History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: March, 1949 Vancouver Medical Association Mar 31, 1949

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 THE
BULLETI
Published By
The Vancouver Medical Association
EDITOR:
dr. j. h. MacDermot
EDITORIAL BOARD
DR. D. E. H. CLEVELAND
DR. H. A. DesBRISAY
Editorial and Business-Office
203 Medical-Dental Building
Vancouver, B. C.
DR. J. H. B. GRANT
DR. D. A. STEELE
Publisher and Advertising Manager
W. E. G. MACDONALD
Vol. XXV
MARCH, 1949
OFFICERS,  1948-49
Dr. Gordon C. Johnston
President
Dr. Gordon Burke
Hon. Treasurer
Dr. W. J. Dorrance        Dr. G. A. Davidson
Vice-President Past President
Dr. Henry Scott
Hon. Secretary
Additional Members of Executive:
Dr. A. S. McConkey, Dr. Rocke Robertson
TRUSTEES
Dr. A. M. Agnew Dr. G. H. Clement Dr. A. C. Frost
Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS
Clinical
Dr. B. B. Trowbridge Chairman Dr. J. A. Ganshorn Secretary
Eye, Ear, Nose and'Throat
Dr. G. H. Francis.. Chainhan Dr. J. F. Minnes.— : Secretary
Paediatric
Dr. G. O. Mathews Chairman Dr. A. F. Hardyment Secretary
Orthopaedic and Traumatic Surgery
Dr. H. H. Boucher Chairman Dr. Bruce Reed Secretary
Neurology and Psychiatry
Dr. A. E. Davidson Chairman Dr. G. H. Gundry Secretary
Radiology
Dr. Andrew Turnbull Chairman Dr. Marvin R. Dickey Secretary
STANDING COMMITTEES
Library:
Dr. F. S. Hobbs, Chairman; Dr. R. A. Palmer, Secretary; Dr. R. P. Kinsman;
Dr. S. E. C. Turvey; Dr. J. E. Walker and Dr. E. F. ^Word.
Summer School:
Dr. A. B. Manson, Chairman; Dr. E. A.. Campbell, Dr. J. A. Ganshorn,
Dr. D. S. Munroe, Dr. D A. Steele, Dr. G~. C. Large.
Credentials:
Dr. H. A. DesBrisay, Dr. Frank Turnbull, Dr. G. A. Davidson.
Representative to B. C. Medical Association: Dr. G. A. Davidson.
Representative to V. O. N.: Dr. Isabel Day.
Representative to Greater Vancouver Health League: Dr. J. W. Shier. A product of proven merit prescribed for
the use of doctors in their offices, for the
following occupational ailments:
Fatigue
Caused by too many unnecessary
steps—to reception office—the lab.,
etc.
Hoarseness
Due to constant calling of receptionist, nurse, etc.
iff #IMM <;
-f&-:#!l$Ftt
Nervous Tension
Resulting from confusion and rush
of trying to locate people, case histories, lab. reports, in limited
amount of time you can devote to
each patient.
"fEfKwt—
o<«'
.ca1
K\<&
sva1
fro*
<M
o&
CO
OM
e&
\eP
ce-
Frankly, you'll be positively amazed at
the way this compact Intercomm Unit can
speed your daily office routine. Reports,
case histories, consultations, nurse-receptionist, all are as near as your fingertip.
Only 8" x 3Va" x 6K2" it is available
in walnut or ivory finished plastic case.
Operates from any 110 volt AC or DC
Outlet. Master station will accommodate
up to four substations.
Master and one substation $59.95
Installation and B.C. Sales Tax Extra
Additional substations $10.45 each
ELECTRONIC PRODUCTS
538 Cambie Street
CO. LTD.
TA. 1421
Vancouver, B. C. VANCOUVER   MEDICAL   ASSOCIATION
Founded 1898     :  :    Incorporated 1906
PROGRAMME FOR FIFTY-FIRST ANNUAL SESSION
(Spring Session)
\pril 12.    GENERAL MEETING—
"The Eye in General Medicine"—Dr. Frank S. Brien, Professor of
Medicine, University of Western Ontario.
April 19.    CLINICAL MEETING—Children's Hospital.
May    3.    ANNUAL MEETING—Tuberculosis Institute Auditorium.
"Publicity—Good Medicine for Doctors"—Clyde Gilmour.
[May 10.    SPECIAL MEETING—Tuberculosis Institute Auditorium.
Dr. John Stokes, Professor of Dermatology and Syphilology, University of Pennsylvania.
EXCLUSIVE AMBULANCE
LIMITED
FAir. 0080
NW.   60
OXYGEN THEEAPY  SUPPLIED  ON YOUR
ORDER. 24 HR. SERVICE
J. H. CRELLIN
W. L. BERTRAND
%$
w.
tE
Page 117  VANCOUVER HEALTH DEPARTMENT
3ASES OF COMMUNICABLE DISEASE REPORTED IN THE
CITY
STATISTICS—NOVEMBER, 1948
'oral Population—Estimated \	
Chinese Population—Estimated       7 979
lindu Population—Estimated ' j ; _  275
Number
Total deaths 336
Chinese deaths       10
Deaths, residents onlyj     271
BIRTH REGISTRATIONS:
Male * 1 _  336
Female 1 296
632
INFANT MORTALITY: Nov., 1948
Deaths under 1 year of age 14
Death rate per 1000 live births___       3 0.0
Stillbirths   (not included above) 6
CASES OF COMMUNICABLE DISEASE REPORTED IN THE CITY
Number   Rate Per
December, 1948
carlet Fever	
►iphtheria	
•iphtheria Carrier.
ihicken Pox	
[easles	
.ubella	
lamps.
^hooping Cough	
yphoid Fever (Carriers) _
ndulant Fever L_
oliomyelitis	
uberculosis	
rysipelas	
leningococcus (Meningitis)-
if ectious Jaundice.
ilmonellosis	
ilmonellosis (Carrier).
ysentery	
ysentery (Carrier).
tetanus	
yphilis	
'onorrhcea	
ancer (Reportable)
Resident	
Non-Resident	
Cases   Deaths
• 2
0
0
352
96
8
11
0
0
1
1
35
0
0
0
2
0
0
0
0
35
197
85
21 V-
INSULIN
PROTAMINE ZINC INSULIN
In treatment of diabetes mellitus, it is frequently necessary tc
supplement control of diet and exercise by the regular use ol
Insulin or Protamine Zinc Insulin.
¥hhm
INSULIN-TORONTO — 10-cc
. vials
; 40 and 80
units pe
r cc.
Made   from   Zine-Insulin
Eapid   Effect   —   Short
Crystals
Duration
PROTAMINE ZINC INSULIN -
— 10-
-cc. vials;
40
and 80
units
per cc
Comparatively Slow Effect — Prolonged Duration
tvl
CONNAUGHT  MEDICAL RESEARCH  LABORATORIES
University of Toronto Toronto 4, Canada
DEPOT FOR BRITISH COLUMBIA
MACDDNALD'S    PRESCRIPTIONS    LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. a
"JUe. &dUv& Poc^e
We print in this issue a brief article by Dr. Frank Turnbull, which is worthy of
rather careful consideration. It is timely, because it comes on the heels of an election
just held to choose members for the Council of the British Columbia College of Physicians and Surgeons—and no better example could have been afforded to Dr. Turnbull as
la text for what he has written. There were, if we remember rightly, some ten or more
names submitted, of whom three were to be elected. It seems almost impossible that,
[under the ordinary single-vote method, a truly representative choice could be made.
