanguineous discharge must not be dismissed as harmless as 43% of the
cases showed this type and 70% of the malignant cases showed this type.
(3) 3 lesions were responsible for about 90% of the cases, i.e. duct papillomata,
chronic cystic mastitis and carcinoma.
(4) The chief problem is the discharging breast with no palpable tumour. Such
a breast must be suspected of harbouring not only the precancerous conditions of duct
papilloma or chronic cystic mastitis with epithelial hyperplasia, but even an actual
cancer.   50% of cases had no palpable tumour.
(5) Duct papillomata were found to be multiple in 60% of cases and show associated hyperplasia in 53%.
(6) Treatment consists of local excision or mastectomy. A certain number of
cases merit observation if this can be adequately carried out. This group should be
made as small as possible-by careful consideration of all possible surgical indications.
In this manner important cancer-preventive surgery can be performed and the surgeon
occasionally rewarded by the discovery of an early impalpable cancer.
Table I
LESION                                T
Duct Papilloma
45  years
Cystic Disease Breast
46 years
Fibro- Adenoma
Fat Necrosis
Comedo Mastitis
54 years
*   1 male.
4 with mixed lesions.
Table II
Bloody   associated  'with
other   types
Clear   or  Milky
Table HI
or Precancerous
Type  of  Discharge
Bloody  with  other
Clear or Milky
Page 168 Table IV
50    %
28    %
14    %
Intra Ductal Papilloma
Intra  Ductal  Carcinoma
Chronic  Cystic Mastitis
Comedo  Mastitis
Paget's Disease
TOTAL 84 100.0%
Table V
Duct Papilloma 23 Cases 56    %
Cystic Mastitis 12     " 50    %
Comedo Mastitis 3     " 50    %
Carcinoma 2     " 15.4%
Duct Papilloma                         18  Cases                            62    %
Cystic Mastitis                               8     "                                   77    %
Comedo Mastitis                          2      "                                  40    %
Carcinoma 1     *' 	
Soyd, W. L.: Surgical Pathology, 6th Edition.
[Campbell, O. T.: Bleeding Nipple Surgery, Vol. 19, 1946, p. 48.
Shields & Warren: Prognosis in Benign Lesions of Female Breast Surgery, Vol. 19, 1946, p. 37.
Foote & Stewart: Classification of Cancer of Breast Surgery, Vol.  19, 1946, p. 74.
[Donnelly, B. A.: Nipple Discharge, Annals—Surgery, Vol. 131, p. 343.
Geschickter, C. F.: Diseases of the Breast, Lippincott, 1943.
Hinckey, P. R.: Annals—Surgery, Vol. 113, 1941, p. 341.
Slaughter, D. P. & Petino, L. W.: S. G. & O., Vol. 85, 1947, p. 456.
Estes & Phillips, S. G. & O., Vol. 89, 1949, p. 345.
Haagenson, Stoutt & Phillips: Annals—Surgery, Vol. 133, 1951, p. 18.
fitts, Maxwell & Horn: Annals—Surgery, Vol. 134,  (July)   1951, p. 29.
The Medical Undergradute Society of the University of British
Columbia is happy to announce that plans are well advanced for the
Third Annual Medical Ball to be held on Friday, March 27, 1953, in
the Ballroom of the Hotel Vancouver. The Society hopes that the
success of the previous years will encourage their many friends in the
medical profession to lend again their splendid support, so that the
bursaries established from the proceeds of the preceding Medical
Balls can be maintained.
A new private, semi-private. Hospital. Chronic and convalescent
care at reasonable rates for private and semi-private accommodation.
Full staff of experienced nurses.
Apply to Matron    —    CE. 5443
2336 West 3rd Avenue
Page 169
V Urtttafj Columbia Ufutstott
Canadian iKritftal As00tiatt0n
1807 West 10th Ave., Vancouver, B.C.      Dr. G. Gordon Ferguson, Exec. Secy
President—Dr. J. A. Ganshorn.
President-elect—Dr. R. G. Large-
Vice-President and Chairman of General Assembly—Dr. F. A. TurnbulL
Hon. Secretary-Treasurer—Dr. W. R. Brewster	
-Prince Rupert
.New "Westminster
Members of the Board of Directors
Dr. G. Chisholm
Dr. E. W. Boak
Dr. C. C. Browne
Prince Rupert and Cariboo
Dr. R. G. Large
New Westminster
Dr. J. A. Sinclair
Dr. W. R. Brewster
Dr. A. S. Underhlll
Dr. C. J. M. Willoughby
Dr. F. A. Turnbull
Dr. A. W. Bagnall
Dr. F. P. Patterson
Dr. P. 0. Lehmann
Dr. G. C. Johnston
Dr. Ross Robertson
Dr. R. A. Gilchrist
Dr. J. Ross Davidson
Dr. R. A. Palmer
Dr. J. McMurchy
Standing Committees
Constitution and By-Laws—
.Dr. R. A. Stanley, Vancouver
Medical Economics.
