History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: July, 1938 Vancouver Medical Association Jul 31, 1938

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Vol. XIV.
No. 10
In This Issue;||
(With Cascara and Bile Salts)
. . FOR . .
Chronic Habitual
Western Wholesale Drug
(1928) Limited
(Or at all Vancouver Drug Co. Stores) THE    VANCOUVER    MEDICAL   ASSOCIATION
Published Monthly under the Auspices of the Vancouver Medieal Association
in the interests of the Medical Profession.
203 Medical-Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. B. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XIV.
JULY, 1938
No. 10
OFFICERS  1938-1939
Dr. Lavell H. Leeson Dr. A. M. Agnew Dr. G. H. Clement
President Vice-President Past President
Dr. W. T. Lockhart Dr. D. F. Busteed
Hon. Treasurer Hon. Secretary
Additional Members of Executive: Dr. J. P. Bilodeau, Dr. J. W. Arbuckle.
Dr. F. Bbodie
Dr. J. A. Gillespie Db. Neil McDougall
Historian: Dr. W. D. Keith
Auditors: Messrs. Shaw, Salter & Plommer.
Clinical Section.
Dr. R. Palmer Chairman     Dr. W. W. Simpson Secretary
Eye, Ear, Nose and Throat
Dr. S. G. Elliott Chairman     Dr. W. M. Paton Secretary
Pediatric Section
Dr. G. A. Lamont Chairman     Dr. J. R. Da vies Secretary
Cancer Section
Dr. B. J. Harrison Chairman     Dr. Roy Huggard Secretary
Dr. A. W. Bagnall; Dr. H. A. Rawlings, Dr. D. E. H. Cleveland,
Dr. R. Palmer, Dr. F. J. Buller, Dr. J. R Davtes.
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. Murray Baird.
Summer School:
Dr. J. R. Naden, Dr. A. C. Frost, Dr. A. B. Schinbein, Dr. A. Y. McNair,
Dr. T. H. Lennie, Dr. Frank Turnbull.
Dr. A. B. Schinbein, Dr. D. M. Meekison, Dr. F. J. Buller.
V. 0. N. Advisory Board:
Dr. I. Day, Dr. G. A. Lamont, Dr. Keith Burwell*.
Metropolitan Health Board Advisory Committee:
Dr. W. T. Ewing, Dr. H. A. Spohn, Dr. F. J. Buller.
Greater Vancouver Health League Representatives:
Dr. W. W. Simpson, Dr. W. N. Paton.
Representative to B. C. Medical Association: Dr. G. H. Clement.
Sickness and Benevolent Fund: The President—The Trustees. Protection Against Typhoid
Typhoid and Typhoid-Paratyphoid Vaccines
Although not epidemic in Canada, typhoid and paratyphoid infections remain a serious menace—particularly
in rural and unorganized areas. This is borne out by the
fact that during the years 1931-1935 there were reported,
in the Dominion, 12,073 cases and 1,616 deaths due to
these infections.
The preventive values of typhoid vaccine and typhoid -
paratyphoid vaccine have been well established by military and civil experience. In order to ensure that these
values be maximum, it is essential that the vaccines be
prepared in accordance with the findings of recent laboratory studies concerning strains, cultural conditions and
dosage. This essential is observed in production of the
vaccines which are available from the Connaught
Residents of areas where danger of typhoid exists and
any one planning vacations or tray/el should have their
attention directed to the protection afforded by vaccination.
Information and prices relating to Typhoid Vaccine and to
Typboid-Paratypboid Vaccine will be supplied
gladly upon request.
Toronto 5
Depot for British Columbia
macdonald's Prescriptions Limited
Total Population—estimated...
Japanese Population—estimated;.
Chinese Population—estimated..
Hindu Population—estimated..
Total deatns	
Japanese deaths-
Chinese deaths	
Deaths—residents onlv.
. 238
_ 207
Male. 210 : Female, 163  373
May, 1938
Deaths under one year of age    16
Death rate—per 1,000 births  .    42.9
Stillbirths (not included in above) _     7
Rate per 1,000
May, 1937
June 1st
•   April, 1938
Scarlet Fever..— __  46
Diphtheria —_ 1
Chicken Pox .... 211
Measles _• '.— 9
Rubella  ... 7
Mumps ,  36. \
Whooping Cough   33
Typhoid Fever „   1
Undtilant Fever  0
Poliomyelitis    0
Tuberculosis  ~  33
Erysipelas     3
Ep. Cerebrospinal Meningitis 0
Vancouver      Hospitals and
Clinic        private doctors      Totals
h, 1938
aths :
Syphilis .
Conducted in accord with the ethics of the Medical
Profession and maintained to the standard suggested by
our slogan:
Pharmaceutical Excellence
McG!ll <S» Olmr,
FORT STREET (opp. Time*)      Phone Garden 1196     VICTORIA, B. C.
There is a story of an Editor of a Western newspaper in the bad old days,
when it took more than mere book-learning to be an Editor. He was sitting
at his desk one day, as the story runs, with his back to the window, writing
up his stuff. A bullet whistled past his ear, and buried itself in the wall in
front of him. "Aha !" said the Editor, without looking up from his work, and
with a chuckle, "I had an idea that last editorial of mine would interest
some of the boys."
So some of our remarks in the latest edition of this family journal seem
to have ruffled the equanimity of one or two of our readers, as is evidenced
by a short but pithy effusion received through the mail recently. It is rather
a pity the epistle was unsigned, as we like to know who our real readers are,
but the writer seemed displeased. He called our editorials "garrulous," complained of the "twaddle" supplied by "Thomas" (we take it he was slandering our good friend the B. C. Medical Secretary), and accused us of giving
free advertising to one "Strong" (again we take it that he was referring to
one Dr. G. F. Strong), and in general thought we were generally lowering
the level of quality of this Bulletin.
We do not want to do that, and yet we cannot feel that his anonymous
criticisms are justified altogether. Perhaps he is right about the editorials,
but that must be ascribed to a defect in the makeup of the Editor, and
regarded as one of those things—it is one of the few chances he gets to be
happy.and talk as much as he wants. As regards the contributions of Dr.
Thomas, we regard them as very valuable, as they are of interest to all men
in the Province, and deal with important matters, and are readable as well,
a most important consideration. And we will promise to advertise the writer
of the anonymous letter just as freely as we do Dr. Strong, just as soon as he
makes equally significant contributions to the public good. We are not at all
repentant about giving publicity and acknowledgment to the work of anyone
who is giving unselfishly of his time and energy towards promoting the interests of his fellow medical men, and his fellow citizens. Dr. Strong, we feel,
falls into this category, as do other men whose work we have mentioned with
commendation in this Bulletin.
The men who do this good work are not necessarily looking for praise and
advertisement, and we think it is rather a reflection, not on their motives,
but on the motives of their accuser, when such accusations are made. There
are men who do things from a deep sense of responsibility and civic obligation, and give time and energy that they can ill afford, and the giving of
which represents a real sacrifice on their part; and do it without any thought
of self-aggrandisement. In fact, if they are not doing it unselfishly, it has
little or no value, and their real aim is speedily evident. But it is well that
the rest of us (including our contributor) who benefit by this work should
acknowledge the fact occasionally, and we propose to. continue, in our small
way, to do just that, and if necessary accept the charges of favouritism and
advertising. It is, after all, lucky that we escaped the accusation of accepting
bribes, or something of the kind, and our mens conscia recti will help us
over this stile. *      *      *      *
The recent Summer School was a great success, if we can judge by the
comments we have heard on all sides. The attendance, we gather, did not
come up to last year's record, but there were several reasons for this. We
suspect that Old Man Depression had something to do with it, but there were
other valid causes for a falling off of attendance. The American Medical
Association was holding its annual meeting in San Francisco, and a good
many regulars took this in, to their great profit, we are told, and enjoyment.
Then there was a very important meeting, in Vancouver, of the Sixth Canadian Conference on Social Work, and this attracted a certain number who
otherwise would no doubt have gone to the Summer School.
Page 221 But the School was, nevertheless, fully up to standard, and that is saying
much. The setting was again perfect, the loud-speaker system worked to
perfection, and all the machinery of the affair functioned without hitch.
To appreciate this smoothness of operation properly, one should have gone
to one or two of the meetings of the other conference referred to, where
unfortunate speakers had to talk, or rather yell, into the absorbent emptiness of that infernal Ballroom, where people sitting close to the speaker
could barely hear a word, and people six or eight rows away could hear,
We have, through the kindness of the speakers of the Summer School,
obtained, in many cases, the complete papers, in others, help in preparing
abstracts, while our able stenographer, Mrs. Ellis, got full notes in other
lectures. We are at present considering whether to publish a separate Supplement, or incorporate these in future numbers of the Bulletin.  In any case,
our readers will have them to read and study at their leisure.
*      *      *      *
It is with great pleasure that we publish in this number the complete text
of the paper read by Mr. Hugh Wolfenden, F.I.A., F.A.S., F.S.S., at the Sixth
Canadian Conference on Social Work, held from June 21 to 25.
This Conference was one of national and international importance, and
we doubt if medical men here realised its tremendous significance. To begin
with, it had a huge attendance, over 500 being registered on the second day.
Then there were delegates and representatives from many other countries.
Great Britain sent many notable people, perhaps the best-known being Miss
Margaret Bondfield, known all over the civilised world as one of the outstanding leaders in Social Work—a speaker of eloquence and fluency, and a
fearless exponent of her beliefs. Many of the things she said must make our
ears as Canadians burn, and our consciences smart, but the frankness and
sincerity of the speaker were obvious and convincing.
The United States, too, sent many delegates, and, in fact, contributed
very greatly to the success of the Conference. Amongst these we should mention, as of especial interest to us, Prof. Paul A. Dodd, of the University of
California, who spoke on Health Insurance, at the same meeitng as the one
where Mr. Wolfenden spoke.
An excellent contribution, too, and one which we hope to present to our
readers at an early date, was the paper\read by Dr. Roy Holmes, on the "Care
of the Medical Indigent." He described^the experience of men in Ontario,
notably Essex County, where experiments of very great importance are
bing carried out, and very important conclusions are being reached. He told
us that the United States Government is waLtchjng^ this work closely and
intends to apply the methods that are working out so well to some nineteen
million people in the States in the near future.
Dr. Holmes' presentation has a close application to many of our problems
in British Columbia, and we shall hear more Of this later.
To return for a moment to Mr. Wolfenden's paper: We bespeak for this
paper the closest scrutiny and most careful reading. It has much in it that
cannot be dwelt on here, but it is plainly and easily written and is a document of considerable importance and weight. It is not lightly to be dismissed, when an actuary of international reputation, who has worked on the
Unemployment Insurance of Great Britain, who is regarded as a leader of
pre-eminence in the United States and Canada, makes a considered statement.