The question of ensuring fair representation of all groups in a constituency has been,
for many years, a very troubling one to a great many people. Many reams liave been
written on the subject—an endless number of speeches have been made, and there is no
;finality yet. When the choice is betwen two candidates, or even perhaps three, the
matter is comparatively simple, and we may fairly expect an equitable decision. But
jwhen there are more than three the single vote method does not give an accurate picture
of the wishes of the voters, and the discrepancies increase in geometrical progression as
the number of candidates mounts—especially when the constituency is numerically a
| small one—for "then a relatively small group, acting in unity, can determine the election
of a candidate or candidates who actually may represent the views of a mere minority.
And there would be nothing wrong or unworthy in such action by a group of men who
[were convinced that their candidate was the right one, and should be elected.
Apparently, no method has yet been evolved that suits everyone—but we agree with
[Dr. Turnbull that we should try a method other than the single-vote system. Proportional Representation some years ago had a very vocal support from some men who had
studied the subject a good deal—it was even tried by our Association on one occasion,
we remember. Mathematically, it is the soundest method of all—but it would seem to
require considerable mathematical ability to understand it, much more explain it. And
so a simpler method, the Majority Vote with numbered preferences, would seem to be
worth a try. It is used actually in certain of our elections, e.g. the Election of Senior
Members to the Canadian Medical Association. It is easy to understand, and easy to
carry out. We believe, but may be wrong, that this is the method the advocacy of which
[by a certain group gave a great deal of trouble at the recent stormy convention of
iLiberals in this province
This is not intended as an amplification or explanation of Dr. Turnbull's article,
which is admirably clear and direct, and can be followed with ease. We feel, however,
that our governing bodies, both provincial and locally, might well take this matter to
heart, and devise for the future a method of voting which will be fairer and more
accurately descriptive of the wishes of the majority, than the one which now obtains,
and satisfies nobody.
4
MEDICAL ECONOMICS AND THE VOTE
By Dr. Frank A. Turnbull, Vancouver
The practice of medicine today is dogged by urgent and complex problems in the
(field of economics.    Even a partial solution will require a lot of hard thinking.    The
(proportion of our time that is presently devoted to consideration of these matters is
increasing.   Discussions and arguments are not restricted to general or committee meet-
Page 119 I.T<
ings. A conversation about fees for social assistance cases, or about state medicine, etc.
will usurp the floor in any hospital cloakroom. Normal medical shop-talk has almost a
nostalgic flavor.
Is this plethora of conversation about economics helping to solve our problems?
Perhaps so. But when occasion requires that we speak as a profession how may we be
assured that the composite view of the majority will be expressed? It is certain that)
we need leaders who can speak with conviction and authority to the public and/or to thej
government. They must represent, without any doubt, the majority of the profession^
To such leaders we can delegate the development of our economic affairs, knowing that)
they will seek advice from every good source, refer back to their constituents the controversial matters of policy, and expect to be voted out of office when they cease to be
able representatives. Do our present methods of electoral voting ensure this leadership^
Possibly, yes—with certainty, no.
It seems to be an opportune time for us to consider the method of voting that is
commonly enjoyed in our medical societies, provincial and district, as well as in major]
groups and committees. If there are several candidates for office, a wrong method may
elect the candidate or candidates whom the majority do not want. A wrong method
may elect the candidates of an organized or lucky minority. If elections produce thesej
unsatisfactory results good candidates are discouraged from running for office.
There is not time in this short communication to discuss methods of voting in any
detail. I would like to point out the difference between Ordinary Vote and Majority!
Preference, and to indicate that the latter method might often be used to great advantage for our medical elections. A third method, Proportional Representation, is mentioned for future consideration.
In Ordinary Vote the voter marks his choices by writing names or crosses; andi
election is by the largest number of names or crosses. This is the best way to choosef
one of only two candidates. When there are more than two candidates Ordinary Vote
often fails to show what the voters want.
In Majority Preference the voter marks the several candidates 1, 2, 3, etc., from hisi
first to his last choice. The preference numbers of each candidate are totalled. The
candidate who scores the lowest total of preference numbers is elected. This method
elects the candidate or candidates whom the electorate taken together prefer over everyi
other candidate. Every candidate is compared with every other candidate, all in a single:
election.
Proportional Representation recognizes  that in  the electorate there may be subgroups, of which one may be a majority.   It allows the election of candidates from the;
minority sub-groups in proportion to their number.    The ballots are marked the same;
as for Majority Preference, but are counted differently.   By Proportional Representation
the voters are expressing themselves, not as a single unit, but as voters whose various]
interests should contribute to every decision that effects the whole electorate.    The use
of this method might well reconcile some of the present trends which appear to be
splitting the profession into agitated sub-groups.
In summary, it is suggested that we reconsider our methods of voting. Ordinary
Vote has a place, but has limited application and can be very unsatisfactory. Majority
Preference could often be employed with benefit in our medical elections. Proportional
Representation is a valuable method, and might well be employed on occasion, after we
have given Majority Preference a trial.
REFERENCE
Taylor, W. S., Three Methods of Voting—Scientific Monthly, 1948, 68, 297.
FOUND
A fountain pen has been found in the Reading Room.   Please apply to the Librarian.
Page 120 I
1949
SUMMER SCHOOL CLINICS
VANCOUVER MEDICAL ASSOCIATION
May 31st to June 4th, inclusive
SPEAKERS:
Dr. D. L. C. Bingham, Professor of Surgery, Queen's University, Kingston,
Ontario.
Dr. Alexander B. HEPLER, Senior Visiting Urologist, Children's Orthopedic Hospital, Consultant and Visiting Urologist at the Swedish
Hospital, Seattle, Washingtin.
Dr. P. E. Ireland, Professor of Oto-laryngology, University of Toronto,
Toronto, Ontario.
Dr. John A. Luetscher, Jr.,  Assistant Professor of Medicine, Stanford
University, San Francisco, California.
Dr. John L. McKelvey, Professor of Obstetrics and Gynaecology, University of Minnesota, Minneapolis, Minnesota.
ee, $10.00 HOTEL VANCOUVER, Vancouver, B. C.
^formation: Dr. A. C. Gardner Frost, 203 Medical-Dental Building, Vancouver, B.C.
LIBRARY NOTES
IOURS—
Monday, Wednehday, Friday  9.00 a.m. to 9.30 p.m.
Tuesday and Thursday .  9.00 a.m. to 5.00 p.m,
Saturday  9.00 a.m. to 1.00 p.m.
LECENT ACCESSIONS TO THE LIBRARY—
Alcohol Education, Manual of References for—Consultative Council on Alcohol
Education and Problems, Department of Education for British Columbia, 1949
(Gift of Dr. G. A. Davidson).
American Congress on Obstetrics and Gynaecology, Transactions of the Third—
edited by Kosmak, G. W., and Rutherford, R. N., 1948.
American Diabetes Association, Proceedings, vol. 8, 1948.
Atlas and Textbook of Human Anatomy by Sobotta, J. and edited by McMurrich,
J. P., 1909-1911   (Gift of Dr. G. E. Seldon).
Banting, Sir Frederick—by L. Stevenson, 1946  (Nicholson Fund).
Elementary Anaesthesia by W. N. Kemp, 1948  (Gift).
Modern Treatment of Syphilis by J. E. Moore et al, 2nd edition, 1947.
Mycoses and Practical Mycology by N. Gohar, 1948.