Medical Education-
Programme and Arrangements.
Public Health	
Special Committees
Arthritis and Rheumatism	
_Dr. W.  R. Brewster, New Westminster
 Dr. J. C. Thomas, Vancouver
 Dr. P. O. Lehman} Vancouver
 Dr. T. R. Sarjeant, Vancouver
 Dr. J. A. Ganshorn, Vancouver
 Dr. Harold Taylor, Vancouver
 Dr. G. F. Kincade, Vancouver
Civil Defence	
Hospital Service	
Industrial Medicine-
Maternal Welfare	
—Dr. F. W. Hurlburt, Vancouver
 Dr. Roger Wilson, Vancouver
 Dr. John Sturdy, Vancouver
—Dr. J. C. Moscovich, Vancouver
_Dr. J. S. Daly, Trail
JDr. A. M. Agnew, Vancouver
—Dr. E. C. McCoy, Vancouver
Public Relations.
_Dr.  D. M. Whitelaw, Vancouver
—Dr. G. C. Johnston, Vancouver
The reconstituted B.C. Division of the C.M.A., has just passed its first birthday
with a terrific amount of work to its credit. There will be some who will not agree
with all the things that have been done, but everyone will have to admit that a
tremendous amount has been accomplished. All economic affairs have been taken over
from the Council of the College, and this transfer in itself has been a big job, though
greatly eased by the co-operation of the Council, for which we sincerely thank them.
There has been a complete revision of the scale of fees, plus the publishing of
the little pamphlet as adopted 15 April. There is to be continuous supervision of this,
with annual changes as indicated.    Here again the ground work done by the Council
Page 170 jof the College has been most helpful, though the final formulation and responsibility
belongs to the Division. An increase of $2.00 per year in the S.A.M.S. rates over
the best offer which had previously been made to the Council, is another achievement
of the Division. The revision of Workmen's Compensation fees is mainly to the credit
of the Council, though the B.C. Division carried on with the good work the former
had undertaken, and brought it to a successful conclusion. These are some of the
most obvious points of economic accomplishment, and undoubtedly we will all gain
far more from them than the small annual fee we owe to the Division. . It is the
hope of your executive therefore, that all physicians will realize that membership in
the B.C. Division of the C.M.A. is most important to them in their own best interests.
However, it is not only in the economic field that things have been happening.
Committiies have been active in all phases of community life. The Public Relations
committee, with its weekly radio broadcast, has started something new in Canada.
Another instance of the general usefulness of these committees is that The Community
Chest requested an official position of the doctors on the narcotic problem. A copy
of our committee's report is included in this section, and I would recommend your
reading it, as you will undoubtedly be asked questions on this frequently.
Many other groups are energetic sections. For example, there has been formed a
Society for those doctors employed by the provincial government and similar groups.
The B.C. Society of Internal Medicine is leading the way in one direction, through having
established an annual bursary of $300.00 for a student of the faculty of Medicine.
All sections are holding frequent meetings, at which excellent clinical material and
talks are given.
*t •£. *t •*.
While checking up on available courses, I found that these are given in considerable
detail in the Journal of the American Medical Association of 13 December. If this
is not available to you, and there is anything in particular you are interested in, write
us, telling the type of course and the approximate time you would like to take this,
and we will tell you what is available. _R L SKINNER> Editor.
Several months ago the Community Chest and Council of Greater Vancouver
undertook an investigation of the problem of narcotic addiction in that area. A
representative committee under Dr. L. E. Ranta secured all available data on this
subject and after a thorough analysis prepared a report which was endorsed by the
Board of Directors of the Chest and Council. This report was made public and printed
in detail in the provincial press. As a result of this a great deal of comment was raised
and. numerous organizations presented their views for and against the recommendations
that were made.
The Executive of the B.C. Medical Association was requested by the President
of the Community Chest and Council of Greater Vancouver to take a public stand in
this matter and actively support the Community Chest. If this was not possible,
constructive criticism and suggestions were requested. For the guidance of the
Executive in formulating a policy for the Medical Association on narcotic addiction a
representative group of members was chosen to study this report. This committee
included medical practitioners drawn from the following groups: Community Chest
and Council, Vancouver Board of Trade, Provincial Department of Health, Department
of Medicine of the University of British Columbia, Provincial Mental Hospital, Section
on Psychiatry and Neurology and the Committee on Public Health of the B.C. Medical
Association. ^^
In studying this report the committee had in mind the results of the survey
conducted by Mr. E. E. Winch in 1947, from which it appeared that medical opinion
was in favour of a treatment centre for drug addicts, as well as for the distribution of
narcotics to "registered addicts".
