History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: February, 1937 Vancouver Medical Association Mar 2, 1937

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 77.e|BULLETIN
OF THE
VANCOUVER MEDICAL
ASSOCIATION 11
Vol. XIII.
FEBRUARY,  1937
No. 5
In This Issue:
HEALTH INSURANCE
TUMOURS OF THE LARG1_|bOWEL AND RECTUM
PEARSON LECTURESHIP^ BULKETTS
(With Cascara and Bile Salts)
m FOR . .
Chronic  Habitual
Constipation
BULKETTS POSSESS ENORMOUS BULK
PRODUCING PROPERTIES AND BEING
PROCESSED    WITH   CASCARA    AND
bile|salts PRODUCE  BULK WITH
MOTILITY.
WE WILL BE PLEASED TO PROVIDE
ORIGINAL CONTAINERS FOR TRIAL
ON REQUEST.
Western Wholesale Drug
(1928) Limited
456 BROADWAY WEST
VANCOUVER   -   BRITISH COLUMBIA
(Or at all Vancouver Drug Co. Stores) THE    VANCOUVER     MEDICAL     ASSOCIATION
BULLETIN
Published ^Monthly under the ^Auspices of the Vancouver ^Medical ^Association in the
interests of the ^Medical 'Profession.
Offices:
203 Medical Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Dr. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address
Vol. XIII.
FEBRUARY, 1937
No.   5
OFFICERS  1936-1937
Dr. W. T. Ewing Dr. G. H. Clement Dr. C. H. Vrooman
President Vice-President Past President
Dr. Lavell H. Leeson Dr. W. T. Lockhart
Hon. Secretary Hon. Treasurer
• Additional Members of Executive—Dr. A. M. Agnew, Dr. J. R. Neilson
TRUSTEES:
Dr. F. Brodie Dr. J. A. Gillespie Dr. F. P. Patterson
Auditors: Messrs. Shaw, Salter & Plommer.
1; SECTIONS
Clinical Section
Dr. Roy Huggard Chairman     Dr. Russell Palmer Secretary
Eye, Ear, Nose and Throat
Dr. L. H. Leeson-— Chairman     Dr. S. G. Elliot Secretary
Pediatric Section
Dr. G. A. Lamont... Chairman     Dr. J. R. Davies Secretary
Cancer Section
Dr. B. J. Harrison Chairman     Dr. Roy Huggard Secretary
STANDING COMMITTEES
Library
Dr. A. W. Bagnall
Dr. H. A. Rawlings
Dr. W. D. Keith
Dr. S. Paulin
Dr. W. F. Emmons
Dr. Roy Huggard
Publications
Dr. J. H. MacDermot
Dr. Murray Baird
Dr. D. E. H. Cleveland
V. O. N. Advisory Board
Dr. I. T. Day
Dr. W. A. Dobson
Dr. G. A. Lamont
Dinner
Dr. A. Lowrie
Dr. A. E. Trites
Dr. J. G. McKay
Summer School
Dr. J. W. Arbuckle
Dr. J. E. Walker
Dr. H. A. DesBrisay
Dr. H. R. Mustard
Dr. A. C. Frost
Dr. J. R. Naden
Credentials
Dr. A. B. Schinbein
Dr. H. A. DesBrisay
Dr. J. R. Naden
Rep. to B. C. Medical Assn.
Dr. Wallace Wilson
Sickness and Benevolent Fund—The President—The Trustees Protamine Zinc Insulin
Investigations by Hagedorn and his collaborators in
Denmark, and by Scott, Fisher et al in the laboratories
of the University of Toronto, have shown that preparations of Insulin suitably modified by the addition of
protamine and a small amount of zinc have a prolonged
effect upon being injected subcutaneously. These findings have led to the evolution of a product now designated
Protamine Zinc Insulin, which has been given intensive
clinical trial during the past year.
For a considerable proportion of patients who require the use of Insulin
in addition to the regulation of diet which is essential in all cases of
diabetes mellitus, use of Protamine Zinc Insulin has proved to be
advantageous. In cases where unmodified Insulin provided an inadequate control or required to be administered in several doses daily,
Protamine Zinc Insulin makes satisfactory control practicable. Its
use is often accompanied by a reduction in total number of units as
well as in the number of injections required per diem; and lessening of
fluctuations in blood-sugar levels has a gratifying effect upon patients'
sense of well-being.
In materia medica, Protamine Zinc Insulin supplements rather than
supplants unmodified aqueous solutions of the specific anti-diabetic
principle such as have been in common use since 1922. In some instances the use of unmodified Insulin alone is desirable; in others,
Protamine Zinc Insulin alone is now indicated; while in others, the
use of both preparations gives best results.
Protamine line Insulin (40 units per cc.) is now available in
10-cc. vial packages. Prices and information relating to the
product and its use will be supplied gladly upon request.
CONNAUGHT LABORATORIES
UNIVERSITY OF TORONTO
TORONTO 5      •     CANADA
Depot for British Columbia
Macdonald's Prescriptions Limited
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. VANCOUVER HEALTH DEPARTMENT
STATISTICS—DECEMBER, 1936
Total Population—estimated  247,5 5 8
Japanese Population—estimated  8,0 5 5
Chinese  Population—estimated  7,8 9 5
Hindu  Population—estimated  320
Rate per 1,000
Number Population
Total   deaths     249 11.9
Japanese deaths .         2 2.9
Chinese deaths        11 16.4
Deaths—Residents  only     219 10.4
BIRTH REGISTRATIONS—
Male, 129; Female, 146     275 13.1
December, December,
INFANTILE MORTALITY— 1936 193 5
Deaths under one year of age       10 5
Death rate—per 1,000 births       36.2 19.4
Stillbirths (not included in above)  3 5
CASES OF COMMUNICABLE DISEASES REPORTED IN CITY
January 1st
November, 1936 December, 1936 to 15 th, 1937
Cases    Deaths Cases Deaths Cases Deaths
Smallpox         0            0 0 0 0 0
Scarlet  Fever       46            0 28 0 11 0
Diphtheria            0             0 0 0 2 0
Chicken Pox       60             0 75 0 112 0
Measles        796            0 1593 5 1091 2
Rubella          6            0 7 0 0 0
Mumps       113             0 143 0 37 0
Whooping Cough          10 0 0 5 0
Typhoid Fever         3             0 0 0 10
Undulant Fever.          0             0 0 0 0 0
Poliomyelitis          1             0 1 0 0 0
Tuberculosis        36           11 25 13 14
Meningitis   (Epidemic)          1             1 1 0 0 0
Erysipelas         16             0 9 0 6 0
Encephalitis Lethargica         0            0 0 0 0 0
Paratyphoid Fever 1         0             0 0 0 0 0
MEMBERS of THE GUILD
of PRESCRIPTION OPTICIANS of AMERICA
Always Maintain the
Ethical   Principles   of
the Medical Profession
Guildcraft Opticians
430 Birks Bldg".        Phone Sey. 9000
Vancouver, Canada.