The next item of importance on our yearly programme is the Annual
Meeting of the B. C. Medical Association in September, and a notice of this
appears in this number. It is going to be held in Victoria, and we need say
little more, though just for the pleasure of it we should like to say something.
Victoria has a reputation, acquired partly through natural gifts of climate, physical beauty, comfortable hotels, and so on, but mainly through the
Page 222 solicitude and kindly courtesy of her people, of being one on of the best of
all places to hold conventions in. We cannot speak for other professions,
though we see that they hold their meetings there, but we can say that any
time that we personally have attended a medical meeting of any kind in
Victoria (and they have them all sizes) the occasion has been a notable one.
They certainly know how to put on a meeting, and how to make one feel
at home and really welcome.
Moreover, they always support us whenever we have conventions, meetings, or whatnot. So we owe it to them, too, to show our appreciation of
their neighbourliness and sportsmanship.
And besides all this, the programme is one that has something for everyone, and that all of us should take in. Full details will be available elsewhere,
but the list of speakers assures of an excellent bill of fare.
Lastly, this is the annual meeting of the medical profession of British
Columbia. Our economic future, our personal prosperity, the maintenance of
high standards of practice, the highest welfare of the public that depends
on us for medical care and education in health and the prevention of disease
—these are all best served by a strong, united and enlightened medical profession, and the work of the B. C. Medical Association, and of the College of
Physicians and Surgeons of B. C, are the forces that weld us, and make us
a power in the community to be reckoned with. This work is the intimate
concern of each one of us, and each of us must do his part, or leave it undone
to the detriment of the whole.
:£ afe s|e ${c
Some time ago we referred to forthcoming changes in the setup and contents that are contemplated for the Bulletin. We stated then that proposals
had been made to include in this publication the Transactions of the Victoria
Medical Society and those of the Vancouver General Hospital, and gave the
reasons for these changes.
It has taken some time to get things in train; it involves considerable
change in the format of the Bulletin, increased size, etc., and unfortunately
any change made now interferes with the regular binding of the journal and
so gives pain to the soul of our Librarian, whose sacred duty it is to see that
we are appropriately indexed and put together each year. However, these
things are no doubt good for the soul, and Miss Choate has accepted the
inevitable gracefully, and is hoping for the best.
We hope to make a definite start in the next number. We have a good
deal of material now from the V. G. H., and some from Victoria. Naturally,
we shall not have our full contributions from the latter yet, as the summer is
a natural drier-up of news, papers and other material, but the Fall will
remedy that. Meantime, the Hospital Publications Board has made an excellent beginning, and we have copy from them, sufficient to go on with.
It is hoped that the arrangement of the material in the Bulletin will be
more methodical in the future, and that definite space will be allocated to
each department, so to speak. Medical Economics, for example, deserves a
place to itself. Even more important, the Library should have a corner to fill
each month. News and Notes have been growing steadily, and we hope some
day to have a very definite space for Public Health matters and Preventive
Medicine. If there is a prescribed play for each thing it will be more satisfactory for all concerned.
Meetings for arrangement of all these details are in progress, and our
readers will see the results later.
*      ♦      *      ♦
We received recently through the mail a reprint of an article by Dr. C.
E. Dolman and Miss V. G. Hudson, of the Provincial Board of Health, on
Brucellosis in and around Vancouver. It makes very interesting and somewhat disturbing reading, when one thinks of the fight that many well-intentioned people are putting up against compulsory pasteurization of milk.
Page 22'S Undulant fever, as the disease is more commonly called, is by no means
a rare disease in this neighbourhood, and the records seem to show that it
is roughly nine times as common here as it is in districts remote from Vancouver.
Nor is it a trifling ailment, to be passed over lightly, as those medical
men who have treated cases will tell us. It is a very chronic condition at
times, and makes life miserable for the victim. And it is all unnecessary.
Simple pasteurization of milk is a certain and harmless remedy. When one
reads that of 1296 samples of pooled raw milk obtained from 55 dairies
delivering in Vancouver, 54.3% showed complete agglutination in Br. abortus
suspensions of diagnostic titre, one cannot but wonder why the presentation
of this simple fact should not be enough in itself to make the authorities take
action. It is for us as medical men to acquaint ourselves with these facts,
and to preach pasteurization in season and out of season, without letting
up until this simple health measure be demanded not only by us who realise
its value, but by the public at large.
Doctors doing relief work please take notice that payment for examinations for Certificates of 111 Health will not be allowed unless such examination is requested by the Relief Department.
The Summer School brought a number of men from the Province to
Vancouver, and several from the Untied States. Those from outside the city
and New Westminster who came were:
Dr. A. N. Beattie, loco; Dr. H. L. Burris, Kamloops: Dr. J. P. Ellis,
Lytton; Dr. G. G. Ferguson, Smithers; Dr. A. N. Hanson, Sidney; Dr. E. R.
Hicks, Cumberland; Dr. H. F. Inglis, Gibsons Landing; Dr. J. A. Ireland,
Kamloops; Dr. G. C. Johnston, Michel; Dr. G. E. Langley, Wells; Dr. Leroux,
Nanaimo; Dr. Geo. More, Shawnigan Lake; Dr. C. H. Ployart, Lillooet;
Dr. Sparling, Haney; Dr. Stalker, Tranquille; Dr. G. G. Stewart, Victoria;
Dr. J. Bain Thorn, Trail; Dr. J. P. Vye, Victoriax; Dr. H. Winter, Victoria.
From Alberta, Dr. W. B. Parson registered frW Red Deer and Dr. W.
A. Shandro from Vegreville.
The following doctors registered from the United States: Dr. C. R.
Mowery, Spokane; Dr. C. R. McCreery, Tacoma; Dr. S. Sawamura, Seattle;
Dr. D. L. Stokesbary, Ferndale; Dr. D. Willard, Tacoma, Washington; Dr.
R. C. McDaniel, Portland, Oregon. \
Dr. D. V. Trueblood of Seattle, a former lecturer at the\ Summer School,
was a visitor to the Summer School for one day, as was also Dr. N. M. Salter
of Williams, California.
* *      *      *
Dr. Perry McCullough of Cleveland spent a few days in town on his way
home from the American Medical Association meeting in San Francisco.
Dr. McCullough is a former lecturer at the Summer School.
* *      *      *
Dr. Howard Spohn attended the meeting of the American Academy of
Paediatrics in Del Monte, where he read a paper on "The Enlarged Thymus.
Diagnosis and Treatment." He also attended the meeting of the American
Medical Association in San Francisco, and then left for a trip to Honolulu.
* *      *      *
Dr. Stewart James attended the Ninth Annual Meeting of the Western
Branch of the American Public Health Association in Portland on June 6th,
7th and 8th, where he gave a paper on "Tuberculin Test in Primary Grade
Children as a Means of Case-finding of Adult Primary Tuberculosis."
Page 22k Dr. T. Dalrymple of Vancouver and Miss Eunice Hayman, R.N., graduate
of St. Paul's Hospital, were married in Kelowna on June 25th, and will motor
in California. They have our best wishes.
* *      *      #
Dr. Gordon A. Lawson of Port Alice has been appointed a Deputy Coroner
in British Columbia.
* *      *      *
Dr. Norman Dick of Chemainus and Miss Anne Plunkett, R.N., a graduate
of the Vancouver General Hospital, were married in May.  They have our
best wishes.
* *      *      *
Dr. and Mrs. H. C. L. Mooney of Courtenay have been visiting on the
V •!• *P 1*
Dr. and Mrs. M. G. Archibald of Kamloops attended the Halifax meeting.
Dr. Archibald served on General Council.
* *      *      *
Dr. F. D. Sinclair of Cloverdale called at the office the other day.
* *      #      *
Dr. G. F. Bayfield, well known in West Vancouver, has been on the
Columbia Coast Mission work as Medical Officer on the Columbia. He called
at the office and told us somewhat of his duties. The doctors in that service
lead a busy and useful life, even if not very profitable from the standpoint of
salary. They never complain but they earn their money.
* *      *      *
Doctors Thomas McPherson and Gordon Kenning of Victoria and S.
Cameron MacEwen of New Westminster were in Vancouver for a meeting
of the Executive of the Council on Monday, June 13th. Doctors W. E. Ainley
and Lyon H. Appleby of Vancouver also attended this meeting.
* *      *     *
Dr. John King Kelly and Miss Virginia Grasse Goddard were wedded on
May 23rd at Zeballos. Sincere good wishes to these pioneers at Zeballos.
* *      *      #
Dr. G. K. MacNaughton of Cumberland will visit Eastern Canada, during
the months of July and August.
* *      *      *
Dr. E. Howard McEwen of New Westminster and family will motor in
Eastern Canada and United States before returning from their Eastern trip.
* *      *      *
Dr. and Mrs. Larry Giovando are being congratulated on the birth of a
son, who will be known as Larry also.
* *      *      *
Dr. S. L. Williams has resumed practice in association with Dr. W. F.
3|C 3p S? IfC
Dr. and Mrs. J. F. Haszard left Kimberley the end of April for a European trip. They expect to return about the middle of August.
During the months
of July and Augus
t the Libr
j w:
ill be
from 9 a.m. to 5 p.m.
Monday to Fridaj
r, and 9 a
1 p.m. on
The Librarian will
be away on vaca
tion durir
weeks of July.
Dr. K. F. Brandon has been appointed, as from June 1st, 1938, to the staff
of Connaught Laboratories, University of Toronto, and will be. attached to
the Western Division at the University of British Columbia, He will be
engaged in research in various problems relating to the bacteriology and
epidemiology of communicable diseases.
Doctor Brandon will continue to act, in a part-time capacity, as Epidemiologist to the Metropolitan Health Committee of Greater Vancouver, and
will remain Director of the Student Health Service at the University of
British Columbia.
SEPTEMBER 15, 16, 17, 1938
De. Edwin George Bannick:, Seattle, Washington, formerly of Mayo Clinic.
Dr. A. T. Bazin, Montreal, Professor of Surgery, McGill University.
Dr. William Boyd, Toronto, Professor of Pathology, University of Toronto.
Dr. Alson R. Kllgore, San Francisco, Associate Clinical Professor of Sur'
gery, University of California.
Dr. Hans Libber, San Francisco, Clinical Professor of Medicine, University
of California.
Dr. K. A. Mackenzie, Halifax, Professor of Medicine and Clinical Medicine,
Dalhousie University.
Dr. L. H. Neweurgh, Ann Arbor, Professor of Clinical Internal Medicine,
University of Michigan Medical School.
Representatives of Canadian Medical Association:
President: Dr. K. A. Mackenzie, Halifax.