Page 171 The Community Chest report had five main recommendations which were as
1. The sponsoring and maintaining of a programme of adult and youth education
concerning the dangers of narcotic addiction.
2. The establishment of a pilot treatment and rehabilitation centre for drug
3. The modification of the Opium and Narcotic Drug Act to permit the establishment of narcotic clinics where "registered narcotic users" could receive the
rninimum required dosage of drugs.
4. The increase of penalties for the illegal importation, manufacture and distribution of narcotic drugs.
5. The segregation of narcotic addicts in provincial jails.
In endorsing Resolutions 1, 4 and 5, the committee felt it could do so without
reservation, except that the educational campaign in schools should have no special
emphasis, other than the presentation of factual information such as is given in lectures
on health. In respect to the increase of minimum penalties for trafficking in narcotics,
it was realized that care must be taken not to increase penalties against the addict as
such, but that much higher penalties should be directed against the trafficker.
Your committee also recommended that as a medical group we should request
clarification of the present position of the physician in his right to administer drugs to
an addict and suggested that this problem might properly be referred to a medical-legal
study committee, because at the present time the position of the physician in thijl
matter is far from clear.
In approaching the problem of establishing a pilot medical treatment and rehabilitation centre together with comprehensive follow-up services and the establishment
of narcotic clinics where "registered narcotic users" could receive their minimum
requirements, it was felt that as physicians we should endorse some plan that would
lead to research into and treatment of such a serious medical problem.
From a study of the problem, it is apparent that the treatment and cure of drug
addiction cannot be accomplished by merely getting the addict off the drug. Many
addicts are taken off narcotics and remain off them for long periods of time only to
return to their use at the first opportunity. For this reason any treatment centre
established must be planned so that psychological investigation and rehabilitation will be
an important part of the programme.
From this standpoint it was recommended that the establishment of a pilot treatment and rehabilitation centre should be approved in principle. To quote from our
report: "It is desired, however, to emphasize that such a pilot plan would be for study
and investigation of the problem. Initially, it would be in the nature of a research
centre which might, in some aspects, expand to a controlled treatment centre. The
committee further recommends that admission to this pilot centre should be selective!
and voluntary but that the patients must agree to complete treatment and follow-up
and the power must be given to the clinic authorities to enforce the completion of
treatment once it is started. The committee realized that this would indicate the need
for some form of committal through voluntary decisions."
As regards "the establishment of narcotic clinics where registered narcotic users
could obtain their minimum required dosages", this appeared to present great difficulties;-
The chief contention of the Community Chest and Council of Greater Vancouver was
that this would eliminate the illicit distribution of narcotics. However, from the
evidence considered it was felt that this was not certain. Your committee was of the
opinion that such a plan might be necessary as a natural sequence of the treatment and
rehabilitation centre and for that reason recommended as follows: "The committed
does not believe there is yet sufficient evidence to come to any definite conclusion as to
the eflfect of such a narcotic clinic in cutting down illicit drug traffic or to solve the
problem.    The committee felt that if such a supply clinic were set up it should be
Page 172 confined, as far as they could see at the present moment, to those addicts who have
gone through a treatment centre and whose treatment has failed. This confirms the
physicians' favourable response to Mr. Winch's 1947 questionnaire when he defined a
registered addict as one who had received treatment for drug addiction in an established
Your committee also expressed the feeling that the Community Chest.and Council
of Greater Vancouver should be commended on the work they had done in bringing
this problem forward and for the ideals they wish to attain.
G. F. KINCADE, Chairman,
Committee on Public Health.
The M-S-A wishes to announce to the practising physician and surgeon that it has
established a Field Accounting Division under the supervision of Mr. A. G. Hodson,
Executive Assistant. The purpose of this Division is to assist the doctors' office staff in
the handling and forwarding of account cards and to be a source of general information,
on non-professional matters. Subjects concerning medical policy should of course be
directed by the doctor to the Director of Medical Services.
Mr. Hodson makes periodic visits to doctors' offices throughout the Province but
it is suggested that the doctors' staff feel free to contact .this office at any time and in
particular whenever a change in the office staff occurs.
In this way, it is hoped that we may ensure a proper flow of account cards spread
throughout the month and thereby expedite their processing and payment to the
doctor. This becomes increasingly important as the number covered by M-S-A
continues to grow.
Of the Duties of Physicians to Their Patients ^|
For the honourable physician the first consideration will always be the welfare of
the sick. On his conscience rests the comfort, health and the lives of those under his
care. To each he gives his utmost in science and art and human helpfulness. Their
confidences are safe in his keeping, except in those rare instances when the safeguarding
of society imposes a higher law. He does not multiply costs without need, nor raise
needless fears, nor allay fears without full consideration. Even when he cannot cure
he will alleviate, and be counsellor and friend.