Page 89 Sampl
es
on
REQUEST
OF HYPERTENSIVE
I   HEADACHES
RELIEVED
iOR rapid, efficient and safe relief of high
blood pressure and its associated symptoms, you can rely on Hypotensyl.
This is a synergistic combination of dependable hypotensive agents—Viscum album (Au-
ropean mistletoe) and hepatic and insulin-free
pancreatic extracts. It hastens recovery and
wins your patient's confidence.
Viscum album has proven remarkably effective for relief of hypertension (O'Hare and
Hoyt 1928, Barrow 1930 and Danzer 1934).
Frequently Hypotensyl effects a reduction of
20 to 30 mm. Hg. in 12 hours. Headaches and
dizziness vanish and reduction is sustained.
Excellent results are obtained in cases of essential hypertension or benign hyperpiesia.
Hypotensyl is also efficacious in treatment of
high blood pressure accompanying pregnancy
or due to fibrotic kidney. The benefit obtained
from careful control of diet, as well as mental
and physical rest, is accentuated by Hypotensyl.
The usual dose is 3 to 6 tablets daily, one-
half hour before meals. Best results are
obtained when treatment is given in courses
lasting two to three weeks, with a "week's
interval between, upplied in bottles of 50
and 500 tablets.
HYPOTENSYL
The Anglo-French  Drug  Company
354 St. Catherine Street East Montreal, Quebec VANCOUVER MEDICAL  ASSOCIATION
Founded 1898
Incorporated 1906
Programme of the 39th Annual Session
GENERAL MEETINGS will be held on the first Tuesday of the month
at 8 p.m.
CLINICAL MEETINGS will be held on the third Tuesday of the month
at 8 p.m.
Place of meeting will appear on the Agenda.
General Meetings will conform to the following order:
8:00 p.m.—Business as per Agenda.
9:00 p.m.—Papers of the evening.
1936*.
October 6th—GENERAL MEETING.
Dr. W. H. Hatfield: "Programme of the Tuberculosis Division of
the Provincial Board of Health."
Dr. A. B. Schinbein and
Dr. W. Elliott Harrison: "Surgical Treatment of Pulmonary Tuberculosis."
October 20th—CLINICAL MEETING.
November 3rd—GENERAL MEETING.
Dr. E. J. Curtis and
Dr. H. Lavell Leeson: "Respiratory Infections of Childhood."
November 17th—CLINICAL MEETING.
December 1st—GENERAL MEETING.
Dr. C. W. Prowd and
Dr. A. Y. McNair: "Tumours of the Large Bowel."
1937 H'
January 5 th—GENERAL MEETING.
Dr. R. Huggard: "Some Physiological Concepts of the Stomach and
Duodenum."
Dr. J. E. Walker: "Physiology of the Stomach."
Discussion opened by Dr. H. A. DesBrisay.
January 19th—CLINICAL MEETING.
February 2nd—GENERAL MEETING.
Dr. T. McPherson and
Dr. J. D. Balfour: "Obstruction of the Small Bowel."
Discussion opened by Dr. L. H. Appleby.
February 16th—CLINICAL MEETING.
March 2nd—OSLER LECTURE.
March 16th—CLINICAL MEETING.
April 6th—GENERAL MEETING.
Dr. Walter Turnbull and Staff: Symposium on
"Pelvic Conditions."
April 20th—CLINICAL MEETING.
Page 90 EDITOR'S PAGE
In this number of the Bulletin will be found an Interim Report of the
Health Insurance Committee of the British Columbia College of Physicians
and Surgeons. It would be well to read it carefully. Every member of the
profession in B. C. will be asked before long for his vote on the acceptance
or rejection of the plan suggested by the Health Insurance C_on_mission.
We are undoubtedly at a very vital crossroads in the history of medicine,
not only in British Columbia but throughout Canada. It behooves us all to
think gravely, and carefully, before we act. Not temporary expediency, and
not apparent self-interest, must guide us, for what may seem of benefit at
the moment may later turn out to be the first step to suicide.
Nor must we let ourselves be influenced by defeatists and those who
would urge us to a sauve qui pent policy. Thank God, there are few of these
in our ranks, but there are some, and we must not give them undue ear.
Nor need we yield to fear. We have been told in no uncertain terms that
the end of bargaining has been reached—that we can expect no further concessions. Further, we are advised to accept the terms that are offered, as
otherwise there will be a fight, and, we are told, a bitter one. So we come to
the end of nearly three years of what may be called bargaining, if by bargaining we are to understand a state of affairs where one side offers less and
less, and the other is expected to yield more and more. Poor as the first Act
was, it was immeasurably ahead of this one, and baits held out have been
withdrawn one by one till there is little in the poor fragment left to attract
the hungriest fish.
One or two outstanding considerations emerge from this long struggle.
The first is that expediency and not statesmanship, political profit and not
service to the state, have gradually cheapened and weakened what was in its
inception a noble scheme, fraught with great promise of good, and demanding the sympathetic co-operation of our profession. But the present scheme
is a miserable patchwork. Those who really need medical care most are
completely omitted from its provisions; those who are dubbed "beneficiaries
under the Act" will not get the full service they have been led to expect.