Natural History of Disease by J. A. Ryle, 2nd edition, 1948.
Symposium on Diseases of the Skin, Medical Clinics of North America, Chicago
Number, 1948.
Symposium on Orthopaedic Surgery, Surgical Clinics of North America, Chicago
Number, 1949.
Page 121 •i»
British Columbia Medical Association
President Dr. Frank M. Bryant, Victoria
President-Elect  : Dr. J. G Thomas, Vancouver
Vice-President Dr. Stewart A. Wallace, Kamlopos
Honorary Secretary-Treasurer Dr. J. A. Ganshorn, Vancouver
Immediate Past President-- % Dr. L. H. Leeson, Vancouver
DOMINION INCOME TAX RETURNS BY MEMBERS OF THE
MEDICAL PROFESSION
As a matter of guidance to the medical profession and to bring about a greater uniformity in the data to be furnished to the Income Tax Division of the Dept. of National
Revenue in the annual Income Tax Return to be filed, the following matters are set out:
Income
1. There should be maintained by the doctor an accurate record of income received,
both as fees from his profession and by way of investment income. The record should
be clear and capable of being readily checked against the return filed. It may be
maintained on cards or in books for the purpose.
Expenses
2. Under the heading of expenses the following accounts should be maintained and
records kept available for checking purposes in support of charges made:
(a) Medical, surgical and like supplies.
(b) Office help, nurse, maid and bookkeeper; laundry and malpractice insurance
premiums. (It is to be noted that the Income War Tax Act does not allow
a deduction a salary paid by a husband to a wife or vice versa. Such amount, if
paid, is to be added back to the income) :
(c) Telephone expenses:
(d) Assistant's fees:
The names and addresses of the assistants to whom fees are paid should bl
furnished. This information is to be given each year on Income Tax form known
as Form T.4 obtainable from the Inspector of Income Tax.
(e) Rentals paid:
The name and address of the owner (preferably) or agent of the rented premises!
should be furnished (See (J) ).
(f) Postage and stationery:
(g) Depreciation on medical equipment:
The following rates will be allowed provided the total depreciation already
charged off. has not already extinguished the asset value:
Instruments—instruments costing $50 or under may be taken as an expense
and charged off in the year of purchase.
Instruments costing over $50 are not to be charged off as an expense in the
year of purchase but are to be capitalized and charged off rateably over the estM
mated life of the instrument at depreciation rates of 15 per cent to 25 per cent,
as may be determined between the practitioner and the Division according tff
the character of the instrument, but whatever rate is determined upon will be
consistently adhered to:
Office furniture and fixtures—10 per cent per annum.
Library—The cost of new books will be allowed as a charge.
Page 122 (h)  Depreciation on motor cars on cost:
Twenty per cent 1st year.
Twenty per cent 2nd year.
Twenty per cent 3 rd year.
Twenty per cent 4th year.
Twenty per cent 5 th year.
The allowance is restricted to the car used in professional practice and does not
apply to cars for personal use.
Effective January 1st, 1947, depreciation on motor cars used in professional
practice may be claimed on cars costing up to a maximum of $2,500.00. The
effect of this regulation is to raise the ceiling on depreciation from the former
figure of $1,800.00.
(i)  Automobile expense; (one car)
This account will include cost of license, oil, grease, insurance, washing, garage
charges and repairs.
Alternatives to (h) and (i) for 1940 and subsequent years—
Effective January 1st, 1947, in lieu of all other expenses connected with the
operation of a motor car, including depreciation, a doctor may be allowed to
charge 7 cents a mile for mileage covered in the * performance of professional
duties. Where the car is not used solely for the purpose of earning income, the
maximum mileage which will be admitted as pertinent to the earning of income
will be 75 per cent of the total mileage for the year under consideration.
For 1940 and subsequent years where a chauffeur is employed, partly for business and partly for private purposes, only such proportion of the remuneration
of the chauffeur shall be allowed as pertains to the earning of income.
(j)   Proportional expenses of doctors practising from their residence—
(a) Owned by the doctor:
Where a doctor practises from a house which he owns and as well resides,
a proportionate allowance of house expenses will be given for the study,
laboratory, office and waiting room space, on the basis that this space bears
to the total space of the residence. The charges cover taxes, light, address
of mortgagee to be stated) :
(b) rented by the doctor:
The rent only will be apportioned inasmuch as the owner of the premises
takes care of all other expenses.
The above allowance will nit exceed one-third of the total house expenses
or rental unless it can be shown that a greater allowance should be made
| for professional purposes.
(k)  Sundry expenses   (not otherwise classified)   — The expenses-charged to this
account should be capable of analysis and supported by records.
Claims for donations paid to charitable organizations will be allowed up to 10
per cent of the net income upon submission of receipts to the Inspector of Income Tax. This is provided for in the Act.
The annual dues paid to governing bodies under which authority to practice is
issued and membership association fees, to be recorded on the return, will be
admitted as a charge. The cost of attending post-graduate courses will not be
allowed.
(1)  Carrying charges:
The charges for interest paid on money borrowed against securities pledged as
collateral may only be charged against the income from investments and not
against professional income. |y§*
(m)  Business tax will be allowed as an expense, but Dominion, Provincial or Municipal income tax will not be allowed.
Page 123
M
&:
= s/rf. (n)  Convention expenses of medical profession:
Effective 1st January, 1948, the reasonable expenses incurred by members of
the medical profession in attending the following Medical Conventions will bef
admitted for Income Tax purposes against income from professional fees:
1. One Convention per year of the Canadian Medical Association.
2. One Convention per year of either Provincial Medical Association or a Provincial Division of the Canadian Medical Association.
3. One Convention per year of a Medical Society or Association of Specialist
in' Canada or the United States of America.
The expenses to be allowed must be reasonable and must be properly substantiated; e.g., the taxpayer to show (1) dates of the Convention, (2) the number
of days present, with proof of claim supported by a certificate of attendance]
issued by the organizations sponsoring the meetings, (3) the expenses incurredJ
segregating between (a) transportation expense, (b) meals and (c) hotel ex-J
penses ,for which vouchers should be obtained and kept available for inspection!
None of the above expenses will be allowed against income received by way off
salary since such deductions are expressly disallowed by statute.
Professional Men Under Salary Contract:
It has been held by the Courts that a salary is "net" for Income Tax purposes.
The salary of a Doctor is therefore taxable in full without allowances for auto-s
mobile expenses, annual medical dues, and other like expenses.    If the contract!
with his employer provides that such expenses are payable by the employer, they!
will be allowed as an expense to the employer in addition to the salary paid to
the assistant.
For the year 1948 a Doctor on Salary Contract can deduct the fee paid to thJ
governing body under which the authority to practise was issued.    The 1949jf
Act, however, ruled this out.
Only the annual fee is deductible, the fee paid for registration is not deductible!
FEDERAL HEALTH GRANTS
(Interim Report by the Three Representatives of the British Columbia Medical
Association on the Health Survey Committee)
Jn May, 1948, the Prime Minister of Canada announced a series of special grants
totalling thirty million dollars to assist the provinces in expanding and improving their
health services. British Columbia's share for the year 1948-49 was approximately two
and one-half million dollars.