It is a special duty for one who stands guard over the lives of men to keep his
science and his art in good repair, to enlarge and refresh his knowledge constantly, and
to give his patients treatment that is not only sympathetic, but the best possible in the
circumstances. To this end he will always be willing to check and supplement his
diagnosis, treatment and prognosis by consultation. No excellence in one respect can
excuse slipshod, ignorant or out-dated service.
Every patient is entitled to adequate examination by the physician. The physician
should aim to give to his patient the same quality of service which he hopes, in time
of need for himself or his family, to receive from another physician.
If a practitioner is confining his study and practice to a special branch, he must
be sure that his special knowledge and outlook are suitable and adequate to all the
needs of the sick person under his care.
In short, the greatest well-being of the sick person should be the whole study
and care of the honourable physician.
"The greatest trust between man and man is the trust of giving counsel." \ —Francis Bacon.
Page 173 Of the Duties of Physicians Regarding Consultations
It is the duty of the attending physician to accept the opportunity of a second
opinion in any illness that is serious, obscure or difficult, or when consultation is desired
by the patient or by persons authorized to act on the patient's behalf. While the physician should name the consultant he prefers, he should not refuse to meet the physician
of the patient's choice, though he may urge, if he so thinks, that such consultant has
not the qualifications or experience that the existing situation demands.
In the following circumstances it is particularly desirable that the attending physician, while dealing with an emergency when this exists, should, whenever possible,
secure consultation with a colleague:
(a) When the propriety of performing an operation or of adopting a course of
treatment which may entail considerable risk to the life, activities or capacities of
the patient has to be considered, and particularly when the condition which it is sought
to relieve by this treatment is in itself not dangerous to life.
(b) When operative measures involving death of the foetus or of an unborn child
are contemplated, particularly if labour has not begun.
(c) When the propriety of prescribing, or repeating a prescription for, any drug
scheduled under the Opium and Narcotic Drug Act, in the case of a person seeking
relief from the symptoms of addiction to that drug, is under consideration.
(d) When there are grounds for suspecting that the patient
(i)   has been subjected to an illegal operation or
(ii)  is the victim of criminal poisoning.
Since consultation is planned wholly for the good of the sick person, there should
enter into it no trace of insincerity, rivalry or envy. Before seeing the patient, the
attending physician should, as a rule, give the consultant a brief history of the case.
On entering the room of the patient, the attending physician should precede the consultant, and should, if necessary, introduce him to the patient. After joint examination,
the physicians should discuss the case in private, then the joint decision should be communicated to the patient and his family by the attending physician, supplemented, if
necessary, by the consultant. If agreement as to diagnosis and treatment should not
be possible, and if the consultant is convinced that the future well-being of the patient
is concerned in his so doing, he should inform the patient and his family in the presence
of the attending physician of the points of disagreement.
If it is impossible for the attending physician and the consultant to make their
examinations at the same time, the consultant's conduct must be especially careful and
tactful. The consultant should in such case communicate his opinion and suggestions
for treatment in a closed letter addressed to the attending physician. Responsibility
for the patient's care rests with the physician in attendance. If he should retire from the
case, the consultant must not replace him during the present illness, except at the
request of the attending physician or with his approval.
Paid Advocacy
The paid advocacy of any commodity, whatever its merits, cannot be reconciled
with the ideals of a physician. He must be free to choose from all elements those be^t
for his patient, not a merchandiser pushing one particular element for gain. It is precisely because he is a physician that his advocacy has extra market value. In thus advertising a commodity, he presumes to sell that which is not his to sell, the common tradition and inheritance of reputation, esteem and standing of the whole profession.
With Medical Record experience, available for typing Manuscripts,
Thesis, etc., setting up Disease Index Systems, or other specialized
work on Medical Records.
Miss Rea W. Dow, R.N., 792 West 26th Ave., Vancouver, B.C.
FAirmont 6369-R
G. F. AMYOT, M.D., D.P.H.,
Deputy Minister of Health, Province of British Columbia
A. M. GEE, M.D.,
Director, Mental Health Services, Province of British Columbia
Over the past few years a great deal of controversy has raged around the choice of
a prophylactic agent for ophthalmia neonatorum.
With the increased use, and known efficacy of penicillin in the treatment of
gonococcal infections, the question has naturally been raised as to whether this antibiotic should be considered the prophylactic agent of choice for the prevention of
ophthalmia neonatorum and as such, should replace the silver nitrate solution recommended by Crede. As this subject is very frequently brought before the Division of
Venereal Disease Control for an opinion, it has been decided to prepare the following
statement as to present policy:
1. In the United States some form of prophylaxis against ophthalmia neonatorum is
now required, by either law or regulation, in all of the forty-eight states and the
District of Columbia. In thirty-two states, the laws or regulations specify the
silver nitrate method, while in only one state, is penicillin mentioned as an
alternative procedure. Among the ten Canadian provinces, all specify the use
of one percent silver nitrate solution, although two (Ontario and Alberta) also
permit the use of forty percent argyrol. Saskatchewan is the only province
which has to date, proposed as an alternative "any equally effective chemo-
prophylactic or antibiotic agent."