We are asked to do a greatly increased amount of work for a sum which
every survey that has ever been made shews to be grossly inadequate. The
Committee on the Cost of Medical Care, the Michigan inquiry, the work
in Ontario, in every other locality, and our own records, compiled through
the excellent work of Dr. W. E. Ainley, all come to exactly the same conclusion, within a few cents, as to what constitutes a fair remuneration for
medical men. The B. C. scheme offers a sum so far below that it means totally
inadequate remuneration.
As for the consultant and specialist-—these are asked to send in bills
according to the schedule of fees of the B. C. Medical Association; but what
share of these they receive will depend, not on this valuation, but upon the
proportion that the total bears to the amount in the fixed pool, which
cannot be exceeded. No business man would consider for one moment signing
any contract on such terms; no member of the Commission would ever
consent to work under such conditions as that his salary would depend, not
on agreement beforehand, but on the amount of money available after all
expenses had been met. Nor should we agree to work on any such conditions.
We are asked to trust the Commission, and their assurance that if means
are found inadequate after a year's trial, they will endeavour to have this
remedied. In other words, we are to try it for a year and then see. This is
Page 91 altogether too much like the spider's invitation to the fly. No, we must
realise that when we take this step there will be no turning back. Increase
of assessment, reduction of benefits, government grants, in our interest, are
just so many airy dreams. They would be fought so bitterly that we should
stand no chance of any success on those lines.
The medical profession has laid down, again and again, the cardinal
principles which it believes should govern Health Insurance. It believes in
Health Insurance, it will agree to work under it, and at a sacrifice to itself
—but it must not be asked to make all the sacrifice, take all the risk, and do
all the work. We have a perfect right to bargain—to dispose of our services
at a fair figure. We believe that we are in the right in this matter, and that
since our quarrel is just, our armour is of triple might. We should know,
before we enter this scheme, which depends entirely on the medical man's
work, what we shall be asked to do, and how much we shall be paid for our
work. The Act does not answer either of these questions.
Anyone who has sat in at the deliberations, month after month, of the
various representatives of the profession must feel, as we feel, intensely
proud of the loyalty and true worth of his fellows. Throughout the discussions, the note of what constitutes a good Act' from the point of view of
the public has been struck; it is quite safe to say that self-interest has been
quite secondary; that the Committee could not sooner let the profession
know all that was going on was due to unavoidable conditions of ignorance
on its own part—it is only within a very short time that the Committee
itself knew the final suggestions of the Commission. Meantime, we feel that
the greatest praise is due to the members of the! profession who have loyally
backed up their Committee, and, in the most trying conditions, have given
them a confidence which alone has made it possible for them to carry on.
We feel that we understand the temper of the medical profession today;
that it will still hold itself ready to work with the Commission and the
Government in any fair and worthy scheme that will give a real and good
medical service to those who really need it, at a cost which can be afforded
by those who have to pay, and on terms of payment to those who work
under it, which are fair and equitable. We believe that the vast majority will
oppose any scheme which does not do this, and not alone from selfish motives
—though we believe, too, that we are entitled, as are all people who must
work for pay, to the usual considerations that apply to every other job under
the sun—definite pay for definite work.
Below appears a notice regarding the lectureship it is proposed to establish in honour of the late John Mawer Pearson. We heartily commend this
to our readers, since in honouring him we are honouring ourselves. We feel
that every Vancouver physician at least will want to subscribe towards this,
and so associate himself with a most worthy project.
THE JOHN MAWER PEARSON LECTURE
Vancouver was a city of twenty thousand people when, in 1898, Dr. J.
M. Pearson called together the medical men of the city and formed the
Vancouver Medical Association. He was its first Secretary, and held this
position for three years. Later he became President and was one of three men
who founded the Library and gave unstintingly of his time and efforts to
carry the Library through its infancy and promote the success of the Association in every phase of its development. When the Bulletin was estab-
Page 92 lished in 1923 Pearson became its first Editor, a position which he filled with
pleasure to himself and great satisfaction to the Association for many years.
At a meeting of the Association held on December 31st, 1936, it was
decided to honour the memory of the late Dr. Pearson by the establishment
of a lectureship to be known as the "John Mawer Pearson Lecture," to conform to the following plan:
The John Mawer Pearson Lecture shall deal with some phase of scientific
medicine apart from purely operative surgery. The Lecturer shall be chosen
by the Executive of the Association on account of his scientific medical
attainments. The Lecture shall be given every third year, or oftener if
funds permit.
Funds for the estabUshment of the Lectureship shall be obtained in the
following manner:
1. A grant from the Association.
2. Voluntary subscriptions from individual member, of the Association.
3. Donations from relatives or friends—'lay or medical—of the late
Dr. Pearson.
With this idea in view every member of the Association is to be given
an opportunity to subscribe according to his own desires. Subscriptions may
be mailed to the office of the Vancouver Medical Association, 925 West
Georgia. The librarian is also authorized to collect subscriptions from the
members during the next few months.
It should be a privilege to assist in honouring, in this way, the man who
really founded the Association to which we now belong, and in order that
the Lectureship may be suitably established every member is asked to contribute.
NEWS AND NOTES
IMPORTANT NOTICE
LECTURE COURSE by DR. WALTER SCHILLER
The Executive Committee of the Vancouver Medical Association is
making arrangements to have Dr. Walter Schiller, of the Westheim Clinic
of Vienna, Austria, give two lectures on February 12th and February
15 th. The subject of the lectures ■will be Practical Gynaecological Endocrinology.
Further notices of this lecture course will be mailed directly to the
members, but in the meantime they are asked to keep these dates free.
Those who heard Dr. Schiller 'when he was here in November will remember his graphic manner of presenting his subject and the authority with
which he spoke. It is to be hoped that every member of the Association
will make an effort to be present at one or the other, of not at both, of
these lectures.
OSLER DINNER
The meeting of the Vancouver Medical Association scheduled for March
2nd will be the occasion of the annual Osier Lecture. Dr. W. A. Whitelaw
will deliver the lecture this year, the title of his lecture being "Facts and
Fancies in a Little Tour of the Gastro-intestinal Tract."