General Secretary: Dr. T. C. Routley, Toronto.
9: 00 a.m.—LECTURES :
Dr. Hans Libber : "Masculinizing Syndromes; A Consideration
of Cushing's Dusease; The Adrenal Cortical Syndrome, and
Arrhenoblastoma of the Ovary."
Dr. E. G. Bannick : "Acute Pancreatitis."
Dr. A. R. Kilgore : "Treatment of Peripheral Vascular Diseases
Threatening Gangrene."
Dr. Hans Libber : "Clinical Observations on the Present Status
of Gonadotropic and Sex Hormone Therapy."
Dr. W. J. Boyd : "Pathology of the Gall Bladder."
Speakers: His Worship Mayor McGavin, Victoria.
Dr. G. W. Bissett, President, Victoria Medical
Dr. Howard Spohn.
Dr. C. E. Dolman.
Page 226 2: 30 p.m.—DEMONSTRATION at Provincial Royal Jubilee Hospital.
Medical, surgical, Obstetrical, x-ray, and pathology.
9: 00 p.m.—INFORMAL DANCE at the Empress Hotel.
9: 00 a.m.—LECTURES :
Dr. K. A. Mackenzie : "Treatment of Hypertension."
Dr. L. H. Newburgh : "The Nature and Management of Nephritic Oedema."
Dr. A. T. Bazin : "Cancer of the Breast."
Dr. A. L. Kllgore: "Extra-abdominal Diseases Simulating the
Acute Abdomen."
Dr. W. J. Boyd : "Tumours of the Neck."
12 : 30 p.m.—LUNCHEON:
Speakers: Dr. K. A. Mackenzie, President, Canadian Medical
Dr. T. C. Routley, General Secretary, Canadian Medical Association.
4: 30 p.m.—TEA at Butchart's Gardens.
8:00 p.m.—ANNUAL MEETINGS of the
College of Physicians and Surgeons of B. C,
to be followed by that of the
British Columbia Medical Association.
Every member of the medical profession is urged to attend these
9 : 00 a.m.—LECTURES :
Dr. Hans Lisser : "Indications for and the Proper Use of Thyroid Substance.
Dr. A. T. Bazin : "Cancer of the Colon and Rectum."
DR. E. G. Bannick : "Medical Treatment of Severe Burns."
Dr. W. J. Boyd : "Bacterial Infection of the Heart."
Dr. A. R. Kllgore : "Practical Considerations in the Handling of
Acute Appendicitis and Its Complications."
12:15 p.m.—LUNCHEON: Board of Directors, British Columbia Medical
1: 30 p.m.—GOLF.
7: 00 p.m.—ANNUAL DINNER of the British Columbia  Medical Association.
SEPTEMBER 15, 16, 17, 193 8
This year we meet in Victoria.
The Empress Hotel will house us.
Already Victoria is ready.
Committees are being convened and the programme of Lectures and
special features await your attendance.
Read the programme of lectures—write for reservations—polish your
golf clubs and bring your wife.
First Day—Five lectures in the morning (see programme elsewhere).
Luncheon with addresses of welcome and Doctors Spohn and Dolman
on the milk problem.
In the afternoon a special feature at the Jubilee Hospital, where you
will have demonstrations of newer apparatus, procedures, diagnostic and
therapeutic, something to see—visual learning, new technique in obstetrics, etc. They have a new apparatus which they are proud of in the matter of preparation of solutions for intravenous infusion.
Thursday evening everyone dances and is introduced.
Second Day—More lectures—five in the morning (see programme).
Luncheon—Dr. MacKenzie, President, and Dr. Routley, General Secretary of the Canadian Medical Association, speak—we need National
The afternoon sessions will be diverse. Public Health for one hour,
followed by Economics under the new Committee. This is the day when
every member of the College and Association finds something for him.
Sectional meetings involving members in special work are being developed
and the whole medical structure will vibrate as each member finds himself participating freely in his annual meeting. We are all members of
the one body and although we function separately we may be likened to
the body, in which specialized cells function for the good of all.
We must not be long-winded, for we must join the ladies at the Tea
Party at "Benvenuto" at the invitation of those generous souls, Mr. and
Mrs. R. P. Butchart.
Friday evening—The Annual Meetings are held under the chairmanship of the President, Dr. Gordon Kenning of Victoria.
First, the meeting of the College of Physicians and Surgeons of B. C,
of which every doctor in this province is a member. •
Second, the Annual Meeting of the British Columbia Medical Association follows, and again you are urged to attend. The members of your
Board of Directors and Committee Chairmen talk to you through the
medium of reports. The interest shown by the members in past years has
encouraged those who serve you. There is much to be discussed and done.
Third Day—Five more lectures in the forenoon (see programme).
In the afternoon Dr. M. J. Keys and his Committee on Golf will (with
the aid of Dr. McMicking and his Committee on Transportation) show
you where to play and encourage you to hope to win a prize (there are
many) or capture the Trophy of the British Columbia Medical Association (presented by Mead-Johnson Co.) from the present holder, Dr. Fraser
Murray of Vancouver.
Saturday evening—The Annual Dinner will be full of surprises.
There will be an address and by an outstanding personality. This is the
Annual Dinner of your Association and you are urged to attend. Golf
prizes will be distributed. In any case, this will be the Annual Dinner
and the wind-up feature of what already lends promise of being a real
Annual Meeting. Remember last year in Vancouver!
Make your reservations now at the Empress Hotel.
# *r * *
Entertainment for Ladies—Husbands, Please Read!
Mrs. Gordon Kenning of Victoria, the charming wife of the President of
the College of Physicians and Surgeons of B. C. and of the British Columbia
Page 228 Medical Association, has already assembled her conveners of committees
and wishes to announce that Victoria invites the ladies to the Annual Meeting
to be held on September 15th, 16th and 17th.
We are now assured of a large attendance. Doctors must accompany their
Doctors are accused of not showing the announcements in the Bulletin
to their wives. This is not absolutely true. We urge you to show this to your
family—then you will come.
Thursday, September 15th
This is the opening day and we are to have a dance and get-acquainted
party. This will be held at the Empress Hotel. Victoria again puts its
better foot forward and steps off properly. You will feel at home and be
ready for the next two days.
Friday, September 16th
Mr. and Mrs. Butchart have extended to the members an invitation to
have tea in the Gardens at "Benvenuto," their beautiful home on Brentwood
Bay. This splendid gesture by these wonderfully hospitable people is much
appreciated by the profession. What a perfect setting for a tea party. The
afternoon sessions will be speeded up to allow the men to join in this function.
Just this once, we will have men at a Ladies' Tea.
Saturday, September 17th
This dinner will be widely popular. The Ladies will meet again, happy
in the knowledge that the husbands are all soberly engaged in the Annual
Dinner of the Association. Under the convenership of Mrs. George Hall,
who joined the provincial medical family last year, we are assured of a
dinner which will prove novelty if not innovation in Ladies' dinners. This
will be held in the Empress Hotel and will be the final feature of a very full
Annual Meeting. The Victoria convention spirit is a very real thing. The
British Columbia profession extends a hearty invitation to its wives.
LADIES—Wives, Please Read!
There are other committees, too, which will make you welcome, will help
you with'your shopping, provide transportation, talk gardens and homes,
look after sports and see that you register. A special committee will locate
lost husbands.
This province will have a great reunion and be happy about it. We would
speculate that the weather will support the effort of Victoria to set a record
in Annual Meetings. Remember last year in Vancouver.
I       f        MEDICAL ASSOCIATION        JBt
The Annual Meeting of the Fraser Valley Medical Society was held on
Thursday, June 2nd, and took the form of a Golf Tournament in the afternoon. In the evening a very successful dinner was held in the Westminster
Club Rooms, Dr. Roy Huggard being the guest speaker.
The officers elected for the coming year were as follows: President, Dr.
E. W. Wylde; Vice-President, Dr. W. A. Clarke; Secretary-Treasurer, Dr.
L. S. Chipperfield, and the Chairman for the Committee on Programme, Dr.
J. Margulius.
President Dr. K. A. MacKenzie, Halifax
President-Elect Dr. F. S. Patch, Montreal
Chairman of Council :.Dr. T. H. Leggett, Ottawa
Honorary Treasurer - Dr. Slater Lewis, Montreal.
Dr. O. C. Trainor, Winnipeg; Dr. A. T. Bazin, Montreal; Dr. Leon Gerin-
Lajoie, Montreal; Dr. H. R. Clouston, Huntingdon, Que.; Dr. J. C. Gillie,
Fort William; Dr. Duncan Graham, Toronto; Dr. W. A. Jones, Kingston;
Dr. Gordon Kenning, Victoria; Dr. W. S. Galbraith, Lethbridge; Dr. J. E.
Bloomer, Moose Jawe; Dr. G. C. Van Wart, Fredericton; Dr. J. R. Corston,
Halifax; Dr. W. J. P. MacMillan, Charlottetown.
Honorary Membership—Sir Humphrey Rolleston, Surrey, England.
Senior Membership—Dr. R. J. Macdonald, St. Peters, P.E.I.; Dr. H. D.
Johnson, Charlottetown; Dr. H. H. McKay, New Glasgow; Dr. G. W. T.
Farish, Yarmouth; Dr. Geo. T. Ross, Montreal; Dr. S. Boucher, Montreal;
Dr. Herbert A. Bruce, Toronto; Dr. A. W. Argue, Grenfell, Sask.; Dr. Alan
M. Lafferty, Lethbridge; Dr. Geo. Sinclair Gordon, Vancouver.
The annual meeting in 1939 will be held in Montreal and it is recommended
that the meeting in 1940 be held in Toronto and the 1941 meeting in Winnipeg.
The British Columbia contingent found warm weather and a warm welcome to greet them in Halifax.
Dr. G. F. Strong formed the advance party and attended the meetings of
the Executive Committee on the 17th and 18th, getting ready for'the meeting
of the General Council on June 20th and 21st.
Dr. Gordon Kenning, our President, accompanied by Mrs. Kenning and
their two sons, Angus and Ian, arrived on Sunday evening, ready for the
meeting of General Council on Monday and Tuesday.
Dr. and Mrs. Wallace Wilson, Dr. G. S. Gordon, and Dr. and Mrs. Archibald of Kamloops and Dr. M. W. Thomas completed that party.
Dr. Stewart Wallace and wife of Kamloops arrived on Monday. Dr.
Wallace presented a paper to the Section of Urology. He also served on
General Council.
Dr. Earle R. Hall of Vancouver also read a paper before the Urological
Section. 1
Dr. G. F. Strong was very busy, and after completing his duties on the
Executive Committee and General Council he presented a paper to the General Session on Thursday afternoon.