2. The National Society for the Prevention of Blindness has also gone on record
as favouring the continued use of one per cent silver nitrate solution as the preferred prophylactic agent. After a meeting of twenty-five medical consultants
to the Society held in Atlantic City last Fall, the Executive Director of the
Society reported that their Medical Advisory Group felt that additional scientific
research was needed before penicillin could be accepted as a safe and adequate
3. The Division of Venereal Disease Control in this province has been guided not
only by opinions of consultants in ophthalmology to the Division during the
past years but also ophthalmologists not associated with this Division. These
ophthalmologists were unanimous in their opinion that silver nitrate should be
retained as the prophylactic of choice, and that the time had not yet come to
advise the use of penicillin for this purpose. It is interesting to note that each
of the ophthalmologists consulted, quoted cases in which there had been apparent
damage to the delicate structures of the eye following the use of silver nitrate
solution, but that these unfortunate incidents had occurred either because silver
nitrate in too concentrated solution had been used, or through inability on the
.part of users to appreciate that care is necessary in the instillation of this
solution into the eyes. In this connection, it has long been the practice of
this Division to recommend that the silver nitrate solution be placed only in the
outer canthus of the eye and that, during the insertion, the lacrimal punctum
be temporarily occluded by pressure. It would seem, therefore, that accidents
and complaints of chemical irritation following the use of silver nitrate could
be largely obviated if solutions of not greater than one percent strength were
used and the drops were inserted in accordance with these recommendations.
Page 175 4. Great danger does exist in that if one policy is not maintained province-wide,
confusion would eventually result as to the proper procedures in the prevention
of Ophthalmia Neonatorum. It is pinted out that if approval were given to
certain of the larger hospitals in this province to use penicillin, internes trained
in these hospitals would enter into private practice and admit patients to smaller
hospitals where silver nitrate is the only drug that could safely be used; this
is due to the fact that it could not always be assured that penicillin would be
freshly prepared and properly stored in the smaller hospitals.
5. The Division of Venereal Disease Control has been interested in the possibilities
of using penicillin in the prophylaxis of Ophthalmia Neonatorum for some
time. Certain studies have already been carried out and it is hoped to investigate
this matter further in collaboration with the appropriate departments of the
Faculty of Medicine, University of British Columbia.
In view of the above, and the fact that the record in the prevention of Ophthalmia
Neonatorum in the province is excellent to date, it is felt that the policy of the
Department of Health must remain in status quo, at least for the present, in regard
to the prevention of Ophthalmia Neonatorum, namely, silver nitrate should continue to
be recognized as the prophylactic of choice.    'Mm
Dr. A. John Nelson, Director, Division of Venereal Disease Control, and Consultant
in Epidemiology, was successful in passing the examinations of the Royal College of
Physicians and Surgeons for Certification in Public Health.
Dr. W. S. Maddin, Physician in Charge of Clinics, Division of Venereal Disease
Control, also passed the examination of the Royal College of Physicians and Surgeons
for Certification in Dermatology and Syphilology.
Director, American College of Surgeons
(Our readers will make the allowances for the fact that this address was given in
the United States where the Blue Shield operates—arid this does not directly apply here,
but his conclusions are equally applicable in Canada, and deserve our consideration—
The College of Surgeons has quite recently undertaken a really active campaign
against this practice, this campaign consisting first of exploring the basic reasons for
fee splitting and then attempting to find a practical method of stopping it. For too
many years, I think, the profession has taken the attitude that fee splitting is a sin
and we are all against it, but there isn't very much that can be done about it.
Now to arrive at a definition. The Committee of the College worked for a long
time to arrive at an all-inclusive definition. I do not think they have succeeded with a
perfect definition, but they have come up with something like this: That it is a
division of a fee for medical care, by subterfuge or otherwise and between two or more
physicians, one of them usually being the referring physician. Fee splitting is not
limited to surgeons, but can be practiced in consultation, clinical pathology, radiology
and almost any association in medicine; and, as a matter of fact, we have uncovered
what might be called a "fee splitting ring" in consultation in a hospital where patients
are habitually passed from one consultant to another and the fees are divided.
There is also another practice, a very similar practice, but one which is not fee splitting for the reason that the moneys paid do not constitute professional fees, and that is
Page 176 h
I the practice of kick backs or commissions on spectacles, orthopedic appliances, or other
I equipment prescribed for the patient. .