Page 93 The following men were elected members of the Vancouver Medical
Association at the meeting held on January 5 th: Drs. F. S. Hobbs and T.
M. Jones of Vancouver; Dr. Thos. McPherson of Victoria, and Drs. G. M.
Kirkpatrick and A. J. Warren from the Provincial Mental Hospital at Esson-
dale, B. C.
*__•**
Drs. L. H. Leeson, Colin Graham, F. W. Brydone-Jack, G. C. Draeseke
and J. A. Montgomery of Vancouver, Dr. A. W. Bowles of New Westminster and Dr. M. J. Keys of Victoria are members of the British Columbia
contingent attending the sixth annual Mid-Winter Clinical Course in
Ophthalmology and Otolaryngology at Los Angeles.
The medical profession are becoming more and more "air-minded." Dr.
M. Meekison attended the annual meeting of the American College of Orthopaedic Surgons at Cleveland, making the trip by aeroplane both ways.
Dr. Karl Haig made a "flying" trip to Southern California for a short
holiday.
_V _-_._!. __
*r *«■ *r ?r
Dr. H. H. Milburn has returned from a visit of several months in Eastern Canada and the Eastern States.
*_»_•■_ »_
*r *e *s" *r
Dr. J. R. Naden left for the Eastern States early in January, to attend the
annual meeting of the American College of Orthopaedic Surgeons. He will
be away until early in February.
5? *iT *f* 5_"
Dr. F. Brodie has left for the east. He expects to be away about a month.
*      *      *      *
Dr. T. McPherson and Dr. J. D. Balfour from Victoria are to be the
speakers at the February meeting of the Vancouver Medical Association.
They will discuss Obstructions of the Small Bowel.
3j? ^ 9p »J"
Dr. G. Elliott is assisting Dr. G. B. Henderson at Creston.
Sr ?r 5r 3r
Dr. R. W. Irving of Kamloops spent a few days in Vancouver during
the past week.
5_* ?r ^ j£
The following members of the Health Insurance Committee of the
College of Physicians and Surgeons have been in Vancouver recently attending meetings of the Committee: Dr. T. McPherson, Victoria; Dr. G. A. B.
Hall, Nanaimo; Dr. R. J. Wride, Princeton; Dr. H. W. Wylde, New Westminster; Dr. R. B. White, Penticton; Dr. J. H. Hamilton, Revelstoke; Dr.
O. O. Lyons, Powell River; Dr. F. M. Auld, Nelson; Dr. F. P. McNamee,
Kamloops; Dr. C. M. Kingston, Grand Forks; Dr. F. W. Green, Cranbrook;
Dr. J. Bain Thorn, Trail; Dr. C. H. Hankinson, Prince Rupert; Dr. E. J.
Lyon, Prince George; Dr. R. McCaffrey, Chilliwack.
Editor The Bulletin:
Dear Sir:—We would like to draw to the attention of all members of
the profession that the Clinical Meeting of the Vancouver General Hospital
staff is held on the fourth Tuesday in every month in the Auditorium of the
Page 94 Vancouver General Hospital at 8 p.m. The Hospital issues a very cordial
invitation to every member of the profession to be present at these meetings
and to participate in the discussion. We would be pleased to let you have
some notes regarding these meetings if you would care to publish them.
Yours truly,
Dr. Bede J. Harrison,
Chairman of Programme Committee.
NOTICE
The Vancouver Relief Department has issued a revised
edition of the "Pharmacopoeia Guide and would like the
medical man to make use of same, discarding previous
editions.
HEALTH INSURANCE COMMITTEE,
COLLEGE OF PHYSICIANS & SURGEONS OF B. C.
INTERIM REPORT
On January 20 th a very full meeting of the Health Insurance Committee of the College of Physicians and Surgeons of B. C. was held at Vancouver, and lasted four and a half hours.
The members of the Committee are as follows: Dr. T. McPherson, Chairman; Drs. Wallace Wilson, W. E. Ainley, L. H. Appleby, J. A. Gillespie,
J. J. Gillis, B. D. Gillies, A. W. Hunter, G. C. Kinning, R. L. Miller, H. H.
Milburn, J. H. MacDermot, S. C. MacEwen, W. H. Sutherland, C. H.
Vrooman, M. W. Thomas.
Supplementing this Committee were representatives from all parts of the
Province, as follows: Drs. G. F. Strong, W. T. Ewing, A. J. MacLachlan, R.
J. Wride, E. W. Wylde, R. B. White, J. H. Hamilton, O. O. Lyons, F. M.
Auld, F. P. McNamee, F. W. Green, J. Bain Thorn, C. H. Harkinson, G. A.
B. Hall, E. J. Lyon, R. McCaffrey, H. C. Graham.
It will thus be seen that the group was a very representative cross-section
of the entire profession of British Columbia.
The Tentative Plan of Medical Practice under the Health Insurance Act
was considered and discussed clause by clause by this group.
A copy of this plan will be received by every member of the profession,
within the next few days, from the Health Insurance Commission.
In all centres, meetings will be held within the next week or two, where
representatives from the group referred to above will be prepared to discuss
all questions that may be raised.
The group considered also: (1) the regulations that would govern the
general practitioner; (2) the regulations that would govern the insured;
(3 ) a list of exemptions prepared by the Commission, to be in force for the
first year or so.
Letters between the Commission and the Committee were considered,
and after a full discussion, it was unanimously decided that the plan as
outlined could not be accepted as satisfactory.
Page 95 On January 20th this enlarged group met the Health Insurance Commission, and had a long discussion with them on the subject of the Tentative
Plan. The Chairman of the Commission answered freely and fully all questions that were asked. The group held a second meeting by itself to consider
the suggestions made, and again unanimously decided that we could not
regard the plan as satisfactory.
Later in the evening, we again met the Commission. Dr. T. McPherson,
the President of the Council of the College of Physicians and Surgeons of
B. G, and Chairman of the Health Insurance Committee, then addressed
the Commission.