Dr. G. S. Gordon of Vancouver was honoured at the Annual Meeting
when Senior Membership was conferred during the ceremonial.
Dr. Gordon Kenning, as President of the British Columbia Medical Association, was the recipient of many tributes to the British Columbia profession. Mrs. Kenning gracefully accepted the position of first lady of the British'
Columbia profession.
Dr. Kenning was elected to the Executive Committee of the Canadian
Medical Association as representative of British Columbia. Dr. Strong has
retired from that committee after a year of valued service.
Dr. Wallace Wilson, as Chairman of the Committee on Economics of the
Canadian Medical Association, was complimented on the presentation and
quality of the report of that committee.
Dr. E. W. Boak of Victoria joined the British Columbia party at Halifax
and served on General Council, attending all sessions.
Dr. H. H. Milburn would have been much heartened by that portion of
the session of General Council which saw Quebec, Prince Edward Island,
Nova Scotia, Ontario, Saskatchewan and British Columbia line up with
Alberta as Divisions of the Canadian Medical Association. In the case of
British Columbia, the final step to the consummation of its entry into the
National Family will be the anticipated ratification in Annual Meeting on
September 16th. That was a great day in Canadian Medicine, and Dr. Mil-
burn would have been happy to see the fruit of his contribution to this grand
Dr. J. S. McEachern of Calgary was awarded the Starr Medal for meritorious service to his profession, and he was sincerely congratulated by all
who know and appreciate him and his work.
The Luncheon Meeting on Cancer was crowded to capacity, and reports
would indicate that Canadian Medicine is going to discharge its full duty in
the development of its Department of Cancer Control and the Canadian
Society for the Control of Cancer.
Dr. A. Y. McNair would have been inspired to even greater effort and
would have realized that British Columbia is not lagging in its interest and
Dr. Gordon Kenning and Dr. Thomas told of the programme in British
Columbia on behalf of Dr. McNair and Dr. Ethlyn Trapp, Chairman and
Secretary of the Committee on Cancer of the British Columbia Medical Association.
The meeting of the Medical Secretaries from all provinces was a great
success and would make it appear that further meetings will be extremely
popular and helpful. The sumptuous repast provided by Dr. Routley might
have several courses deleted with no harmful effects. In this Dr. T. H.
Leggett of Ottawa, Immediate Past President of the Canadian Medical Association and by popular choice the Kingfish of this group, concurred.
"Western hospitality" is difficult to define, but Maritime courtesy is a
real thing. Our brothers and sisters on the Atlantic seaboard not only possess
charm but exhibit it with a naive artistry.
As the Canadian Society for the Control of Cancer is in the process of
organization throughout British Columbia, some detailed explanation of its
aims and objects, and its contemplated plan of development, seems in order
at the moment, especially since, as members of the B. C. Medical Association,
it is our responsibility to see that the movement is successfully launched
and supported.
To reiterate what has already been mentioned in the pages of this journal:
some $14,000 per annum was allotted last year to the Canadian Medical
Association by the Trustees of the King George V Jubilee Cancer Fund to
put into operation across Canada a general plan which Dr. McEachern,
Chairman of the Cancer Study Committee of the C. M. A., and by virtue of
his position also one of the Trustees of the Fund, had formulated and presented to the Trustees with the approval of the Canadian Medical Association. I might say in passing that this gesture on the part of the Trustees
of the Fund was a very high tribute to Canadian medicine through the
Canadian Medical Association, and is an expression of confidence that we
should respect. If the medical profession is to maintain leadership in its
own field it must not overlook opportunities of this type to show the public
that as a body we are vitally interested in public health matters and that
we are willing and capable at all times to do our part in directing such
Page 281 activities that we feel will be of benefit to the health and well-being of our
fellow men.
The plan submitted by Dr. McEachern provided for:
(1) The Department of Cancer Control of the Canadian Medical Association, which is a medical and hospital activity; and
(2) The Canadian Society for the Control of Cancer, a lay-medical
Dr. Routley, our general secretary, is Chairman and Managing Director
of the Department of Cancer Control of the C. M. A. (he is also general
secretary of the Canadian Society for the Control of Cancer). The Chairman
of each provincial Cancer Committee and the full-time secretary of each
provincial medical association are directors. These men, together wihch a
small nucleus committee in Toronto, which includes Dr. Roscoe Graham, Dr.
Wm. Boyd, Dr. R. I. Harris, Dr. Geo. S. Young, Dr. Wm. Scott and Dr. Harvey
Agnew, form the Board. Dr. A. Y. McNair and Dr. Thomas are our representatives this year.
To enlist the interest and sincere co-operation of every member of the
medical profession of Canada in this study of the problem of cancer is perhaps the main objective of this department of the C. M. A., and to this end
the authorship committee, under Dr. Roscoe Graham and Dr. Boyd, have
compiled a series of carefully prepared articles by various well-known
authorities on cancer in Canada, which will in the near future be available
in book form to every medical man in the Dominion. These articles have
already been submitted to the Provincial Cancer Committees and suggestions
invited. One can safely say that the book will be a valued addition to any
The creation of Cancer Study Groups in hospitals, particularly the larger
ones with capacity in the neighborhood of 100 beds and over, is also part of
the plan. This group study work is particularly interesting and stimulating.
Besides studying the cases that the members of the group refer to the clinic
and the cases that come under the staff of the hospital, medical men in the
district may take cases there for study and advice. Clinics in the smaller
hospitals as well as the larger ones can be made most interesting and instructive. Standard record forms, which are quite simple and easy to complete,
will soon be available to the profession. Careful records of our cancer cases
with good follow-up notes should be of considerable value in the future. How
else can we obtain important data and the results of treatment be evaluated?
The providing of post-graduate speakers at provincial medical conventions
ond other meetings is also part of the programme of this department. Dr.
Bazin will be with us at our Annual Meeting in Victoria in September next
in this capacity. It is the policy of the Provincial Cancer Committees to
encourage papers on cancer topics at district meetings and on post-graduate
tours and provide speakers if requested to do so. There is a sub-committee
of the B. C. Medical Cancer Committee under the chairmanship of Dr. Roy
Huggard now arranging a roster of speakers that will be available for such
meetings and it is also arranging a roster of speakers to talk to lay groups
on various phases of the cancer problem. With the development of the
Canadian Society for the Control of Cancer there undoubtedly will be an
increasing demand for talks of this sort, and we can assist Dr. Huggard
very materially by allowing our names to be placed on his roster.
Now a word about the Canadian Society for the Control of Cancer. This
Society was incorporated under Dominion charter about two months ago
and is now getting under way in the matter of organization. It is lay-medical in
its composition, and the Grand Council, with offices in Toronto, is composed of
one medical and one lay representative from each province, besides its officers.
Dr. McEachern has been elected its president and Dr. Routley its secretary.
Provincial branches are in the process of being established, and already here
in British Columbia considerable work has been done. The Provincial Coun-
232 cil, consisting of six laymen and seven medical men under the chairmanship
of Dr. A. Y. McNair, has been working consistently for the past, few weeks
and a definite plan of organization has been formulated. As the responsibility of launching the Society devolves on the B. C. Medical Association,
it was decided to use the offices of the Association for that purpose and
through its membership establish units in communities throughout the whole
province. A member of our Association in each community has been written
to and asked to act as temporary secretary and convener in organizing a
unit; membership fee is one dollar. Once the unit executive has been
appointed, a membership drive can be undertaken. It is the objective of the
Society in British Columbia to obtain a membership of 50,000, and with the
aid of women's organizations, churches, services clubs, etc., whose services
should be very easily enlisted in such a worthy cause, I see no reason why
our objective cannot be reached in the sourse of six months to a year.
From each unit, two representatives to the district council will be selected,
one a layman and one a medical man, and from each district council two
representatives will be elected to the provincial council, one of them being
a medical man. One can redily see that such a plan will make for a representative organization, both of laymen and medical men, and should be a
substantial factor in Cancer Control activities in the province.
What are the objects of the Society? They are largely educational in
character; by talks on yarious phases of cancer to lay groups, educational
films, pamphlets, and perhaps radio broadcasts, the public will be instructed
as to the early signs and symptoms of the disease, the importance of periodic
physical examinations, and of seeking medical advice as soon as suspicions
are aroused, in order that early recognition may be accomplished and treatment instituted at a time when a reasonable hope of cure can be expected.
As 75% of the membership fee is to be retained in the province for local use,
considerable money would be available each year to assist and co-operate
with other organizations in the matter of treatment. In a drive for funds to
improve therapeutic facilities in the province, the Canadian Society could,
as an established educational organization, materially assist in such a
Space does not allow me to further elaborate on this activity, but I hope
sufficient has been said to arouse the interest of the members of our Association and secure your support and active assistance. This Cancer Control,
programme is one of the most important activities that the Canadian Medical
Association has undertaken, and one that offers the medical profession an
excellent opportunity, through its own organization, of being a directing
force in the public health field. The increasing death rate from cancer, and
the* increasing concern of the public generally regarding it, is a challenge to
us to do all we can to meet the issue. H „ ]yrILBTjR^
Choosing the beautiful setting of the Qualicum Beach Hotel for their
day's activities, members of the Upper Island Medical Association held their
semi-annual meeting at this resort on May 27th, at which some 18 members
of the medical profession and their wives attended, representing all sections
of the Upper Island.
Golf was enjoyed during the afternoon, following which Mrs. C. Davidson,
Parksville, entertained the guests to afternoon tea.
In the evening the meeting took the form of a banquet, and during the
social hour Mrs. W. F. Drysdale rendered delightful solos, accompanied by
Mrs. C. C. Browne.
Following the toast to the King, Dr. G. K. MacNaughton, Cumberland,
proposed a toast to the ladies, responded to by Dr. M. W. Thomas, Executive
Page 233 Secretary of the B. C. Medical Association. Dr. S. C. Turvey proposed the
toast to Miss Cromie, the bride-to-be of Dr. J. A. Wright, Vancouver, the
latter suitably responding.
The business session, presided over by Dr. A. H. Meneely, was featured
by addresses by Doctors D. H. Williams, S. C. Turvey and J. A. Wright, all
of Vancouver, who spoke on the modern aspects of venereal diseases.
The day's activities were concluded by an informal dance in the hotel
Doctors attending were: Dr. H. A. Meneely, Dr. S. L. Williams, Dr. G. A.
B. Hall, Dr. L. Giovando, Dr. J. A. Leroux, Dr. E. D. Emery and Dr. W. F.
Drysdale of Nanaimo; Dr. Campbell Davidson of Qualicum; Dr. N. B. Hall
of Campbell River; Drs. T. A. Briggs and A. L. Cornish of Courtenay; Dr.