Why is fee splitting unmoral?   It is immoral because the interest of the patient
lis sacrificed to the greed of doctors. Curiously enough, in another great profession fee
splitting is not only habitual but is considered highly ethical, and this is in the profession
| of law. Lawyers all split fees when they refer cases to another lawyer, and lawyers
are sometimes unable to understand why, in the practice of medicine, fee splitting is
considered unethical.
In fee splitting, patients are referred usually not to the best surgeons, not to the
best consultant, but to one who offers the most to the referring physician. Fee splitting
is, therefore, the sale of the patient's pathology to the highest bidder. It is larceny
since the doctor does not own the patient's pathology and is selling something which
is not his own. It is embezzlement because the doctor has converted for his own use
and his own gain something which the patient has placed in the doctor's trust. Fee
splitting reduces surgery to the level of a confidence game, and the fee splitter to the
level of a race track tout. Fee splitting is illegal in some thirty States. In most States,
it is a crime which can be punished by imprisonment, and, of course, it is highly immoral
everywhere. The very fact that laws have been passed against it is another warning
to the medical profession that, if we don't clean our own house, the public is one of
these days going to clean it for us. I think that it is rather terrible that legislatures in
thirty States have felt compelled to pass laws against the division of professional fees.
It is curious in how many ways that fee splitting can be practiced. The first and
obvious way is just the plain division of fees in a surgical case with no service rendered
by the referring physician. Another, and in fact a much more common way, is the
habitual use of the referring physician as an assistant or anesthetist. There is a great deal
of surgery done in this country under conditions where there are no trained assistants,
no residents, no interns in hospitals, and the surgeon must look to another practitioner
for assistance and for the anesthetic. In most cases, we find the surgeons habitually
turn to the same practitioner. He is very often a general practitioner, not qualified in
surgery but having had wide experience in assistance or in giving anesthesia. Regardless
of who refers the case, the surgeon will habitually take the same other practitioner for
his assistant, rather than taking whatever physician refers the patient to him.
There is also a new way of practising division of fees, which rather astounded me
when I discovered it a few months ago;—showing that there is nothing new under the
sun and that it is almost impossible to make a rule that someone cannot circumvent—
and that is, there are several, I don't know how many, clinics in the country which
are placing general practitioners on the payroll of the clinic as members of the clinic—
general practitioners within the radius of fifty miles.
Their salaries are then adjusted each year according to the amount of work referred
to the clinic in the previous year. There is no direct division of fees in each case, but
it all adds up to the same. >
Another practice, an unethical practice, closely allied to the division of fees is the
practice of ghost surgery. As far as the patient knows, his family doctor does the operation; but, after the patient is well anesthetized, some young surgeon, who is having
to struggle to get established, steps in and does the operation for which the family
physician pays him out of pocket, and then the family physician submits the bill to
the family for the surgery done. This is frowned upon by better surgeons because of
the overall essential responsibility that the surgeon must assume in the care of the
surgical patient. It is not right; it is not proper that he should merely be a technician
and step in and operate without ever having seen the patient before and have no
responsibility at all in the after care of that patient.
It seems to me that the yery existence of this practice, although it is not
widespread when you consider the amount of surgery and referred work that is being
Page 177
f done every day in this country, but tjie fact that it exists at all is evidence of the
presence of some and perhaps too much greed in the medical profession.
One very interesting thing to me is the spotty distribution of this practice of fee
splitting. There are certain parts of this country in which it is prevalent, very prevalent
—in the Middle West, Illinois, Indiana, and Iowa—and yet in the State of Virginia
I am assured by men whose veracity I wouldn't question at all that it just doesn't exist
there. They say they have practised surgery there all their lives and they have never
been asked to divide a fee and they have never known anyone who did divide a fee.
On the other hand a distinguished Canadian surgeon told me last week that there is one
little spot up in Canada where no one could make a living unless he divided fees. It has
been established there for one hundred years and is accepted pattern of practice. It
would be very hard to break up because the people themselves know all about it and
consider that it is an established pattern of practice which doesn't concern them.
As long as we in the profession tolerate this affair, we can't go before the court
of public opinion with clean hands and expect the public to support us. I am quite
certain that one of our most important duties is for the profession to clean its own
house. One way, and perhaps the only way, we can do that is to deny professional
association to those people who do bring discredit upon the profession. For many years
we have assured the public that membership in the local medical society is the profession's
stamp of approval upon the individual doctor, and yet we do admit to these professional
associations people whom we know to be unethical and who are bringing discredit upon
the medical profession.