He pointed out to them: First, that, as a committee, we could not accept
or reject the proposals of the Health Insurance Commission, but must refer
them to the profession for their vote; second, that, as a committee, we were
of the opinion that the Act as at present proposed was unsatisfactory, for
the following reasons:
I. As regards the insured:
That the Act gives insufficient service, in that it does not include the
indigent, or make any provision for them, or the people on relief;
It does not include: Old age or mothers' pensioners; domestic servants; casual and part-time labourers; those in receipt of less than $10
per week.
Hospitalisation- as offered under the Act is impossible of attainment
under present conditions, or for a long time to come, as there is no possibility, in any of the larger, and most of the smaller, centres of the province, of providing enough accommodation for any increase.
Mileage is not paid for, and will have to be charged to the patient by
the doctor.
II. As regards the profession:
We regard the remuneration proposed as insufficient for the general
practitioner, secondly for the specialist and consultant. All our studies,
and all studies made all over the continent, shew that the fund proposed
is not adequate by a considerable amount.
The Conirnission will not allow any choice of payment, but insists
on the capitation fee for doctors.
We estimate that the amount of work demanded of the doctors will
be greatly increased, and that this, too, is an important factor.
Dr. McPherson, further speaking for the Committee, assured the Commission that we were prepared to recommend to the profession that they be
willing to work under a partial service for the first year, such as, for example,
a system that would provide hospitalization, drugs, and complete diagnostic
methods; or any other scheme that might be devised jointly by ourselves and
the Commission which would give a service commensurate with the amount
of money available.
The Commission, on the other hand, urged that we try the scheme for
a year, and that at the end of that time, if funds were shewn to be inadequate, they would be willing to go to the Government and recommend one
of the following plans, or any combination of two or more: (1) increase of
assessment; (2) decrease of benefits; (3) a subvention by the Government
to the fund.
Your C_ommittee felt that this was entirely too vague and uncertain,
and meant that the medical profession had to assume all the risks, and make
all the sacrifices, while we also feel that these suggestions are of very doubt-
Page 96 ful value, unless definite promises can be obtained before the Act is put into
operation.
The Commission would only undertake to make an attempt to secure
such promises on the condition that the profession agree to make trial of
the Act for a year.
At parting, the matter was left open for further negotiations.
A BRIEF ANALYSIS OF THE TENTATIVE PLAN
SUGGESTED BY THE HEALTH INSURANCE
|     I   COMMITTEE
1—The Distribution of Medical Services.
On the whole, there is room for only minor criticisms here; questions of
detail arise, especially with regard to specialists: e.g., Roentgenologists
working in hospitals may receive cases either from the hospital, or referred
from outside; the method of payment is not clear, whether from the hospital, the specialist pool, or other funds.
Exemptions. Here there is a question of great importance. First, it must
be clearly pointed out that this list of exemptions was prepared on the
insistence of the Commission, and in face of the protest of the Committee,
who felt that, in a proper Health Insurance Scheme, there should be no
exemptions. The Committee felt, too, that if exemptions were laid down,
the actual wage-earner should be free of them, and as regards the dependents, only those conditions which could have been diagnosed and treated to
a cure before Health Insurance came in, should be included.
The Commission, on the other hand, stated frankly that they felt
exemptions were necessary to prevent excessive cost, especially the cost of
hospitalisation.
The actual list of exemptions contains some conditions that, we feel,
are bound to lead to conflict, e.g., postpartum conditions. Here the possibility of cancer in later life, and of other conditions arising, is going to lead
to much confusion and discussion.
The diabetic, too, cannot obtain insulin, or the pernicious anaemia
patient liver extract, as part of the free benefits.
From our point of view, this list of exemptions promises to lead to much
trouble, as has been found to be the case in many places where contracts
are in force, and attempted exemptions have caused trouble—nor has the
doctor been able to collect payment for them.
2.—The Method of Payment for Medical Services
It is in this part of the plan that the chief differences arise between the
Commission and ourselves.
The charge of $1.00 or $1.50 for first house calls in any one illness is
an innovation, we feel, that is not satisfactory. In the first place, the insured
will resent it greatly, and, we cannot but feel, with considerable justice.
This is in direct contradiction to the principle of a complete service.
In the second place, there can be no doubt that it will be very difficult
to collect, though we must acknowledge that the Commission has shewn
its desire to co-operate in the methods it has suggested to make this fee a
reality. But these methods, while they may work, can be evaded, and there
is no definite, certain method of collection devised; and in places where some
such scheme has been tried under contract practice, it has always failed,
after proving to be a fertile source of trouble.
Page 97 The method of payment, by capitation fee for the general practitioner,
by payment from a fixed pool of taxed bills for the specialist.
The capitation fee method of payment is, we believe, a bad method,
based on a wrong principle. The medical profession of Canada has always
opposed it. We cannot here go into detail—but we again record our settled
opinion that, as has always been our rule, definite service should be paid for
on the basis of a definite schedule of fees, as is done by the Workmen's Compensation Board and in private practice. We still adhere to this principle.
Next, as regards payment from a fixed pool. This is a most pernicious
principle, as we believe. The specialist does the work, renders his bill according to the scale of fees adopted by the B. C. Medical Association, and then
has no means of knowing what percentage of his bill he will receive—since
this depends on the ratio of the total amount of bills sent in to the fixed
pool. We have no hesitation whatever in saying that this is entirely wrong.
No man in any other walk of life would undertake to do work without
knowing how much he could be sure of receiving—no business man would
sign any such contract as this. It is none of our business to tell the Commission where they are to get the money—but we have a right, before we undertake work, to know how much we shall receive.
As regards the total available for general practitioners—$4 for those
who do their own surgery, $3.60 or more for those who do none or part,
and so on.
We regard this as quite inadequate. In the first place, this represents the
gross income: i.e., for 1000 patients the medical man may receive $4000
gross, plus allowance for maternity patients at $24 each, plus a quite
unknown amount for first house calls, plus a possible amount for exempted
diseases, plus any consultations or special work he may do. Workmen's
Compensation fees continue as at present.
Apart from the Workmen's Compensation Board, the general practitioner cannot possibly receive more than $4.3 5, plus the problematical
amounts for first house calls and Exemptions and consultations, plus a share
of the 5 0 cents extra allowed for contingencies.