The Provincial Minister of Health and Welfare, the Honourable G. S. Pearson,!
appointed a central commitee to advise on and coordinate plans for the expenditure of
these funds. Dr. W. H. Hatfield and Dr. J. M. Hershey are co-chairmen of this committee, which is known as the Health Survey Committee, and includes representatives
from the Provincial Health Branch, B. C. Medical Association, and the Registered
Nurses' Association of British Columbia. In addition, a sub-committee under each of
thegrants—Crippled Children, Professional Training, Hospital Construction, Venereal
Disease, Mental Health, Tuberculosis, Research, General Public Health and Cancer—has
also been set up to carry out the more detailed work of surveying and assessing present
programmes and future plans. A sub-committee on Medical Care has also been appointed. The Chairman of each sub-committee is a member of the Health Survey
Committee, which is thereby kept informed of the activities under the grants. Dr.
G. R. F. Elliot, Assistant Provincial Health Officer, is directly in charge of all matters
relating to the Federal Health Grants, a District Office of the Provincial Health Branch
having been opened for this purpose at 2670 Laurel Street, Vancouver.
Page 124 The total amount available under the Federal Health Grants is $2,536,653. Included
in this is the Hospital Construction Grant ($1,080,745) and the Health Survey Grant
($52,744), which may both be carried over to the fiscal year 1949-50, and the Cancer
Grant ($290,970), which is also an exception to the other grants in that the Province
must supply matching funds. The total amount of the Public Health Research Grant
for all provinces is $100,000 and is controlled from Ottawa. Thus, the amount available
to British Columbia, which either lapses at March 31st, 1949, or does not require matching money, is $1,104,694. Of this sum the Federal Government has received to date
requests in the form of projects for $926,673 or 84 per cent.
Where provincial programmes are well developed, such as in tuberculosis and local
health services, the Federal Health Grants have made it possible to accelerate the planned
expansion of these programmes. In other fields, it will be necessary to finalize plans in
order to ensure the wisest expenditure of the funds.
Four surveys have been completed or are now under way. Dr. O. H. Warwick,
Executive Director, National Cancer Institute of Canada, conducted a survey in British
Columbia in regard to cancer in December, 1948, and the sub-committee on Cancer
Control is presently considering a plan by the B. C. Cancer Foundation for the implementation of Dr. Warwick's recommendations. In order to obtain data as to the extent
of the problem of crippled children in British Columbia, a province-wide survey is being
undertaken within the next month. A third survey is that being done by Dr. D. H.
Williams on all phases of the venereal disease control programme in this province. The
Hospital Survey by Messrs. J. A. Hamilton and Associates, Minneapolis, is primarily
for the Hospital Insurance Service, but as a result considerable data will be available to
the Health Survey Committee.
New developments which are of particular interest to practising physicians include
the inauguration of a provincial programme in cooperation with the B. C. Division,
Canadian Arthritis and Rheumatism Society, for the investigation and treatment of
persons suffering from arthritis, provision of x-ray equipment for general hospitals to
make possible routine chest x-rays of all admissions, and increased public health laboratory facilities. It has also been possible to distribute greater amounts of free streptomycin and penicillin for use in the treatment of tuberculosis and venereal disease.
Courses in cancer cytology, haematology and radiology are being taken by physicians who
will return to the staff of the Vancouver General Hospital. Local health services are
also expanding as a result of additional nurses, sanitarians and equipment. Other equipment to be purchased includes premature care units and orthopaedic appliances for general hospitals, as well as extensive equipment for the Crease Clinic of Psychological
Medicine and the Surgical and Educational Unit of the Tuberculosis Division.
April 11th, 1949.
F. M. BRYANT.
C. J. M. WILLOUGHBY.
J. H. MacDERMOT.
m
Isi'H? ■
WANTED FOR HONGKONG
Assistant to Eye, Ear, Nose Specialist with large practice. Ultimate view,
partnership. Excellent prospects. Reply stating terms, Advertiser, c/i A. B.
Coleman, Esq. Promenade Apartments, 307, 1861 Beach Avenue, Vancouver,
B. C.   PAcific 4991.
Page 125 A "BRIEF" ON RHEUMATIC DISEASE CONTROL
i
*>r
Si
»»•;
Supplied by Dr. A. W. Bagnall, Chairman of Committee
By request, the Chairman of the special Committee on Arthritis and Rhuematism
of the B.C.M.A. submitted in January, 1949, an "appreciation" of the situation in this
Province to the Minister of Health and Welfare, the Honourable George S. Pearson. A
copy of this somewhat lengthy review has been sent to all members of the Profession
for their information. Doubtless, most will not have time to read it at length and a
summary is herein contained for those physicians.
Fundamental Assumptions
The programme is based on a few fundamental assumptions.    They are—
(1) The average busy practitioner has too little time-to investigate, in detail, complex
cases of rheumatic disease and too often is forced to undertake treatment without
an adequate diagnosis.
(2) The basic principles of physical therapy.
(a) maintenance of the fullest possible range of joint movement.
(b) restoration of full muscle power for protection of joints, and
(c) application of simple measures of deformity prevention require a great deal of
time to instil into the mind of the patient. The average practitioner can
merely rehearse the principles for the benefit of his patient and must depend
on a suitably-trained physical therapist to go into detail. Even now, physical
therapy, to the lay and professional mind alike, signifies complicated machinery
aimed at providing some form of heat at a cost medically not commensurate
with the benefit accruing—rather a luxury than a necessity since simple home
appliances can furnish much the same heat at negligible cost. In dealing wit!
the physical therapy aspect, because medical principles are fundamentally at
stake, it was the Committee's decision to work at least at the start with the
only group that is by definition, welltrained, viz. the C.P.A. (Chartered Physical Therapists). There may be those among the other two groups, the Registered Physical Therapists and the Masseurs, who have good training—but of
this there is no assurance since, for them, no basic training schedule is laid
down.
(3) The number of such qualified physical therapists is not sufficient at present to permit of home visiting for "bed-patients" even when the patient could afford it.
(4) The average medical practitioner has had no opportunity to observe the good results
of treatment ofv the rheumatic diseases under ideal conditions and is therefore not
only pessimistic but unfamiliar with the best treatment methods.
(5) While considerable fundamental knowledge has been gleaned, there is great need
for more, and accurate, statistical knowledge for clinical research purposes.
Proposed Programme for Control of the Rheumatic Diseases in British Columbia \
Working on the foregoing assumptions the B. C. Division of the (lay and medical)
Canadian Arthritis and Rheumatism Society, under advice from the special Committee
on Arthritis and Rheumatism of the B.C.M.A., with the help of private government
funds, proposed the following programme for the coming year, 1949-1950.
(1)  Pilot Centres.
In each of the five medical districts of the Province, at least one "pilot centre"
will be set up. Such a centre will constitute a consulting service for the regional
practitioners, both as regards diagnosis and suggestions for treatment. Considerable
confusion arises in developing this programme because of the simultaneous inception
of the "Social Assistance Medical Service." In former times this class of patient
would constitute the group to be serviced. Now, these patients will only be seen
if referred by a physician.    Local arrangements will dictate the details.    There is
Page 126 no intention of interfering with the private practitioner—all proposals deal only
with making it easier for him to diagnose and treat the cases of rheumatic disease
occurring in his practise. For lack of time, he may wish to avail himself of the
faciliies of the "pilot centres" and carry ou the suggested reatment wih recourse
to he centre should furher problems arise.
It was easier to establish the first such centre in the area if densest population.