G. K. MacNaughton of Cumberland; Dr. R. W. Garner of Port Alberni; Dr.
W. Sutherland Groves of Chemainus, and Drs. D. H. Williams, S. C. Turvey,
J. A. Wright and M. W. Thomas of Vancouver.
♦ ♦ ♦ ♦
Dr. W. C. Pitts, formerly of Fraser Lake, is now practising at Port Alberni.
* *      *      *
Dr. J. A. Leroux of Nanaimo is on holidays. The first part of them were
spent taking in the Vancouver Medical Association Summer School.
* *      *      *
Dr. C. H. Hankinson of Prince Rupert is in the South.
Dr. Stanley Mills returned to Terrace from a visit to Toronto, having
received three or four weeks ago an urgent call to his old home, where his
mother was seriously ill. While away, Dr. Mills engaged in work with Sir
Frederick Banting at Banting Institute, Toronto.
*      *      ♦      *
Dr. W. S. Kergin of Premier attended the wedding of his sister,
Margaret Kergin, to Dr. Ralph Outerbridge at Prince Rupert.
Dr. and Mrs. R. G. Large of Prince Rupert have left for a trip abroad.
They will attend the British Empire Exposition in Glasgow and Dr. Large
will then go to Edinburgh and London to take up medical post-graduate work.
They expect to return about the middle of August.
* *      #      *
Dr. D. T. R. McColl of Queen Charlotte has his new launch ^urniing now.
Last week he made a trip to Skidegate Mission against a strong north wind
and heavy weather, but the staunch vessel proved its worth.
* *      *      *
Dr. H. A. 'Whillans, formerly of Stewart, is assisting Dr. C. A.I Armstrong
of Port Simpson during the summer months.
The following paper will be of interest to all medical men, as indicating the views taken by an actuary of unquestioned pre-eminence, in
the matter of Health Insurance.—Ed.
By Hugh H. Wolfenden; F.I.A., F.A.S., F.S.S.,
Consulting Actuary and Statistician.
[Read before the Sixth Canadian Conference on Social Work, June, 1938.]
Any discussion of "The Financial Implications of Compulsory Health
Insurance"—particularly by an actuary, and before an audience such as
this—should, I think, begin by stating some fundamental definitions, and
considering certain basic propositions, in order that the various matters
which present themselves for investigation may be quite clear.
Page 28k Since I am speaking in British Columbia, where a Health Insurance Bill
has been actively under discussion for several years without agreement on
its terms having been reached, I shall necessarily frame some of these observations on the circumstances underlying that particular legislation. In so
doing, however, I ask you, in all sincerity, to interpret my remarks as being
prompted solely by a desire to secure, for any such measure which may
ultimately be adopted in Canada, the soundest possible financial basis and
the fullest degree of co-operation.
My desire for a sound financial basis is natural, of course, to an actuary
—for reasons which I shall explain.
The hope that real co-operation may be attained between the Government
and the medical profession arises in my case with perhaps special force
because my own father was a doctor. I was brought up in a household where
the devotion of physicians was a matter of daily observation, and the attainments and ethics of the medical profession occupied a very honoured place.
The Meaning and Capacity of Health "Insurance"
I should, accordingly, like to direct your attention first of all to the
meaning of "Health Insurance." Even though it entails repeating what has
so often been explained, it may be said that "Insurance" involves the co-operative association of a large number of persons, who agree to share amongst
themselves the burdens arising from the occurrence of a particular contingency—in this case sickness—by the payment of the necessary contributions into a common fund, from which benefits, related strictly to those
contributions, are distributed in alleviation of the burdens against which
the insurance is effected.
"Insurance" thus defined is not in any sense a new, or even a recent,
concept. It is not, I think, generally appreciated that voluntary societies for
insurance against the losses resulting from sickness existed in Europe centuries ago. Over the intervening period, and especially during the last 140
years, a very extensive experience has been gained in the evolution of certain
fundamental principles and practical methods of procedure. A great body
of statistical data has also been accumulated and systematically analyzed.
The actuary may not therefore be said, quite properly, to be in a position to
embark upon the preparation of the necessary estimates and regulations for
any scheme of health insurance with much valuable material—and yet with
a very salutary degree of caution. Again at the risk of repeating well established facts, I should like in this connection to ask you to note that the rate
of sickness in any community, or scheme, has been shown to depend upon a
great variety of circumstances, of which the most significant are age, sex,
marital conditions, occupation, personal and family history, locality of domicile, and economic status. Moreover, while these are the major influences
determining the rates at which illnesses actually occur, it is important to
.remember that the introduction of any plan which offers either benefits in
cash or benefits in kind immediately brings into prominence the psychology
and ethics of the persons insured, so that the rate at which claims for sickness benefits are made shows marked differentiation from the previously
mentioned rate at which the sicknesses actually arise. The factors which
thus, in addition to those already enumerated, have a significant effect upon
the rate of claim—and therefore upon the financial experience of any insurance plan—are:
Firstly—the "qualifying period," i.e., the period which must be passed
before the insured person first becomes eligible to file a claim.
Secondly—the "waiting period," that is to say, the number of days of
sickness which must elapse before payment of any cash benefit shall commence.
Thirdly—the "benefit period," being the length of time for which benefits
will be paid.
Page 235 Fourthly—the so-called "periods of attack," generally used in the case of
benefits in cash, by which the claims are segregated according to their incidence in, for example, the "first three months" of claim, "second three
months," "second six months," etc.
Fifthly—the "re-qualifying" period, during which eligibility must be
re-established after exhaustion of any benefit period.
Sixthly—the relation of the character and amount of the benefit to the
normal standard of living and earnings of the claimant prior to occurrence
of the sickness; and
Lastly—the nature and size of the organization through which the payment of benefits is obtainable, and the facilities for and regulations governing the filing of claims, their medical certification, and their final scrutiny.
All that sounds, I well know, a formidable recital; in many ways almost
every one of these factors presents a difficult problem of calculation and
administration. Yet they must all be taken into account. If they are not
clearly understood by both the administrators of any plan and the insured
persons who are to be covered by it, the result will inevitably be wide-spread
dissatisfaction. Any scheme of "health insurance" must accordingly be based
on certain definite principles and regulations; it cannot promise or attempt
to give benefits on an unrestricted scale—to do so would mean financial bankruptcy for the plan, and loss and disappointment for those who had thought
they were "insured."
The Meaning of the Phrase "Actuarially Sound"
In connection with these explanations of the meaning of "insurance," I
now wish to ask your attention to an important matter which next, in logical
order, arises for consideration, and Which, I think, has been somewhat misunderstood in many of the discussions surrounding the British Columbia Act.
I refer to the meaning of the phrase "actuarially sound."
By way of introduction, I should describe briefly the functions and duties
of the actuary. The designation "actuary" was first used officially in the deed
of settlement of the old Equitable Society, founded in London for the insurance of lives over 175 years ago. Charged originally merely with keeping the
registers of the risks carried on the books of the insuring institution, the
actuary soon was faced with the necessity.for tabulating and analyzing the
records, in which special mathematical processes rapidly assumed a position
of importance. Concurrently with this evolution of the actuary's technique
with respect to life insurance, it is particularly significant' to note that the
first formal recognition in Great Britain of the profession of actuary is to be
found in an Act of Parliament, passed as early as 1819, providing that the
tables, and the rules, of all death and sickness "benefit societies" should be
approved by an "actuary." The methods of calculation, and the (formulation
of the rules, in respect both of life insurance and sickness benefits, have thus
for many years been primarily the actuary's responsibility. Comparable
methods have naturally been developed in connection also with the other
contingencies of human life, in addition to sickness and death—namely, birth,
marriage, accident, disability and unemployment—so that today the actuary
may be described as the professional man whose duty it is to deal with all
the statistical, mathematical and financial calculations which form the basis
of any schemes involving the contingencies of human life.
Remembering the definition of "insurance," and these essential responsibilities of the actuary, it is abundantly obvious that any form of health
insurance is a type of insurance with which the actuary, if he is to discharge
his full duties, must be immediately and directly concerned. Health insurance, whether it is to give benefits in cash or benefits in kind, and whether it
is instituted through voluntary action, or enforced partially or wholly by
governmental compulsion, is therefore clearly a type of insurance which can
be—and I do not hesitate to say should be—set upon a framework complying
with the well-known and well-tried principles and methods which have been
Page 286 developed by those fully qualified actuaries who have been trained both in the
theoretical requirements and in the school of practical experience.
If official confirmation of this view should be required, it is to be found
in detail in the Year Book of the Institute of Actuaries of Great Britain,
where clearly defined responsibilities of precisely this character are placed
upon the actuary by a wide variety of Acts of Parliament, and in Canada, for
example, in the Memorandum issued by the Superintendent of Insurance (of
the Dominion Department of Insurance) respecting actuarial valuations of
fraternal benefit societies—which, it is to be noted, generally provide benefits
during sickness, sometimes in cash and sometimes in kind, based on principles very similar to those involved in governmental "health insurance"
There would not seem to be any good reason for legislative apathy concerning the actuarial aspects of governmental schemes, when the legislatures
have so insistently and properly demanded actuarial supervision of voluntary plans. It would appear that sound principles of government finance
should require that a government's financial adventures ought to be regarded
in the same manner, and regulated by the same types of prudent supervision,
as those which quite properly are imposed on voluntary forms of business.
I use the word "adventures" in no invidious sense—for all our economic and
financial efforts, whether undertaken by individuals, or by some voluntary
collection of individuals, or by that all-inclusive collective known as "government," must always be in reality "adventures"—expeditions into the partially
unknown—a realm to be explored intelligently, cautiously, without recklessness, and always, if at all possible, with an ever open road for orderly and
dignified retreat. It is precisely through neglecting these cautionary restrictions in many fields of activity—politically nationalized railroads, free old-
age pensions instituted with almost no financial investigation, governmental
pensions sold at inadequate rates (often to the rich, though originally intended for those with only moderate incomes), insufficiently controlled unemployment relief, and governmental subsidies to all and sundry—that we have,
even in this greatly favoured country, reared an edifice of governmental debt
of a dangerously top-heavy character, with all the resultant and growing
sectionalisms so threatening to our national unity.
Since, therefore, as I see the problem, the actuary must have an unavoidable responsibility in the establishment of health insurance, let us examine
in some detail what those duties ought to be, and are:
In the first place, the scales of benefits which are to be given by the plan
must be settled and the conditions under which they will become payable
must be drawn. When those scales of benefits, and conditions for payment,
are definitely known—but not until they are definitely known—no person
but a qualified actuary has at his command either the technical mathematical-
statistical knowledge or the practical administrative experience necessary
for the calculation and prescription of the financial contributions which will
be essential for their support.