Very careful studies have been made all over the world, and one of the
most thorough computations of all has been made in Vancouver. From
every study, including those of the Committee on the Costs of Medical
Care, the studies in Michigan, in Ontario, here and elsewhere comes a figure
which is roughly the same everywhere, namely $7.30 to $7.50 for a complete medical service, including Workmen's Compensation Act, specialists,
etc. Workmen's Compensation fees average, we believe, about 5 0 cents per
capita, certainly not much more.
So there is evidently a wide discrepancy, and nowhere in the world is
$5.50 accepted as a fair figure—nor do we believe that it begins to give
adequate remuneration.
All these points have been made clear, again and again, to the Commission, to no avail.
We know, too, that under any scheme of Health Insurance work has
always greatly increased—in fact, it is evident from the Preamble to the
original Brief of Dr. G. M. Weir that a very great increase will be expected
from us.
As regards specialists, the fund provided is quite inadequate, in our
opinion.
Mileage.—We must further point out that the Commission has definitely declined to make any allowance for mileage, which must be collected
Page 98 by arrangement between the doctor and the patient. This is grossly unfair
to the latter, and in fact will, we believe, make service under this scheme
impossible in large areas of the Province.
II.   From the standpoint of the Insured.
The Committee feels, and so informed the Commission, that it cannot
consider this Act adequate from the public standpoint.
In the first place, it omits all the very people in the community who
most need medical care—the indigent, those on relief, domestic servants,
old-age and mothers' pensioners, casual and part-time labourers, and those
earning less than ten dollars a week.
No provision is made for these at all, and the medical profession must
still continue to carry this whole load of unpaid work, both in and out of
the hospital, without any compensation whatever.
After we had made many requests for action along this line—which, in
our belief, was promised again and again, with no result—we finally obtained
a statement from Premier Pattullo that the question of the indigent would
be taken up and settled after the Health Act was in force. We frankly cannot
accept this as of any value at all.
Secondly, the service given is not complete. The list of exemptions is
the first break—and denies essential treatment to certain groups, e.g., the
diabetic, the patient with pernicious anaemia, and to certain women who
need surgical attention.
The charges for first calls are an additional tax to the man with a
family, and may constitute quite a burden.
Hospitalisation.—This is, in our opinion, a very serious matter. Every
hospital in British Columbia, almost without exception, is now filled to
capacity. In such centres as Vancouver there is already a grave shortage, of
some 500 or 600 beds. It is quite certain that when Health Insurance comes
in there will be a great increase in hospitalisation—far more than the Commission will allow will be the case. Further, the experience of Australia and
other places shews a great increase in hospital days for each patient under
free plans.
Free hospitalisation is promised, and is one of the chief elements in the
plan.
We do not believe that there is any possibility of giving it under present
conditions.
Mileage.—This, as shewn above, will also be a tax on the insured that
is unfair and unjust.
If insufficient remuneration is paid to the medical profession, good work
cannot be expected, and this is bound to react on those receiving benefits.
We believe that under a cheap, underpaid scheme, the quality of medical
service given is bound to be low, and to deteriorate—and the chief sufferers
will be the insured.
The medical profession is not opposed, as we assured the Commission,
to Health Insurance. Rather, it is in favour of it, almost U-ianimously; but
there are certain principles which we feel must be observed, amongst them
a fair and adequate remuneration for the medical man, on scales which conform with the findings of all the major surveys. We believe, too, that payment should be by a definite fee for definite work, not by capitation fee.
That service given should be complete and inclusive, without exemptions,
if a complete scheme is to be inaugurated—and if this is to be the case, sufficient money should be provided. We feel that if there is not enough money
to provide a complete scheme, under terms fair to all concerned, then a
Page 99 partial scheme should be installed at first, under which we could feel our
way safely and without injustice to any, towards a more ample scheme later.
We oppose strongly the idea that the medical profession should take all the
risk, but we reiterate our complete willingness to explore all avenues towards
the establishment of a fair and practicable scheme, and will prepare and
suggest alternative plans to that end, or consider honestly any that may be
brought forward. But, as this plan stands at present, we cannot feel that it
is satisfactory, or recommend it to the general profession.
NATIONAL HEALTH INSURANCE
Supplement to the New Zealand Medical Journal
[This is a report which will to some extent interest us here In British Columbia
very greatly. New Zealand is not unlike British Columbia as regards medical practice. It has, too, an enviable reputation as regards child mortality, maternal mortality and the like, and does not, we imagine, want this jeopardised.]
By G. E. Waterworth
Napier.
The fact that the Government has announced that National Health
Insurance will not be introduced this year gives time for all concerned to
study the question. The first requirement is to get a broad grasp of the
principles at stake.
In order to do this I propose to survey the present medical services to
the country under four main headings:—
(1) Private Medical Practitioners.
(2) Public Hospitals.
(3) Friendly Societies.
(4) Auxiliary Societies, etc.
(1)  Private Medical Practitioners
The New Zealand doctor is a special type whom it is well for all who
are interested in national health matters to understand. He is the product
of his isolated environment. He has learnt the foundation of his work in the
medical schools of New Zealand, England or Australia, but his practice in
this country is unique, and is what is demanded by a discriminating and
educated population, of one million people scattered over a country 1,000
miles long, and that country completely isolated as far as medical help is
concerned. Even our largest cities are too small to encourage absolute
specialization and it is only attained by a few individuals. These specialists
have usually graduated from general practice and carry with them the
training and ideals there acquired. The average city doctor is and will remain
till the population more than doubles, a general practitioner, though he may
devote himself more particularly to one branch of practice in order to perfect himself in it.
His country brother has to be -even more completely independent.
Whether the patient has a broken leg, pneumonia, appendicitis, or requires
delivery of an infant, that patient's chance of survival or restoration to full
earning capacity depends upon the country doctor who is called to diagnose
and most often to treat the trouble. A standard of work and a spirit of
independence have been reached that is probably unequalled in any other
country.
The contrast with the standard of general practice in England, for
example, is great. There the custom is for the general practitioner to rely
Page 100 on the specialist or consultant, who is called in to almost every case not of
a trivial nature.