Early in March, 1949, the first "Pilot Centre" was opened at the Vancouver General
Hospital with both In-patients and Out-patients facilities. To this centre at
present only those of Out-patient financial status may be referred by their physician. If it is deemed advisable by all concerned, this service may be expanded to
include "near-indigents" but at present this group is not included. It is understood that, after investigation, patients will be sent back to the referring physician
for the suggested treatment. If the physician so desires it, the Centre will carry
out treatment but specific request for this should be made at the time of referral.
To some extent, the experience at this centre will govern the establishment of
other centres. Information, chiefly statistical and clinical, will become available
as a result of these operations and will be applied to direct Research.
(2) Physical Therapy.
In connection with each "pilot centre," operating only on requisition from a
physician, there will be set up one or more home-visiting physical therapists. Their
purpose will be primarily to teach the basic physical therapy programme to those
unable, or in whose cases it would be unwise, to attend the "pilot centre" or a
private physical therapist for such instruction. Three such "mobile" physical
therapists, with transportation, are attached to the V.G.H. pilot centre and may
be requisitioned either by referring the patient for investigation to the Pilot Centre
or by the private physician contacting the Divisional Office of the Canadian Arthritis and Rheumatism Association at 997 West Broadway, CEdar 5114. It is
intended that, at least at first, the services of the mobile physical therapists shall be
restricted to those patients who could not otherwise afford it. In exceptional cases,
where home-visiting cannot otherwise be arranged, financially competent patients
will be attended. Fees will then be assessed and deposited to the account of the
B. C. Division of the Canadian Arthritis and Rheumatism Society to defray the
costs of further expansion (in the same manner as the Victorian Order of Nurses).
A special course in Physical Therapy as applied to the rheumatic diseases was
held at Shaugnessy Hospital, Vancouver, from 21-25 February, 1949, under the
ausupices of all concerned organizations, expenses financed by Provincial Government grant, and attended by C.P.A. representatives from most institutions and
regions of the Province. This attempt to co-ordinate physical therapy on a provincial basis met with wide acceptance and implies a considerable increase, both of
interest and facilities.
Tentative arrangements are under way for similar "pilot centres" with attached
"mobile units" in Victoria and Trail. Announcement will be made as soon as
/ possible of new facilities in these and other centres as they become available. Expectation is that the programme will go into effect in Victoria by July and in Trail by
October—other districts to follow.
(3) Under the auspices of the B.C.M.A. special committee, there will appear monthly
in the V.M.A. Bulletin a one-page "digest" of some phase of the rheumatic diseases.
These and other appropriate articles will be incorporated in a "Rheumatic Diseases'
Annual Bulletin" and issued gratis to all registered physicians in the Province.
(4) Reference to the full report on "The Problem of Control of the Rheumatic Diseases
in B. C." will show that many other matters of great importance require attention.
These include family allowance funds, home-making services, treatment and research, hospital beds, animal research facilities, vocational rehabilitation and job-
Page 127 finding agencies.    These cannot, however, be coped with at present and to a considerable extent rest upon the pleasure of the voters of the Province.
It should be noted that great co-operation has been received from the present;
Government—indeed, much of the stimulus for initiation of a Rheumatic Diseases ControtJ
programme came from the people and the Government of, the Province. This proves
but one point, that there is great demand for such a programme. This demand must be
answered by the medical profession—else we fail our duty and become subject to just'
censure. When 5 per cent of the population are afflicted at some time by rheumatic
pain, it is obvious that no small group of "specialists" can handle the problem. It is
one for the whole profession and the natural objective must ever remain to make it easier
for every practioner to handle his rheumatic disease problems. This it is hoped to
accomplish slowly, but eventually, along the above lines. The cimmittee welcomes any
comments or offers of assistance on the part of practioners throughout the Province.
Further information may be obtained by addressing queries
(a) On Provincial matters,
to: Dr. A. W. Bagnall, 925 West Georgia Street, Chairman of the Special
Committee of the B.C.M.A.
or
(b) On the "Pilot Centre" at the Vancouver General Hospital,
to: Dr. Brock S. Fahrni, Director of the Arthritis Clinic, V.G.H.
NATIONAL CANCER INSTITUTE
Establishment at the federal Laboratory of Hygiene, Ottawa, of a central tumour
registry to assist in the general programme of the National Cancer Institute of Canada
was announced here today by Hon. Paul Martin, minister of National Health and
Welfare.
Providing scientific facilities for the war against cancer, the government has approved
expenditures for the creation and functioning of the registry. Staff is now being appointed, and necessary equipment and supplies are on order.
The National Cancer Institute of Canada has named Dr. Desmond Magner, professor of Pathology at the University of Ottawa, as registrar of the new establishment,
and the minister of National Health and Welfare is making available the services of
two health officials, Dr. H. A. Ansley, assistant director of health services, and Jamesj
Gibbard, B.S.A., M.Sc., chief of the Laboratory of Hygiene, who will be associated with
Dr. Magner in administering the registry. -
In addition to other work in this field, the registry will assist pathologists in the
classification of various cancers and other tumours and will collect case histories and other
relative data for future studies. A panel of leading consultants from all across Canada
has been appointed to act as a technical group for the classification of tumours.
Medical, public health and research workers everywhere, are expected to be heartened by this latest move in the war on cancer, one of Canada's great health threats.
Creation of the tumour registry is a sequel to the all-out attack launched aearly
two years ago when Hon. Paul Martin called a conference of leading scientific, medical
and lay leaders to study the problem of cancer. From that meeting was born the National
Page 128 Cancer Institute of Canada, to carry on surveys and to mobilize science against all
tumours, while working with the Canadian Cancer Society, which had already begun an
intensive educational campaign in this field. Mr. Martin then arranged for the trustees
of the King George V Silver Jubilee Cancer Fund to turn over a sum of $450,000 for
the purpose of the new institute. The Institute and the Canadian Cancer Society have
since joined forces in one organization with Dr. O. H. Warwick as executive director.
Tremendous impetus has been given to cancer control in Canada by the national
health programme inaugurated last year by the federal government.   This programme
[includes an annual grant of $3,500,000 to the provinces, which constitutes an important
addition to the federal health programme first proposed in 1945.
Establishment of a tumour registry such as is now provided was recommended some
time ago by the technical advisory committee on public health laboratory services,
which expressed concern at the lack of facilities in Canada for recording and organizing
pathological data relating to malignant tumours.
"Desmond Magner, M.D., B.Sc, who has been appointed registrar, is a native of
Ireland but came to Canada in 1921 and was educated at Upper Canada College and the
Jniversity of Toronto, graduating in medicine in 1936. Following interneship, he was
on the staff of the Banting Institute, Toronto. He joined the Royal Canadian Army
medical Corps in September, 1939, and, proceeding overseas in 1940, served as pathologist
rwith base hospitals in England, North Africa and Italy. On 'return to civil life Dr.
Magner served in 1946 and 1947 as director of laboratories of Regina city hospitals
and the Saskatchewan Cancer Clinic.   He was appointed Professor of Pathology at the
^University of Ottawa in October, 1947, and has made his home in Ottawa since that
I time. |jM
"It is an important part of modern treatment procedures that mental patients should
be kept occupied," Mr. Martin said.    Accordingly, funds have been set aside to pur-
; chase occupational therapy equipment. When the programme—which is for both men and
women—is fully in operation, use will be made of such skills as leatherwork, weaving,
Brood-working, pottery, metal-working, oil painting, water colors, drawing and drafting in the treatment of patients."
Provision has also been made for the purchase of audiovisual equipment to be used
both in recreation programmes for the patients and for teaching.