Alternatively, of course, in some instances it may be thought desirable to
set, first of all, the scale of contributions, and for the actuary thence to
determine the benefits which they may be expected to provide.
In either case the two considerations of paramount importance are:
Firstly, that a proper relationship, founded upon actuarial principles
and calculations, must be established between the scales and conditions of
benefits, on the one hand, and the contributions on the other hand; and
Secondly, that the scales and prescribed provisions for payment both of
contributions and of benefits must be specifically- defined. Only under such
circumstances can the actuary make his calculations, and give a certificate
that the plan is "actuarially sound."
A certicate of "actuarial soundness"—or "actuarial solvency," to use an
alternative  and equivalent term—therefore  requires  that  the certifying
Page 287 actuary has satisfied himself, after complete investigation of all the relevant
circumstances determining the conditions for payment of contributions,
benefits, and all other possible expenditures, that the financial basis and
control of the entire scheme is so constructed that "in his opinion . . . the
reserve shown by (his) valuation, together with the . . .contributions to be
thereafter received from the members according to the scale in force at the
date of valuation, is sufficient to provide for the payment at maturity of all
the obligations of the fund without deduction or abatement." That phrase-
as an example, is the official requirement with which a certifying
actuary must conform in reporting on the state of a fraternal society in
Canada. That certifying actuary, moreover, by general legislative prescription throughout Great Britain, and in Canada, must, of course, be fully
qualified; that is to say, he must (except where special circumstances justify
the supervising authorities in allowing some other person to perform the
work) be a Fellow of one of the four recognized bodies—the Institute of
Actuaries of Great Britain, the Faculty of Actuaries in Scotland, the Actuarial Society of America or the American Institute of Actuaries. Clearly an
Associate only of one of those bodies cannot generally be admitted as a qualified certifying officer, seeing that the examinations for Associateship cover
only the less practical first portion of the training, and at the Actuarial
Society and the American Institute on this continent do not include the
technique or valuation of, or any but the most superficial acquaintance with,
health insurance in any of its forms.
"Actuarial soundness," accordingly, can be claimed for any plan only
when all of the following conditions are fulfilled:
(1) The benefits offered by the plan must be defined, and the conditions
for their payment must be clear;
(2) The corresponding contributions, or other financial arrangements by
which the costs of such prescribed benefits are to be met, must be determined
by proper actuarial calculation, as previously described;
(3) Any power to alter the basis, terms, or conditions of the scheme must
be subject to an actuarial certificate that the costs of such alteration are
within the financial capacity of the plan; and
(4) Adequate machinery must exist for the certification, ^inspection and
control of claims for benefits, in order to make certain that they fall within
the terms and conditions of the scheme, and for the impartial\and judicial
interpretation of the numerous and difficult administrative problems which
inevitably arise.
If any plan of insurance cannot meet these tests, it cannot be certified as
actuarially sound." It must then obviously be classed as being either
"actuarially indeterminate" or "actuarially unsound." If the actuary cannot
set out the benefits, conditions, contributions, powers of alteration, and
methods of organization and control in such a distinct manner that he can,
according to his best judgment and experience, formulate his methods of
calculation with reasonable certainty and with adequate (though not, of
course, excessive) margins of safety, then it is obvious that the basis of the
plan must be "actuarially indeterminate"—"void for uncertainty," as I
believe the lawyers would say. If, on the other hand, a plan is definable
enough, but shows itself, on actuarial calculation, to propose benefits greater
than the contributions can support, then there is no alternative to its being
reported as "actuarially unsound."
What, for Instance, Is the Actuarial Basis of the
British Columbia Health Insurance Act?
I have dealt at some length with this matter because, having in 1935 been
retained to report to the Hon. G. M. Weir, Provincial Secretary, on the cash
benefit provisions then included in the British Columbia Health Insurance
Bill, and having estimated the probable incidence of claims thereunder without any necessity arising in that report for a certification of "actuarial sound-
Page 238 ness" of the whole Bill, I have since been named in some quarters as a fully
qualified actuary who has examined the entire scheme without having
questioned it, in others as an actuary who has definitely opposed it, while
again I have been challenged to state specifically that the scheme is not
"actuarially sound." In view of a great many quite erroneous interpretations
of my position which have thus been circulated, I think it is only proper that
I should repeat here the opinion which I have previously expressed, and
which, I hope, may now be understood in view of the preceding definitions.
It is this:
The Act, as finally passed, calls for employees' contributions of 2% of
wages up to $1800 per annum, but varying from 35c weekly (reducible, however, by the Commission) up to 70c weekly, and employers' contributions of
1%, but varying between 20c weekly (again reducible by the Commission)
and 35c weekly—that is to say, it calls for contributions lying somewhere
between a minimum of 55c weekly, or less, and a maximum of .$1.05 per week.
The benefits to be given, however, are not at all clearly ascertainable in
advance. They are stated at first to be:
(a) Physician's services (including pre-natal and maternity treatment,
and surgical and specialist services) ;
(b) Public-ward hospitalization (including all services which the hospital is equipped to provide) ;
(c) Drugs, medicines and dressings (of which possibly one-half may be
payable by the insured) ;
(d) Laboratory, x-ray, biochemical and other services.
It is, however, to be noted very specially that the following extremely
important conditions are attached, either by specific statements in other
portions of the Act or by obvious implication:
(1) The hospitalization benefit is limited to 10 weeks, but may be
extended by regulations.
(2) Additional benefits may be provided by the Commission to the extent
that the resources of the fund permit.
(3) Any or all of the benefits may be limited by the Commission.
(4) No benefits can be obtained during a first qualifying period of four
weeks; thereafter they shall be obtainable so long as the contributions are
payable and for four more weeks and also for such additional period as may
be determined by the Commission; if the employee falls ill and is unable to
work he (but not his dependents) may receive benefits for 12 more weeks,
or for a longer period if prescribed by the regulations; and the right to benefits can be re-established, after eligibility ceases, at the end of a re-qualifying period of one week, after which benefits are obtainable while contributions are payable and for one more week, and also for such additional period
as may be determined by the Commission.
(5) The physicians are to be remunerated, at a rate not less than $4.50
per annum, by salary, per capita, or fee system, as may be fixed and determined by the Commission's regulations; the scales of payment to all others—
pharmacists, hospitals, laboratories, etc.—shall be fixed and determined by
the Commission's regulations; and in all cases the Commission can penalize
any physician, pharmacist, manager of hospital or laboratory, or any other
person, who fails to provide services according to the standards prescribed
•by the Commission; and
(6) The Commission (of five members)—who may, but need not, be
advised by a Technical Advisory Council—is clothed with such exceedingly
wide powers that it is, I believe, essential that very careful examination (to
which I shall return) should be given by everyone concerned to their inevitable meaning and effect.
Page 289 It will be seen at once that the benefits to be offered in return for the contributions are, in reality, almost wholly undefined. It is also to be noted
especially that the Commission has almost absolute power to state which of
the listed benefits shall be granted, whether they shall be provided at the
suggested or at a lower or higher scale, for how long they shall be receivable,
what the rates of payment shall be for every one of the necessary services,
and how, when, and where every single function under the Act shall be performed. Under such circumstances it is manifestly impossible to set out, with
any approach to definiteness, either what the benefits are likely to be, or
what they are likely to cost. The plan consequently means nothing more
than that the employees and employers are to be required to pay over to the
Commission certain widely varying sums, which the Commission can disburse
in almost any manner whatsoever that it may choose. No relationship is
stated between any of the possible amounts of contributions and any of the
innumerable scales of benefit which the Commission might adopt.
In my opinion, therefore, it is impossible to certify the scheme as being
"actuarially sound." It is likewise impossible to certify it as being "actuarially unsound." An actuarial basis simply does not exist—for the possible
limits of variation are so wide that no reasonable estimates of probable
future experience can be made. The scheme in its present form, accordingly,
can only be held to be "actuarially indeterminate."
This situation, I believe, is made even more serious by the extraordinary
powers vested in the Commission, to which I have already referred—for
those powers render the financial implications of the plan even more un-
measurable. Subject only in certain cases—not in all cases—to the approval
of the Lieutenant-Governor in Council, the Commission is to be almost entirely
a law unto itself, backed by severe punitive powers, against which the citizen is apparently to have no right of appeal. The following provisions of the
Act are extremely enlightening in this connection.
(1) The Commission, of five, can function perfectly so long as it can
muster a quorum of only two of its members.
(2) Even if the suggested "Technical Advisory Council" should be appointed—and its establishment is not obligatory—the Commission can ignore
its advice completely.
(3) The Commission may "penalize any person . . . who fails to provide services according to the standards prescribed by the Commission . . .
by debarring him . . . from all rights of serving or of providing benefits
. . . under this Act."
(4) "The Commission shall have the like powers as the Supreme Court
for compelling the attendance of witnesses and of examining them under
oath," etc., etc.
(5) "The Commission shall have exclusive jurisdiction to inquire into,
hear, and determine all matters and questions of fact and law arising under
this Act, and no proceedings by or before the Commission shall be restrained
by injunction, prohibition, or other process or proceeding in any court, or be
removable by certiorari or otherwise into any court."
(6) "The Commission shall have full discretionary power at any time to
reopen, rehear, and redetermine any matter which has been dealt with by it."
(7) Every person is to become .subject to a fine up to $500 who even
"neglects to perform or observe any duty or obligation imposed on him" by
the Act; the Commission may by regulation itself prescribe fines up to $50;
and the Commission may impose upon any monetary defaulter "such a percentage upon the sum in' default as may be prescribed by the Commission";
and lastly,
(8) "Where default is made by any employer or person in the payment
... of any sum of money . . . the Commission may issue its certificate
stating the sum so required to be paid . . . and such certificate or a copy of
it . . . may be filed with the Registrar of the Supreme or any County Court,
Page 2A0 and when so filed shall become an order of that Court and may be enforced
as a judgment of the Court."
It would seem that the implications of these provisions should be realized
more widely than appears to be the case.
The Approach to a Constructive Policy
I have dealt with the preceding matters at some length because they
obviously fall within the title of this address since they influence directly the
financial arrangements and obligations implied by any such scheme of compulsory health insurance. Some of these observations, admittedly, are open
criticisms. I sincerely trust, however, that you will understand that they are
not meant to be merely destructive. Criticism, whenever possible, should be
constructive. I should therefore like to submit the following suggestions,
which, I believe, in the light of the experiences of other similar plans both
in Canada and elsewhere, should form the basis of any attempt to establish
a scheme of compulsory health insurance, and which might well lead to its
successful operation.
(1) The plan ought not to be conceived as a punitive measure, predicated
on the supposition—as I have heard it stated—that the medical profession
and all its ancillary services are now organized on a wrong foundation, which
must be compelled to undergo improvement by being brought under the rule
of a wholly non-medical Government Commission. The basis of approach
should preferably be to recognize the devotion and sincerity of those who
take the Hippocratic oath, and who so often give almost every moment of
their lives in their attendance on the sick, whether rich or poor.