At the same time, the average New Zealand doctor, whose abilities are
always being put to the highest test by his daily work, has the ambition to
give of his best by study of his medical books and journals, by getting
appointed to the local hospital staff and by visits abroad.
These latter represent a tremendous expense, because a "brush-up" in
England takes anything from six to twelve months and during that time
he has not only to provide for himself and his dependents, but maintain a
locum in his own house. The contrast in expense between him and his brother
in England, who perhaps has only to walk down the street to see the ablest
men in the profession at work, needs only to be mentioned to be appreciated.
The medical men who travel communicate their knowledge to their
colleagues on their return in accordance with the tradition of the medical
profession. As a little leaven leaveneth the whole lump, the profession in
New Zealand is thus kept up to date, and it is the patient who reaps the
benefit.
Movements within the profession like the Institution of the Australasian
College of Surgeons, Clinical Societies, etc., are evidence of the deep desire
of the profession to better their standard of work.
To calculate the effect of National Health Insurance on the medical
profession, we have only to ask and answer a few questions:—
(1) Would the profession have attained its present state of efficiency
if it had grown and been trained under a system of National Health
Insurance, without the spirit of private enterprise?
No.
(2) Are the leaders in the medical world at Home practitioners under
the National Health Insurance Scheme in England?
No. The teachers and leaders in the medical schools, hospitals, and
universities at Home are never "panel doctors." Generally speaking, they are consultants engaged in private practice.
(3) Do we ever go Home to see "panel" practitioners at work?
No. There is probably nothing we could learn from them beyond
celerity at rushing through a herd of patients.
We can only conclude that the effect of National Health Insurance on
the medical profession will be to lower its general status to that of the
"panel" practitioner at Home.
(2)  Public Hospitals
In New Zealand we have developed a system of hospitals co-ordinated in
the Health Department, of which, in spite of certain remediable defects,
we have great reason to be proud. The defects are connected with undue
expenditure, uneven administration, occasional abuse, but the results obtained in the humanitarian work the hospitals set out to do, are highly
creditable. Outside praise of the standard of work in New Zealand hospitals,
and of the hospitals themselves, was not long ago given by Donald Balfour,
the distinguished surgeon of the Mayo Clinic, in a considered criticism.
Mr. Fagge of Guy's Hospital, London, and Mr. Gordon-Taylor, examiner
for the Royal College of Surgeons of England, reached the same conclusion.
Those medical men who have travelled in England and on the Continent
know that our public hospitals compare very favourably with similar institutions abroad.
The bulk of the medical work is done in our public hospitals by surgeons
and physicians who give their services in an honorary capacity, and if the
Page 101 hospital is not abused by those well able to afford private treatment, the
system works well and the doctors gain in experience and have the satisfaction of knowing that they are doing the medical work of the country that
supports and has trained them.
It is difficult to see how anything like the present honorary staff system
in the public hospitals could be continued under National Health Insurance.
Economic pressure will probably require physicians and surgeons, largely
deprived by National Health Insurance of their private practice, to require
payment for their services in the public hospitals. The introduction of
National Health Insurance will thus throw the whole public hospital system
into the melting pot, and some of its best features that the medical profession have striven to maintain will be lost.
(3 ) Friendly Societies
The Friendly Societies provide medical benefit at a low cost to a large
section of the population, numbering with dependents about 300,000. They
provide insurance against illness for the man of small income and even
members who become unemployed frequently find it feasible and worth
while to maintain their membership. The standard of medical work done by
the Lodge doctors is high because they are engaged in private medical practice as well, and do not distinguish between the Lodge member who appears
in their waiting rooms, and the private patient, it being generally recognised
that the average Lodge patient is the provident type of man of modest means
who year by year contributes what is roughly within his means to do.
(4) Auxiliary Societies, Like Plunket and Ambulance Societies
Regarding these, is is not necessary for our present purpose to say more
than this; that without the assistance of doctors in training personnel, they
would not exist.
From this brief survey of the medical service in New Zealand, it should
be clear that the medical profession forms the backbone of all medical service
in this country, and their interests and the interests of the sick are one.
I do not think that financial considerations, important as those are,
should be allowed to cloud the issue, because I think the desirability or
otherwise of National Health Insurance will be decided on other grounds.
If, after consideration of the real principles at stake, the Government decides that National Health Insurance is certain to provide a superior health
service for the country, no doubt the finance will be forthcoming. The
medical profession stands for the best medical service for the people that
can be provided and would not oppose any beneficial measure on the grounds
of expense, either to themselves or the general taxpayer. Yet, unfortunately,
financial interests have already spoken on the subject, and the whole question
was first brought into prominence by the Hospital Boards Association, with
a view to easing their finances. If the incidence of hospital taxation is at
present unf air, bearing too heavily on the country taxpayer or anyone else,
it is surely not beyond the resources of statesmanship to correct it, without
introducing a system of National Health Insurance that is on fundamental
grounds not desired.
Conclusions
1. That New Zealand has evolved the present system in answer to her
medical requirements.
2. That any improvement should be by a process of evolution, not
revolution.
3. That National Health Insurance would be in the nature of a revo-
Page 102 lution in its effects on the status and independence of the medical man, in
the future efficiency of the profession, and in the staffing of the public
hospitals.
4. That National Health Insurance proposals would impose at great
cost (estimated at four to eight million pounds per annum) a system of
insurance on this country which would leave it with a medical system
inferior to what it has now.
We would have sold our birthright for a mess of pottage.
A ROENTGENOLOGICAL CONSIDERATION OF
Igjlp TUMOURS OF THE COLON
By Dr. C. W. Prowd, Radiologist, St. Paul's Hospital, and
Dr. F. H. Bonnell, Assistant Radiologist, St. Paul's Hospital.
Roentgenological diagnosis related to any part of the anatomy is founded
upon a clinico-pathological correlation augmented by those special methods
peculiar to roentgenology.
The endeavours of the clinicians have evolved various syndromes. The
efforts of the internist, surgeon and pathologist have demonstrated the factors responsible for these symptoms. It remained for the radiologists to
evolve their diagnostic procedures and explain their findings on a basis of
pathology.