Provision is being made to expand the equipment of the department of physical
Imedicine at the Essondale hospital and to extend this department's facilities to the new
tclinic. The new equipment will enable the staff to give quicker and better treatment to
I minor physical ailments.
Funds have been set aside for occupational and recreational therapy equipment for
the Colony Farm Continued Treatment Building where one floor will be used for this
.purpose.   About 220 male patients will be under treatment here.
All these projects were advanced by the provincial Department of Health and Welfare, and notice of the federal government's concurrence has already been forwarded to
the provincial health and welfare minister, Hon. George S. Pearson.
Costs will be charged against the $338,832 allotted this year to British Columbia
ffifor the promotion of better mental health.
W.
JJT5
Page 129 VcmcQ46uesi QenetoU ^(MfUtcU Section
RADIOLOGY IN PAIN IN THE ABDOMEN OF INFANTS
■   |§|||f      f^-,      AND CHILDREN   §'
R. W. Boyd, M.D.
Department of Radiology, The Vancouver General Hospital
The following is a review of a few diseases of infancy and childhood in which abdominal pain seemed to be the one common symptom though not necessarily the most significant. The review is specifically presented to illustrate the value and versatility of
modern roentgenoloogy in children when properly applied to the clinical problem.
Physicians who are examining children daily realize the difficulty in diagnosing the
many causes of pain which a child will localize in its abdomen. One cannot always be
certain that the pain is really in the abdomen, or if it is, in what part it is located. The
testimony of young children as to these points is notoriously unreliable and may be
influenced by the parents. Careful clinical observation and analysis of the striking
characteristics of pain of various abdominal diseases enables the physician to arrive at a
speedy and accurate diagnosis in most cases, but the chances of error are considerable
and it is in* the patient's interest that a complete roentgen study be utilized wheneyjH
possible.
Roentgenology of infants and children has lagged considerably behind other advances I
in paediatrics. Only recently has it emerged from the status of radiography of a small
scale adult to its present scientific state. Until 1945, no book on paediatric roentgen
diagnosis had been published in English for thirty-five years. The absence of paediatric
roentgenology in the medical texts during the last three decades constitutes a dereliction
unmatched in any other equally important fields of medical diagnosis—or is, as Caffey1
states, "a literary developmental hypoplasia."
Until the perfection of x-ray equipment and technical procedures which ciuld
"stop" patient movement, roentgenologists frequently avoided examinations of infants
and children as irksome, dull and time-consuming tasks. They are still no easy problem
but constitute one of the most difficult and challenging branches of radiology, which is
continuing to increase in scope and now necessitates the full-time attention of radiologists in many larger centres.
Appendicitis
For years controversy has continued over the radiological diagnosis of appendicular
colic, chronic or acute appendicitis. It has followed its clinical counterpart in fashion
and out. Radiology plays no part in the direct diagnosis of acute appendicitis although
it will aid in differentiating symptoms due to other diseases. Many variable diagnostic
signs have been described. Definite finger-tip tenderness over the shadow of the barium-
filled appendix during careful fluoroscopic palpation is the one sign of considerable
importance that inflammatory disease is localized to the appendix. The tenderness must
be elicited and localized with careful precision. Non-filling of the appendix, incomplete
filling, appendicular concretions, irregularity of the lumen, fixation, deformities, spasm,
stasis, and so forth—each of these signs is susceptible to two interpretations—as a normal variation or as a pathological condition.
Peptic Ulcer
The value of the x-ray examination in the differentiation of appendicular disease
from other lesions is demonstrated in the following case history.    A thirteen-year-old
girl was admitted to the Emergency Department at night with clinical signs suggestive
Page 130 p
of a retrocascal acute appendicitis. She gave a history of previous attacks of pain and
Indigestion. Since her clinical and laboratory findings did not warrant immediate operation, she was treated in a conservative manner and submitted to a routine gastrointestinal examination after a few days in bed. This patient presented definite x-ray
evidence of a lesser curvature gastric ulcer (Fig. I) and has subsequently been followed
>n a dietetic treatment in the outdior clinic.
The first essential in the diagnosis of peptic ulcer in childhood is recognition of the
fact that it actually does occur, even in the neonatal period.    Reports2 of peptic ulcer
I in children are appearing in ever-increasing numbers owing to more careful clinical, path-
| ological and radiological investigation.   Ulcers in children seem to develop very rapidly.
They are relatively more numerous in infants.   The typical periodic hunger pains noted
I in adults are not usually described.   It is barely possible that some of the vague abdom-
inal pains and recurrent alimentary disturbances, which are so frequent in childhood,
I may be due to ulcers more often than is now believed.    It is interesting to note the
frequency in which young adults with peptic ulcers date their symptoms back to early
childhood.   The most recent confirmation of early onset of some peptic ulcers has been
reported in the course of mass investigation of young soldiers with dyspepsia.   The x-ray
linvestigation should be done by a radiologist experienced in gastro-intestinal study.    In
I some cases in which investigation can be carried no further than the roentgenological
Iexamination, the findings of a duodenal deformity considered characteristic of ulcer in
i adults may be open to question as a basis for diagnosis, although there is no good evidence
I which renders this finding less acceptable in the case of a child than in that of an older
I person.
Intra-thoracic Lesions
^Whenever a neighbouring lesion causes inflammation or mechanical irritation of the
| serous membranes of the diaphragm, afferent impulses are excited in the diaphragm
£. which the brain is unable to localize accurately. It mostly projects or refers these sensations to a region of the body wall which is supplied by the same posterior nerve roots
as supply the membranes. Stimulation of the pleura over the central region of the
diaphragm gives rise to referred pain in the neck in the distribution of the third and
fourth posterior cervical nerve roots. Stimulation of the peripheral diaphragmatic pleura
produces pain referred to the body wall, front or back, if the same side or both sides, in
the distribution of the sixth to the twelfth thoracic nerves. Exactly similar results are
obtained on stimulation of peritoneal surfaces of the central and peripheral portions of
the diaphragm.
t Manifestations of the referred pain phenomenon were a prominent feature in a six-
year-old schoolgirl who was admitted to Hospital late at night. She was acutely ill,
with vomiting, severe upper left abdominal pain and tenderness. There was muscle
■; splinting and rigidity. Her temperature was 104.5, white blood count 20,000. She
: gave a long history of periodic asthmatic attacks and, more recently, an upper respiratory infection for several days.
Fluoroscopy and films of the abdomen and chest in the supine position showed an
| inconclusive density in the neighbourhood of the left diaphragm. Despite her acute
pain, this girl was persuaded to sit for a film in the upright position (Fig. II). It indicated an air-fluid level in the left diaphragmatic area, surrounded by a dense shadow
suggestive of infiltration around a large abscess cavity. This finding accounted for the
symptoms but it was not so easy to decide whether it was above or below the diaphragm.
Its high position was in favour of it being in the thorax.
Under competent, adequate, conservative treatment, the true intrapulmonary loca-
f tion of the abscess was revealed in another film five days later (Fig. Ill). With the
resolution of the infiltration around the cavity, the shadow of the left diaphragm could
be identified in relation to the lesion. Eleven days later, this remarkable lesion, the
etiology of which remained obscure, had completely disappeared and the child was well
(Fig. IV).