(2) As the very first step, the plan should reach a clear and honourable
agreement with all those indispensable groups—doctors, nurses, druggists,
hospital officials and laboratory technicians—without whose co-operation
any such plan must be foredoomed to failure.
(3) Adequate provisions should be included for administrative control by
a non-political Commission of practical and fully qualified men, thoroughly
experienced in medicine, insurance administration and claim supervision,
and finance. An "Advisory Council," moreover, should be mandatory, and
should function in such a manner (as in the cases of the Advisory Committees under the British and the 1935 Canadian unemployment insurance
schemes) that its recommendations cannot be ignored.
(4) Definite provisions should be included for the refereeing of disputed
claims and controversial and administrative questions, with adequate
machinery for the judicial determination of all such matters, and for appeals,
so that no single body, whether political or non-political, should have any
opportunity for the exercise of arbitrary powers.
(5) Provision should be made for proper certification, by a fully qualified
actuary, of the original scales of contributions and benefits, which should be
specifically stated, and also for the certification of any changes in those
stated benefits and contribution scales, so that every financial adjustment
of the plan should be explored adequately and reported on publicly prior to
its adoption, to the end that the beneficiary may have some reasonably close
idea of the benefits which he may expect to receive, and employers and
employees may know how their funds are to be used.
The Place of "Health Insurance" in Co-ordinated "Health Services"
If the problem could be approached carefully along those lines, with all
the emphasis upon the rights both of the persons to be insured and those
who would be called upon to provide the services, and also with the most
complete elimination possible of every political influence and opportunity for
arbitrary control, then it might well be that the present organization of the
"medical services"—using that term in its widest sense—could be rendered
more effective. But, in order to attain any such objective, I should like again
to direct your attention to the fact that the usual types of government-spo™-
Page 2kl sored "health insurance" fail entirely to reach several of the most important
basic aspects of the real problem which is involved.
It is important to remember that these governmental "health insurance"
plans are essentially an attempt to provide medical services through a system
of regularized payments in advance. But they do so only for a special group
of persons, and then only during a certain period of their lives; they leave
out of consideration entirely not only all the rest of the community, but even
the special group itself almost immediately the insured person ceases to stand
in the particular relationship to some "employer" of being an "employee" of
an arbitrarily specified earning power, or that employee's dependent. What
is there, moreover, in the figure of $1800 per annum which calls for the provision of a government-regulated medical service for those earning up to
that amount, while the person earning $1801 per annum or more, or not
earning anything at all, is to be excluded?
All these plans, of course, are in reality attempts to improve the conditions under which medical services shall he available. But I think it may
be asked, most appropriately, whether they do not begin at the wrong end of
the problem. The fact that I have explained "actuarial soundness" at some
length is not, of course, special pleading in any sense—for the real problem
involved is, in my opinion, hardly "actuarial" at all. It is, as I have suggested on a number of previous occasions, essentially a "public health" matter, to be settled according to obvious principles of common sense. I would
ask you to recall the manner in which we permit uncontrolled birth, provide
only partial health supervision during the school years, and then allow the
adult to impair his health in any way he chooses—through misfortune, ignorance, carelessness or abuse; and then, when people of all classes thus
eventually fall ill, the "health insurance" plan suggests that only a special
class of them shall be assisted, in respect of certain particular types of illness,
and for an arbitrary length of time. Is not that illogical? Does it reflect
much crerit on our statesmanship? Yet we insist—rightly—upon universal
education. Why do we not insist, even more rightly, on co-ordinated efforts
to attain a better state of general health ? A healthy but uneducated person
—who at the least will probably grow up as one of "Nature's gentlemen,"
imbibing his knowledge from a contemplation of the wonders and beauties
of the universe—will surely be a sounder, safer, and a better citizen than the
unfortunate descendant of a bad heredtiy, doomed from infancy to bear
throughout a miserable life the failings of incompetence and disability. What
do I mean by "co-ordinated efforts" to attain a better state of general health?"
I mean emphasis first of all on intelligent maternity, and on proper physical
and mental recreation—in short, emphasis on prevention rather than cure—
and for all the people—not merely for a special group earning up t<j> $1800
per annum or some other arbitrary figure.
I am not intending to suggest, even remotely, any form of "state medicine," under which the physicians and others engaged in the medical services
would become merely salaried employees of the state. I do, however, believe
that the co-ordination and enlargement of the preventive services, for all the
people, could do much more to eliminate illness, to prevent its spread, and
to control its ill effects than we have yet realized. "Health insurance"—not
necessarily in the stereotyped and limited form which we now generally discuss, and not only, perhaps, for a special group during a limited time—might
then be able to deal more advantageously with the residual sicknesses which
the preventive measures had not been able to control. Under such circumstances a "health insurance" scheme, conforming with sound insurance
principles, could take its proper place as an essentially curative agency, at
greatly lessened cost. Even if the saving were wholly absorbed by the preventive services which I have suggested, we should in reality be much more
prosperous—physically and spiritually—and much more capable of exhibiting
any efficiency which we might inherently possess.
Page 2k2
—- 11
| CARCINOMA      |
Dr. Donald V. Trueblood.
(Read at Vancouver Medical Association Summer School, June, 1937.)
The subject this morning eliminates cancer, not because it is not important
—it is the most important disease that can attack the human breast—but
because next Friday night I am to have the pleasure of discussing with you
the treatment of cancer of the breast. So this morning we shall deal with
other things, but it will be natural to turn back to cancer occasionally,
because we must always eliminate that disease first. When a woman or
child or man comes to your office complaining of something in the breast, it
will be due to one of a very few things. There are a few common symptoms,
but before we discuss these let us discuss the anatomy of the breast. I will
particularly point out to you this fascial layer on top of the chest and
Cooper's ligaments from the breast tissue to the surface and note that breast
tissue enters into this invagination. So that should there be any change in
this surface you might have multiple nodules. If the condition is deeper you
would not obtain that same thing. This slide is the same, only a cross-section
showing the ligaments and the ducts. Refresh your memory as to the manner
in which the ducts enter the nipple. Between these lobules there is connective
tissue of the supporting type and of a functional type. Another diagrammatic
picture is this, calling your attention to the ducts and nipple, and right
here these sebaceous glands very often produce inflammation on squeezing
some fat material. Again in this picture we see the ducts, lobules, etc.
These are the more common symptoms that will be given to you by the
patient: Enlargement of the breast, there may be vague sensations, there
may be pain (which is the commonest of all), some abnormal condition of
the nipple, some discharge, the nipple itself being normal. Enlargement often
is seen at infancy and a mother will bring the boy or girl to your office with
an enlargement of the breast. It is supposed that the infant receives this
while in utero and that this is responsible for it. However, should you find
a lump you should consider it. Again, boys about the age of puberty will often
show an enlargement of one or both breasts. That will disappear after a time
unless there is some endocrine disturbance. Often a man beyond the age
of 40 to 45 will present bilateral or monolateral enlargement of the breast.
Examination of this should always include examination of the testicle.
However, you should search carefully for a lump. Cancer of the breast occurs
in men, and of the tumours which do occur it is more common than cancer
of the breast of women. It is often much more serious than in women. Peculiar
sensations are usual—this is neurological. And in some only a careful general examination will reveal a lump in the breast; it must be found the first
time. The patient may not come back a second time.
Pain is the most common and may appear in one or both breasts. Often it
is associated with menstrual periods, but it may not be so. The woman comes
because she has had discomfort and worries because she believes she has
carcinoma. That is too bad. This woman—I take her as an example of taking
care of a patient with pain in the breast. You have taken a complete history,
story of menstrual periods, story of miscarriages, etc.; you have "made a
pelvic examination. Then I believe it is better to have the patient in a sitting
position, because when the breast is hanging down you are more likely to
palpate a gland in the axilla, so examine the glands of the axilla in a sitting
position. The palpation of the breasts in the sitting position through your
two hands is used by many, but there you palpate two layers of skin and it
is exaggerated, but there is a difference in the two breasts. At the same time
observe the nipple, and if she is complaining of discharge you find out where
on the nipple the discharge is coming. Watch how she grasps the breast and
you may be able to see just where the discharge is coming from. Then have
the patient in the lying position and palpate the breast gently with the
Page 2k8 lower surface of the fingers and palm of your hand against the chest wall.
The examination in this manner will reveal to you whether or not you have
a distinct line. Now, this woman is complaining of pain. She points at one
particular spot. We examine it and find it no different from the rest of the
breast. If she complains of both breasts being painful and they seem alike,
you may not think there is anything serious involved. However, that should
be taken into consideration. After you have dismissed her, it would be wise
to say, "Come back ten days after your next menstrual period has ceased."
Diffuse pain very often is very difficult for you to control. I advise them to
change the brassiere and have one which gives the breast a lift. Use hot
packs; but after you have convinced the patient that she hasn't cancer, very
often the pain goes away. Now this woman had cancer of the breast. They
were both painful and she had a definite lesion.
I believe this is a good opportunity to talk about chronic cystic mastitis.
There are so many conditions found in the breast tissue after removal that it
would suggest that it is not a definite disease. I rarely put down that a
patient has chronic cystic mastitis. I usually say hypertrophy, a nodule, or
something like that. The variable picture seen in these patients is very
different from the type called mazoplasia. Many believe that there is a continuous process that develops early in the twenties, is not noticeable, continues to be active through the various occasions (or actions) of menstruation, again through pregnancy and in the menopause. It is a distinct entity.
But we must consider when the patient comes in with a lump that we
have to rule out the one important thing—cancer. This is a diagrammatic
slide to call attention to this breast tissue. This connective tissue responds
functionally to various changes which occur in the breast during the period
of puberty, at each menstrual change, at the time of pregnancy and during
the menopause. So we have these two major structures—the epithelium and
this connective tissue. We have chronic cystic mastitis or mazoplasia when
no cyst has formed. Or you might call it adenofibroma. This is Cutler's idea
which is rather helpful. He believes there is a difference between a hyperplasia and mazoplasia—that when mazoplasia appears there is potential
malignancy. Of the connective tissue tumours, there are the adenofibroma,
etc., and the malignant tumours. This is merely a picture of the type in which
the epithelial elements are in excess, no cyst formations and simple mazoplasia ; the ducts are dilated in this picture. Again, similar cystic formation. Here, a little more exaggerated piling up of epithelium which may go
further on to malignancy. That last picture would be a good example to
eliminate the habit of some to aspirate the cyst. It is often done and you may
get fluid, but you never know what is going on in that tissue. This shows
the increase in the connective tissue phase with not much increase in the
epithelium. Here is another adenofibroma—epithelial increase with adenoma
formation, cystic as well.