Now, as far as the Blue Shield and other Plans are concerned, there is one very
important aspect of fee splitting. In the past few months at the sectional meetings
of the College of Surgeons, I must have been asked fifty times, "What are insurance
companies, commercial carriers as well as the nonprofit plans, going to do about fixing
a pattern for the ethical division of fees?" Now that is something that. Blue Shield
must do. In many plans, perhaps yet in the majority of Plans, there is only one fee
paid for a surgical operation. So long as the operation is done in a hospital where there
are residents and there are no assistants to be employed, there is only one man who does
share in the fees; but there is very much surgery done in places where the assistant
is also a practising physician and must be paid for his assistance; and yet there is no
provision made, not only by Blue Shield but by insurance companies and in many
cases by Workmen's Compensation agencies, whereby that fee can be divided. It must
be divided by the man who gets it. It is rather encouraging to me to find out how
many men doing surgery shudder even at that, although that is obviously not against
the patient's interest at all; but they feel guilty, they feel that their hands are not
clean and they ask me repeatedly to try and get Blue Shield to work out a formula
whereby the fees paid can be honestly and ethically divided when outside assistants
must be paid for in surgery.
I hope that the Blue Shield organization will study this problem. Perhaps the
appointment of a committee to give it some thought and come up with a formula will
solve it. Now these surgeons are not asking for two fees to be paid so they can pay
assistants. I have not heard anyone say that at all. They don't want any more money.
They just want some honest and ethical way that they can divide that money with the
assistant whom they must employ to help them.
(Taken from Proceedings of 1951  Annual Conference of Blue Shield Plans, Biloxi,
Mississippi—April 16th, 17th and 18 th, 1951.
Complete office space for medical man available. Desirable location
on main street at Cloverdale, twelve miles from New Westminster.
Occupancy in June.
For further particulars write to
Dr. J. C. Rife, Box 150, Cloverdale, B.C.
Page 178 r
Below we publish a memorandum supplied by Dr. Lynn Gunn, Registrar of the
B.C.  College  of  Physicians  and Surgeons.    This  document  speaks  for  itself—and
emphasises two things.   First, the fact that there is a strongly-organised group working
ostensibly within the framework of the United Nations, which is frankly laying plans
for state medicine.   Secondly, they show a certain lack of scruple in their method of
bringing this about.  They will employ subterfuge and even resort to misrepresentation
of facts, to accomplish their end.    We shall do well, all of us, to <(read, mark, learn
and inwardly digest" this document.
—Editors Note.
The May, 1952, issue of the "Bulletin" contained an editorial concerning the
proposed programme of the International Labour Organization for a Compulsory Welfare
State. Details of the proposed plan will be found in a large document, Report V (a) (2)
Minhnurn Standards of Social Security issued by the International Labour Office in
1952. At the end of this document there is appended a "Statement of W.H.O. Consultant Group". It should be noted that not a single member of this group is a
practicing physician.
The report issued by the consultant group, and which will reach all delegates to
the I.L.O. convention, definitely recommends a full-time salaried medical service.    It
1 discusses the fee for service system and ruthlessly discards it, stating that "the system
exposes the physician to the temptation to care for a patient who should be sent to a
j specialist or an institution. It gives an incentive for the prolongation, rather than the
reduction of illness." It then discusses the capitation system, which it thinks better
than the fee for service system, but discards it as "permitting a perfunctory quality of
j medical care since the physician receives no more reward for extra service".    Finally,
j it lauds the salary system in an illogical and unfounded manner.
It is evident that a social security scheme can do anything between two extremes—
one leaving the medical profession entirely free, and the other (which is advocated by
the International Labour Organization) of transferring it into a group of whole-time
The World Medical Association on the other hand is carrying the torch on an
international level for freedom in medical practice, for quality of medical service to
j patients and for elimination of political considerations in medicine.
The Council of the W.M.A., which includes a Canadian member, Dr. T. C. Rout-
ley, prepared a document refuting the ideas of the I.L.O. and interviewed personally
the Deputy Director General of I.L.O. and two of his associates in Geneva. While
Mr. Roo, the Deputy Director General, intimated that he would be personally interested
in reading the document, he refused to have it distributed to the delegates. Apparently
the only way it could reach the delegates would be either for the document to be sent
to the Chairman of the Conference Committee on Social Security, who might distribute
it, or for the World Medical Association to attempt to distribute it. Both methods
will be used.
The World Medical Association have set down the following twelve principles of
socia lsecurity, as expressing the views of the Profession on the relationship between
I itself and social security.
Whenever medical care is provided as part of social security, the following
principles should govern its provisions:
1. Freedom of choice of physician by the patient, liberty of physician to choose patient
except in cases of emergency or humanitarianism.
2. No intervention of third party between physician and patient.
3. Where medical service is to be submitted to control, the control should be exercised
by physicians.
Page 179 4. Freedom of choice of hospital by patient.
5. Freedom of the physician to choose the location and type of his practice.
6. No restriction of medication or mode of treatment by physician except in case
of abuse.
7. Appropriate representation of medical profession in every official body dealing
with medical care.