Page 131
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riffrX
MS Disease of the Spine
Only in rare instances are children brought to the attention of the doctor primarily
for abdominal pain, with disease of the spine not having ben recognized or even suspected.   Nevertheless it has occurred.    Usually in Pott's disease, other symptoms direct
the attention of the physician to the spine.    Tuberculous spondylitis or a vertebral;!
tumour should always be kept in mind when investigating abdominal pain in childhood.1
The destruction of the vertebra may be complete with very little obvious kyphosis.   It
should not be missed if the spine is examined and flexibility tested.    Although the complaints of  an eight-year-old girl who was  admitted  to hospital  were  not  primarily!
referred to the abdomen, she was having right ilio-lumbar pain and fever fir five months.
She had been treated with some symptomatic success outside for pyelitis.    A plain film
(Fig. V), preliminary to intravenous urography, revealed a huge paravertebral tuberculous abscess of the tenth dorsal body.
Malformations of the Gut
During approximately the fourth month of gestation, the caecum leaves its position
on the left side.,of the abdomen, ascends, and with its mesenteric attachment as a handle,
rotates in the form of a partly opened fan into the right iliac fossa. Disease of the
appendix which may be found extra- or intra-peritoneal anywhere along the course
described by the caecum may result in confusing symptoms, as do those arising from
other malformations of the gut.
Most of the serious malformations will have caused death in infancy.    One of those
which is consistent with life is illustrated in the following case.    A well-nourished six-
year-old boy suffered from colicky pain and constipation all his life, having had three
major attacks of nauses and vomiting.   A barium enema demonstrated a left-sided colon
which was also elongated and presented several transverse folds.    The caecum was lyings
beneath the splenic flexura  (Fig. VI).    Laparotomy revealed the more serious malfor-\
mation of the small bowel, which usually accompanies this picture.    The mesentery of
the small bowel was lacking in its normal fixation.    Instead, it had only a short rudimentary attachment below the origin of the superior mesenteric artery and presented"
a classical clockwise volvulus of the gut.    Peritoneal folds also compressed the second
and third parts of the duodenum.    Following reduction of the volvulus and release of
the duodenum, the boy has remained well.
Redundant Colon
There is doubt in the minds of some physicians as to the true significance of the so-
called redundant colon in patients with dyspeptic or colicky symptoms. Nevertheless,
the condition seems to be a definite anatomical fact and it is frequently encountered
by roentgenologists.
At birth and throughout infancy, the large intestine, especially the sigmoid, is relatively longer in proportion to the small intestine than in later life. This fact must
always be kept in mind before drawing the conclusion from x-ray evidence alone that
the colon is longer than normal. Even in childhood it must be remembered that on
account of the narrow pelvis, the colon is forced to adjjust itself to its surroundings
by re-duplication and will, in consequence, give a different picture from that of the
adult. There is little doubt that the attainment of the adult relationship is not infrequently delayed and that the colon really is redundant and constitutes an abnormality.
In these cases, however, the colon, while long and crowded into folds, is not dilated,
such as occurs in Hirschsrprung's disease. Redundant colon is said to be one of the
common causes of constipation in early life and the constipation is not infrequently
accompanied by pain as a result of the exaggerated peristalsis. This bowel gives considerable anxiety to the radiologist. Its reduplication and deep festooning overshadows
other coils, increasing the risk of missing significant filling defects and deformities. The
cleansing of this type of bowel ,preliminary to roentgen visualization, is invariably incomplete or unsatisfactory.
Page 132 Intussusception
Telescoping of one portion of the intestine or colon into a more distal segment of
the enteric tube is one of the mist important surgical emergencies in infants and children. The etiological agent is 90 per cent unknown. It is occasionally due to polypoidal
tumors or extensive lymphoid hyperplasia in the caecum or ileum. The alarming colicky
abdominal pain is almost a universal finding, and an abdominal mass is usually felt,
especially with the aid of a rectal examination. This my be difficult in a fat or uncooperative child. Ladd and Gross3, in their text on abdominal surgery of infants and
children, state: "In typical cases of acute intusssuception, the history and physical findings are sufficient to make a diagnosis." Most paediatricians will admit, however, after
critical thought that the diagnosis is by no means always easy and that laparotomy is
occasionally performed in infants with negative findings.
The usual method of investigating a suspected intussusception is by a  thin, low
gravity pressure barium enema.    One has only to observe personally, under fluoroscopic
control, a typical case, to realize the signs of intussusception are as striking and pathognomic as observed in any gastro-intestinal radiology.    The various radiological appear-
ances of intussusception depend upon the relationship of the contrast medium to the
^entering and receiving loops (Fig. VII).    There may be complete arrest of the enema.
This gives no particular features but a close examination of the site of obstruction may
reveal slight ^ringing" due to the emulsion becoming partially insinuated about a large
central defect.    There may be a transient arrest of the head of the enema with gradual
movement proximal toward the caecum.    The production of a "cupola" defect is frequently observed which, when further defined, may be termed a "pincer" defect.   There
lay be considerable ensheathment by the barium emulsion, leaving a large central filling
lefect in the long axis of the colon.   This ensheathment is due to the emulsion becoming
insinuated between the flattened oedematous mucosal folds of the two layers of the gut,
[which are closely opposed.    The central defect is the result of an intussusception with
large in-drawn mesentery.
A rare observation is noted when the emulsion enters the central cylinder of the
intussusception as a thin streak with a fine linear longitudinal marking.    This combination is rarely observed during a barium enema but jt is commonly noted during the
'investigation of a chronic intussusception by barium meal.
There are certain pitfalls in diagnosis. The "cupola" defect may be noted in cases
with a polypoidal tumour of the gut but without intussusception, even with an apparent
reductiin due to the mobility of a pedunculated tumour. A large faecal mass may produce such a defect but would not give any further signs of intussusception. It is important that every effort be made to show the emulsion in the terminal ileum. A complete enema filling of the large gut does not enable the examiner to exclude an ileo-ileal
^invagination.
Value of Plain Abdominal Films
A barium enema is not the only means by which information can be obtained in
[•intussusception.    The plain film is frequently valuable and may present sufficient evidence to confirm the diagnosis.    Only in a few of the published reports on intussusception is there any mention of the x-ray appearance apart from the use of contrast media.
Before analyzing plain abdominal films in cases of intussusception, one should be
familiar with the normal gas pattern of a child's abdomen (Fig. VIII). The shadows
of the caecum and the ascending colon lie in their usual position and can be identified
by typical mottled shadows due to semi-emulsified liquid and gas contents characteristic
of this part of the bowel. Unless a cleansing enema has been 100 per cent effectual,
these significant shadows can be used to identify the right side of the colon.
When intussusception is present the plain film may demonstrate complete absence
of normal right-sided large bowel shadows. The invagination of the caecum up into
the colon causes the right lower quadrant to appear "empty"—a radiographic counterpart of the clinical "Dance's sign."   One may note distended loops of obstructed small
Page 133
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Hi
ft bowel in the lower abdomen. A soft tissue shadow, representing the head of the entering loop of an intussusception is sometimes projected in contrast to the surrounding air
in the receiving segment of the bowel (Fig. IX).
Intussusception Simulating Polypoidal Tumour
A six-year-old boy with chronic intermittent colicky pain was admitted for investigation and treatment. He was not acutely ill and was free from discomfort at the
time of his roentgen study. Barium enema disclosed a large, smooth, round defect in
the caecum near the ileo-caecal valve, suggesting a polypoidal tumour. The ileo-caecal
valve could not be filled. Operation revealed a thick, ofcdematous terminal ileum, surrounded by large lymph glands, some of which were three centimetres in diameter. No
tumour was discovered in the caecum. This was evidently an ileo-caecal intussusception,
simulating a tumour and originating in the thick swollen terminal ileum and the adjacent lymphadenitis. The intussusception apparently reduced itself during the three-day
interval between the x-ray study and the operation.