Of the diseases of the nipple, Paget's disease is the most important. It
begins with a scaling of the nipple, often is bilateral. The scales will peel off,
leaving a red, weepy surface. Often they are overlooked and treated as
eczema. This patient told us that this plug would come out of the nipple
(slide). There were no glands in the axilla. I was not sure and I sent slides
to three different places. One was positive and two negative. I removed the
breast in order to be safe and on further examination we were still doubtful.
This woman had a scaling nipple for five or six years. This nipple is now
practically gone; she has had glands in the axilla and glands above the
clavicle. It was too late to treat. The next case—the nipples showed some
involvement, and was beyond surgical cure. This nipple looks similar to the
first, gives a similar story; there was no lump. It was a case of bilateral
Paget's disease. We should always have a biopsy. You have not done much
damage if you are wrong by doing a biopsy. You remember the picture in
which I showed the glands in the neighborhood of the nipple. I wish to discuss
Page 2kk the discharge from the nipple a little more fully. A patient will say she has
a discharge and will describe it. You attempt to find out in what portion of
the nipple surface this discharge appears, and if you find it coming from the
centre of the nipple then you know it is probably a deep duct and the same
is true if it is in the periphery of the nipple. In addition to that, you attempt
to palpate and see if you can determine if there is an area around the
ampulla, if one is larger than the other. If that enlargement coincides with
your picture on the surface you may feel pretty sure you have the right duct.
Again, transillumination is of help here, in a dark room with a good light.
I use a light and put a long rubber tube on it and have the tube beneath the
end of the rubber tube and it does not disturb the patient and does not get
hot. You can find a dark spot. If all your three investigations fit together,
you are justified in making a surgical investigation.
Af operation, an incision around the areola should be made (some such
picture as this) and you very often can, without much difficulty, find this
large duct. It looks like a large vein. It is not difficult at all. Here is a picture
of multiple papillomata. Here is a microscopic picture of it, showing the
papillomatous growth in the duct. Here is another one. This duct has been
split open. Here is another one, the same one in different areas, showing the
changes in the areas. None of these were malignant and all we did was to
remove the papilloma. Now, there is often more than one papilloma, so the
patient should be watched for further discharge or further formation of a
lump. If the pathologist tells you that it is malignant you must then do your
radical operation.
This woman had nipple discharge and was beyond operative interference.
Now to discuss some lumps. This woman hesitated to come to the doctor
because she was sure she had cancer. All she had was lumps. Then we have
lipoma of the breast. I have seen many of them. I thought this patient had
malignancy. The reason for this is because the fascia was thick over the
chest wall. This patient thought she had carcinoma, but it was syphilis.
Under anti-luetic treatment she improved. Occasionally there will be a lesion
here at the fold which is often mistaken for furuncle, boil or sebaceous cyst.
We always treat them with considerable concern, and at the time of biopsy a
large incision is made and a whole piece taken out for examination. Here is
an advanced case showing the skin metastases. Here, also, is an advanced
one. This woman was operated on about eight years ago. She had no evidence
of recurrence until about two years ago and she was operated on with excellent results. Here is the old scar. Her condition came back all of a sudden.
This one, taken prone, shows skin metastases, an ulcerated lesion which was
smelling badly. This moman's case is interesting. For fifteen years she had
a lesion in her breast, one of the slow-growing type. She had some glands in
the axilla. We did a radical on her and found the glands in the axilla were
negative. Two years since that operation now and no recurrence. Here is a
case, very advanced. She refused operation. This is an interesting picture.
If you can see the pigskin arrangement it will explain to you why we are
showing it. This is supposed to be one of the late signs of carcinoma advanced.
This woman said she would find that her eyes would be swollen shut in the
mornings. We came to the conclusion that this was allergy—which proved to
be correct. Here is another advanced case showing the marked shrinkage of
the breast. This was shiny and red, slightly tender, with glands in the axilla.
It was a question whether it was an infected sebaceous cyst or a malignancy.
It proved to be a benign one.
I did not touch upon the question of tuberculosis. Occasionally a lump in
the breast is tubercular. It is very rare and is usually a single lump. It is
tender and there is some induration about it. It has all the signs of carcinoma
of the breast, and you cannot really make a diagnosis ahead of time without
a biopsy. You are obligated to explore and have the lump removed for definite diagnosis. Syphilis is different, because there you have the positive blood
findings. You can then give antiluetic treatment and see if the condition
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pennies more?
You can do this by prescribing the
new, economical 50-centigram capsules of
now obtainable in bottles of 12, 24 and
100 capsules at $1.00, $1.75 and $6.00
a bottle respectively.
ARHEOL is the purified active principle of sandalwood oil. It is a uniform, standardized product with which
prompt and dependable results may
be expected. Undesirable sequelae
often associated with sandalwood therapy are either absent or reduced to a
negligible degree.
Dr. P. Astier Laboratories
36-48 Caledonia ltd., Toronto.
Please send me a sample of
ARHEOL (Astier) in the new
economical dosage form.
„•_ M.D.
City  Prov.
36-48 Caledonia Road, Toronto The New Synthetic Antispasmodic
Trasentin "Ciba"
Tablets—bottles of 20 and 100. Ampoules—boxes of 5 and 20.
1 tablet or 1 ampoule contains 0.075 grm.
of the active substance.
mmm^mmmml^^^^^^ m
13 th Ave. and Heather St.
Exclusive  Ambulance  Service
in a Wide Therapeutic Field
Among the many conditions in which Neo-Synephrin Hydrochloride
has proved its clinical effectiveness, safety, and convenience as a
vasoconstrictor may be included:
Allergic Rhinitis (hay fever, rose
fever, pollen allergy)
The "Common Cold"   (coryza,
Sinusitis (acute or chronic)
Vasomotor Rhinitis
Eustachian Catarrh
Postoperative Intranasal Edema
offers these outstanding advantages: 1. No sting; 2. More sustained
action than epinephrine or ephedrine;  3. Less toxic in therapeutic
dosage than epinephrine or ephedrine;  4. So stable that it may be
sterilized by boiling; 5. Does not produce "nervousness" or insomnia.
Convenient Forms for Instillation
by Dropper, Spray or Applicator
EMULSION 1/4% (1-oz. bottle with dropper).
SOLUTION  ^4% for dropper or spray    { 1 Qz   bott|e
1% for resistant cases        £
JELLY y2% (in collapsible tubes with applicator).
Sample and literature on request.
Makers of Kasagra
Detroit, Mich. New York, N.Y. Kansas City, Mo.
San Francisco, Calif. Sydney, Australia
is a handy, convenient, clean commodity for the bag or the office. Supplied
in one yard, five yards and twenty-five yard packages.
Phone Seymour 698
730 Richards St., Vancouver, B. C.
Phone 993
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and  stabilizing the tone of its
musculature. Controls ||e utero-ovarian
circulation a%jd thereby encourages a
normal m4tt^|iS?cycIe.
fe.      sVlio lAfAYETTE STREET, NEW YORK, N. Y.
Full formula and descriptive
literature on request
Dosage:   1 to 2 capsules
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule is cut in half at seam. Nttntt $c
2559 Cambie Street
Vancouver, B. C.
p Institute
Post Graduate Mayo Bros.
Up-to-date treatment rooms;
scientific care for cases such as
Colitis, Constipation, Worms,
Gastro-intestinal Disturbances,
Diarrhoea, Diverticulitis, Rheumatism, Arthritis, Acne.
Individual Treatment $ 2.50
Entire Course $10.00
Medication (if necessary)
$1 to $3 Extra
Phone: Sey. 2443
Phone: Empire 2721
effectively  used; in
.. especially in combination with calcium, iodine and lysidine (ethylene-
ethenyldiaminO)"in the:form of
t astier!
Relieves pain, subdues swelling, removes stiffness, increases articular motility, secures rapid removal of periarticular infiltration, promotes
active elimination of irritant
and toxic waste.
Xon-irritant, does not disturb
digestion. In usual dose, chola-
gogue; in larger dose, laxative.
Usually renders use of salicylates, aspirin, or other analgesics unnecessary.
[lii^lr • •*- teaspoonful,
UVLJIj. well dissolved
in a glass of water, on
an empty stomach, every
morning for 20 days.
Rest 10 days. Repeat, if
Please send Sample and Literature
of Lyxanthine Astier.
City    Province	
36-48 Caledonia Road, Toronto . Jjpa NEUTRASIL
Neutrasil is an adsorptive alkaline powder (specially-prepared
hydrated magnesium trisilicate), large doses of which will not
cause alkalosis, nor smaller doses abnormal alkalinity of the
stomach contents.
Neutrasil, which presents magnesium trisilicate in its most active
form, can be regarded as possessing, in a high degree, the essential
desiderata of a satisfactory adsorbent and neutralising agent, and
its indication in the treatment of gastric and duodenal ulcer and of
hyperacidity is well supported by clinical evidence.
After ingestion, Neutrasil is decomposed slowly to produce a
steady supply of alkali in such amounts as will maintain the
gastric content in a practically neutral condition; at the same
time, a gel is formed which has the property of adsorbing toxins
and unneutralised acid and of assisting in their elimination.
Neutrasil is issued in bottles, each containing 70 grammes,
and full particulars arc obtainable from:
Terminal Warehouse
Toronto, 2, Ont.
flDount pleasant 1Hnbertakin$ Co. 5Ltb.
KINGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C.
R. F. HARRISON W. R. REYNOLDS In all quarters of the globe
I ^| OT only in countries of the
Temperate Zone, but within the
Arctic Circle, as well as in the
Torrid Regions, Antiphlogistine
is known and prescribed regularly by the Medical Profession.
Inflammation's antidote
Sample and literature on request
153 Lagauchetiere St. W.
Mude in Canada. «••&. m
THE use of cow's milk, water and carbohydrate mixtures represents the
one system of infant feeding that consistently, for three decades, has
received universal pediatric recognition. No carbohydrate employed in this
system of infant feeding enjoys so rich and enduring a background of
authoritative clinical experience as Dextri-Maltose.
Please enclose professional card when requesting samples of Mead Johnson products to cooperate in preventing their reaching unauthorized persona.
 Mead Johnson & Co. of Canada, Ltd., Belleville, Ont. \— For the
Accepted for advertising by the
Publications of the
American Medical
L. 1 M
Center $c patina 10ft
Established 1893
North Vancouver, B. C.   Powell River, B. C.
Published monthly at Vancouver, b. c. by ROY wrigley LTD., 300 west Pender street gg%S3£S3SS3g^^
Hollywood Sanitarium
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Reference--B. (7. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288


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