8. It is not in the public interest that physicians should be full-time salaried servants
of the government or social security bodies.
9. Remuneration of medical services ought not to depend directly on the financial
condition of the insurance organization.
10. Any social security or insurance plan must be open to the participation of any
licensed physician, and no physician should be compelled to participate if he does
not wish to do so.
11. Compulsory health insurance plans should cover only those persons who are unable
to make their own arrangements for medical care.
12. There shall be no exploitation of the physician, the physician's services, or the
public, by any person or organization.
It is interesting to note that the above principles have been approved by the;
medical representatives of 43 nations.
The above information is submitted to show some trends in international thinking?
regarding the Welfare State.
Vancouver, B.C., College of Physicians and Surgeons
July 9th, 1952. of British Columbia.
at St.
Dr. S. C. Angelomatis is now practising in the Broadway Medical district of?
Dr. S. C. Thor son is now practising in Haney.
Dr. Edward Boyd, formerly of England, is now in association with Dr.
Gould of Vancouver.
Dr. P. F. Dubois is now practising at Dawson Creek.
Dr. Percy DeKoven is now with the Crease Clinic.
Dr. E. F. Word of Vancouver is taking six months' study in pathology
Paul's Hospital.
To Dr. and Mrs. Gordon Westgate of Vancouver, a daughter.
To Dr. and Mrs. Murray Edgar of Vancouver, a daughter.
To Dr. and Mrs. A. M. Inglis of Vancouver, a daughter.
Two awards for a year's training in psychiatry have been made to Dr. G. H.
Stephenson and Dr. N. L. Richardson, both of Vancouver. Dr. Stephenson is enrolled
at the University of Toronto and Dr. Richardson at McGill University, Montreal.
Dr. S. Elizabeth Mahaffy, assistant medical health officer for the Victoria-Esquimalt
Board of Health, has been granted a bursary for a year's study in public health at the
University of California.
The members of the British Columbia Division were saddened to learn
on Boxing Day of the sudden death of the President of the C.M.A.% Dr. Harold
Orr, in the Toronto General Hospital. The President became ill while attending
a meeting of the World Medical Association in Greece on behalf of the C.M.A.
On his way home he was detained in hospital in London, England, and again
in New York City. Although not fully recovered, he seemed able to travel
and arrived at Toronto safely where he entered the Toronto General Hospital.
He was looking forward to completing the last lap of his journey home when
in the early hours of December 26 he died. The funeral was held in Edmonton
on Tuesday, December 30th, and representatives of the Western Divisions
were present on behalf of their membership. Many members of the profession
in Alberta honoured the late President who had practised among them for
nearly forty years.
Dr. Harold Orr graduated from the University of Toronto in 1911 and
registered and entered practice in southern Alberta in 1912. He soon showed
great interest in the aspects of public health and just before the first World
War moved to Edmonton to do public health work. In the course of distinguished service in the CAMC during 1914-18, he left his mark by devising
what has come to be known as the "Orr Disinfector", a device well known to
many medical officers today. For these distinguished services he was honoured
by being made a Member of the Order of the British Empire.
In the years following the war he trained and practised as a specialist in
dermatology and syphilology and maintained an interest in public health
through being director of the Division of Venereal Disease for the Government
of Alberta. He was also Professor of Dermatology and Syphilology at the
University. As practitioner, teacher and administrator, he was a wise choice
for the presidency of the Canadian Medical Association and it is with a great
sense of loss that we realize,his passing. Having completed most of the arduous
responsibilities of the presidency and having decided to relinquish his practice, at
least in part, it was his intention to settle with his family in Victoria, B.C., to
to enjoy a well-earned rest after a lifetime of service.
We shall all wish to extend to his widow and daughter our great sympathy
in their loss.
[The Bulletin joins with the writer of the above, in a most sincere expression
of sorrow, at the loss of this fine man. We heard Dr. Orr speak at the luncheon
given in his honour during the B.C. Medical Association's Annual Meeting, and
were struck by his sincerity and devotion to the task he had undertaken of the
Presidency of the Canadian Medical Association, a most strenuous undertaking.
Dr. Orr is the second President of the C.M.A. who has died in harness.
Dr. Alec Monro, it will be remembered, some twenty years ago or more, died
while on his way back from the East, during his tour as President.]
References supplied — W. C. Wolfe, Manager
5f * * *
503 - 535 W. Georgia St., Vancouver, B.C.
TAtlow 4826
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Telephone: EMerald 2161
Dividend Record
The 1952 Financial Post Dividend Record will be
available about January 15th. We will gladly forward
a free copy of this useful publication upon request.
Members:  Montreal Stock Exchange
Vancouver Stock Exchange
Market  quotations  broadcast  daily,   7:45  a.m.
and   1:05  p.m.   Station CKMO—1410  KC
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Page 182


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