Primary Malignant Tumours in the Abdomen
A three-and-one-half-year-old boy of good nutrition and development was admitted
the day following his first medical examination. He had fever, anaemia, severe right
upper abdominal pain, tenderness and was very resistant to palpation. The plain film,
shortly after admission, revealed the faint calcified shadow (Fig. X). A lateral film
demonstrated the shadow to lie well posterior. It seemed to be in the adrenal area and
the right kidney shadow was slightly lower than normal. Calcification of such density
in this location in a small child is most unusual and is likely due to calcium salts in the
degenerating centre of a haemorrhagic or necrotic adrenal tuberculosis or tumour. Operation demonstrated an extensive infiltrating tumour which, autopsy, was shown to originate as an adrenal neuroblastoma.
CONCLUSION
Methods of roentgen investigation of children presenting abdominal pain have been described.
Fluoroscopy is a useful aid, especially in intussusception.
The plain film of the abdomen is a simple valuable procedure, even with the acutely ill patient.
If the attending physician presents  the  clinical problem to the radiologist, the latter is in a better
position to direct the proper sequence of informative x-ray procedures.
REFERENCES
Caffey, J.j Pediatric.X-Ray Diagnosis, The Year Book Publishers Inc., Chicago,  1945.
Guthrie, K. J.: Arch.  Dis. Child.,  17:28,  1942.
Ladd, W. E., and Gross, R. E.: Abdominal Surgery of Infancy and Childhood, W. B. Saunders & Co.,
Philadelphia, 1941.
PROVISION OF DRUGS UNDER THE HOSPITAL
INSURANCE ACT
The drugs which may be ordered for patients in hospitals, under the Hospital Insurance scheme, have been enumerated in B. C. Hospital Insurance Circular, No. 13.    There has been some comment and criticism over this list.
Doctor W. W. Simpson, chairman of the Committee on Pharmacy, has agreed
to receive directly all comments, criticism, or advice from the doctors of the
Province in regard to the supply of drugs for patients in hospital, to sift their
merits, and to make recommendations to the Hospital Commissioner.
Any doctor who has any comments to make should forward them as soon
as possible to Dr. W. W. Simpson, Chairman, The Committee on Pharmacy,
The British Columbia Medical Association, 203 Medical-Dental Building, Vancouver, B. C. General satisfaction greets the news of the appointment of Dean of the Medical
Faculty of the University of British Columbia, and the profession welcomes Doctor
Myron K. Weaver, the newly appointed Dean. Doctor Weaver is, at present, the Assistant Dean of Medical Sciences at the University of Minnesota, an associate of the American College of Physicians, and a Diplomate of the American Board of Internal Medicine.
A long expressed desire for a Medical School in British Columbia will be fulfilled witih
the admission of the first class to the first year of the medical course in the fall of 1950.
Congratulations and best wishes are extended to the following doctors and their
■rives, on their recent marriages: Dr. and Mrs. William La Croix, who will make their
home in Penticton; Dr. and Mrs. R. D. Morrison of Hope; and Mr. and Dr. J. A. Singleton (nee Dr. Jean Agnes Morrison) who have gone to Nairobi, Kenya Colony, Africa.
Dr. G. B. Wilson from Harrison is now Assistant Resident in Medicine at the Vancouver General Hospital.
Several doctors have left this Province to take up practice in other cities:
Dr. W. H. Ormond, formerly of Kimberley, has gone to Brooks, Alta.
Dr. A. E. Shore from Victoria has»gone to Calgary, Alta.
Dr. D. D. Sturdy of Vancouver is now living in Climax, Sask.
Dr. R. S. Clarke from New Westminster has gone to Toronto, Ont.
Dr. J. G. Ward, formerly of Victoria, is now living in San Francisco, California.
Dr. G. N. Cormack has left Fort St. John and is now practising in Edmonton, Alta.
Dr. Peter Barg from Oliver is now living in Toronto, Ont.
Dr. E. A. Boxall, formerly of Vancouver, has gone to Kingston, Ont.
We note with interest the publication of a story, "Klinker," by Dr. F. W. Andrew
of Summerland.
We regret to record the passing of Dr. J. C. S. Dunn of Masset, and sincere sympathy
ps extended to Mrs. Dunn and family.
Deepest sympathy is extended to the following doctors on their recent bereavements:
Doctors G. L. Burke, W. T. Kergin, L. W. Kergin, A. B. Nash and C. G. G. MacLean.
Dr. L. C. Kindree, formerly with St. Paul's Hospital, Vancouver, is now practising
at Squamish.
Dr. D. P. Hanington has left Ladysmith and is now associated with the Workmen's
Compensation Board in Vancouver.
Dr. F. P. Sparks has left the Vancouver General Hospital to accept an appointment
pith the Royal Inland Hospital at Kamloops.
Dr. L. V. Mason has left Tulsequah to make his home in Vancouver.
Congratulations to Dr. W. D. Marshall, newly-elected President of the Victoria
Wing of the new R.C.A.F. Association.
Among those doctors who have recently left British Columbia to do post-graduate
work are:
Dr. A. L. Swanson, now at the Northwestern University, Chicago, Illinois.
Dr. W. P. Fister has gone to the Neurological Institute at McGill University.
Dr. Mary F. Callaghan, now at the Mayo Foundation, Rochester, Minnesota.
Dr. J. T. Hugill, who is now at the Children's Memorial Hospital in Montreal.
Dr. A. J. Sherban is taking post-graduate studies in radiology in New York.
Page 135
% 1
Dr. H. J. O'Brien has left Vancouver to practise at Dawson Creek.
Dr. B. Meth has left loco and is now practising in New Westminster .
Dr. J. A. Macdonald, formerly of Port Simpson, is now in practice in Burnaby.
Congratulations are extended to the following doctors and their wives on their recent
good fortune:
Dr. and Mrs. Leonard Bapty—a son; Dr. and Mrs. C. C. Covernton—a daughter;
Dr. and Mrs. W. P. Goldman—a son; Dr. and Mrs. Grant Gould—a daughter; Dr. and
Mrs. F. E.( Kinsey—a daughter; Dr. and Mrs. O. C. Lucas—a son; Dr. and Mrs. R. D.
MacLaren—a daughter; Dr. and Mrs. E. T. W. Nash—a son; Dr. and Mrs. J. T.
O'Donnell—a daughter; Dr .and Mrs. J. F. Tysoe—a son; Dr. and Mrs. R. L. Whitman
—a son.
Dr. G. L. Stoker has left Salmon Arm and is now practising in Sorrento.
Dr. Alan Beech, formerly of North Vancouver, is now practising in Pender Island.
The following doctors have rejoined the Active Service Forces: Doctors W. G. Rice
and A. B. Weir are stationed at Esquimalt, and Dr. J. H. Preston is with the R.C.A.F.
at Sea Island.
Congratulations are extended to Dr. John D. F. Alexander, of Vancouver, who has
recently been elected to Fellowship in the Royal College of Surgeons of Canada, and is
now F.R.C.S. (Canada).
FOR SALE
Seven-room residence, exceptionally well built, suitable for Medical
Practitioner. One acre of gardens with adjoining acre cleared. Excellent location for Nursing Home.
For further particulars phone DExter 9752-R.
T. W. BRIDGES 1|
2750 Sperling Avenue
Burnaby, B. C.

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