Methods and Their Evolutions
In 1896—one year after Roentgen's discovery of x-rays—parts of the
alimentary tract were demonstrated by artificially creating a difference in
density. Early workers used bismuth as a contrast medium, but between
1911 and 1923 barium sulphate supplanted bismuth. Fischer advocated the
combined method of colon visualization in 1923.1
He advocated air inflation after expulsion of the opaque enema. Various
modifications of this have since attained wide popularity.
Diagnostic methods now currently employed for colon visualization are
the opaque enema, the double contrast enema, demonstration of mucosal
relief and the contrast or motor meal.
Deductions concerning the conditions of the colon based solely on the
motor meal should be guardedly made. It is of value in the determination of
the functional behavior of the colon, but, at best, it is unphysiological. Of
course, should any gross obstructive lesion exist, this will no doubt be adequately demonstrated—ofttimes to the discomfort of patient, surgeon and
radiologist when the barium becomes impacted above the obstruction.
The opaque enema administered under fluoroscopic control supplemented by radiographic records remains the basic and most reliable method
of investigation of the colon for the radiologist. Additional data may be
elicited by the double contract method, which is of particular value in the
demonstration of polypi. Studies of the mucosal pattern appear to offer the
most promising field for early diagnosis of lesions involving the bowel wall.
A consideration of tumours of the colon should include intrinsic, benign
and malignant lesions; inflammatory conditions with tumour formation and
extrinsic lesions involving the colon. Our time, however, does not permit of
a complete survey of the subject. Consequently we shall deal with only the
salient features.
Read before the Vancouver Medical Association, November 1st, 1936.
Page 103 Roentgeno-Pathology
Malignant Lesions.—A malignant tumour of the colon, as is true of
malignancy elsewhere, produces morphological and physiological alterations
at its point of\>rigin and in adjacent tissues. Some pathologists divide carcinoma of the colon into several anatomical varieties; roentgenologically,
they may be divided into two groups, i.e., those which project intra-lumin-
ally (fungating or proliferating), and those which infiltrate the bowel wall
(scirrhus).
Colon malignancy usually presents a fairly characteristic roentgen syndrome. The filling defect is the cardinal sign. This, as the term implies, is
an encroachment on, or projection into, the bowel lumen by the tumour.
Thus we encounter a narrowed segment of the bowel with irregular outline.
Ulceration, which is of early occurrence in the f ungating type, is productive
of an associated spasm. The bowel wall at* the site of the growth exhibits a
loss of the normal pliability. Dilatation of the colon proximal to the lesion
may be evident. It is not always possible to distinguish between the two types.
The infiltrative type of lesion tends to exhibit the napkin-ring constriction, stenosing the bowel. The growth may spread proximally and distally
from its point of origin and produce a stenosis of a segment of bowel. The
degree of fixation depends on pericolic extension. When these lesions arise
in the right half of the colon where the contents are fluid, they may be late
in producing symptoms.
At times one encounters a complete obstruction to the retrograde flow
of barium, in spite of the fact that the patient may not exhibit symptoms
of any marked obstruction. Kohler states that this is usually indicative of
carcinoma.
Differential Diagnosis
Diverticulitis.—The differential diagnosis of diverticulitis from carcinoma occasionally presents a difficult problem. The sigmoid and descending
colon are the most frequent sites of diverticula but the condition may appear
anywhere in the large intestine. Statistics place the incidence of diverticulitis as from 5 to 10% of cases examined radiologically and at post-mortem.2
Pre-diverticular and diverticular conditions and diverticulitis are the
stages recognized. Herein it is the last stage with which we are concerned
as a diagnostic difficulty. Diverticulitis exhibits bud-like projections from
the bowel with an,associated spasm of the involved segment. Peri-diverticular
fibrous hyperplasia may develop. Contraction of the fibrous tissue leads to
a stenosis of the gut and an infiltrative carcinoma may be simulated.3
Tuberculosis.—Three types of tuberculosis of the colon are recognized.
1. Part of a general or miliary tuberculosis.
2. Tuberculous ulceration.
3. Hyperplastic tuberculosis.
The two latter may require differentiation from malignancy. Tuberculous ulceration may give rise to stricture formation. These lesions are multiple. There is usually evidence of tuberculosis elsewhere in the body. This
has an earlier age incidence than carcinoma.
Hyperplastic tuberculosis is a rare condition and is usually diagnosed as
carcinoma, as in each case the symptomatology is practically identical.
Eighty-seven per cent of these lesions occur in the caecum and ascending
colon. Eighty per cent of these cases are under 40 years of age.4
The motor meal is an aid in differentiation, as Stierlin's symptom5 is
frequently manifested, that is, circumscribed hyper-motility of the involved
Page 104 segment is apparent. In tuberculosis the ascending colon is usually remarkably shortened.
Simple Tumours
A variety of benign tumours of the colon are reported. These are covered
with normal epithelium and show a circumscribed projection into the lumen.
Some of this type at times encountered are fibromata, myomata, lipomata.
Polypi deserve special mention. These may arise in the course of a chronic
colitis or as true adenoma, either single or multiple. The consensus of
opinion appears to be that these should be regarded as potentially malignant.
The double contrast enema affords a very striking visualization of this
condition.
Rectum
While the colon has been indicated as the part under consideration, the
rectum merits some attention as 60% of intestinal carcinomas are said to
arise in this section.
In addition to intrinsic malignancies of the rectum, the recto-sigmoid
region is occasionally involved by extension of pelvic lesions, such as carcinoma of the cervix, endometriosis and pelvic tuberculosis.
The rectal ampulla usually becomes well filled before the barium enema
progresses into the sigmoid. Small tumours on the anterior or posterior wall
thus may readily escape detection. Further, the distal end of the rectum
exhibits a variety of silhouettes within the bounds of normal. Consequently
an encircling lesion just within the internal sphincter may be radiologically
unrecognizable. Therefore it cannot be too strongly urged that the patient
be examined digitally and proctoscopicafly as a routine.
Conclusion
Attention is again drawn to the fallacy of the motor meal.
One desires to stress the importance of adequate preparation of the
patients and the desirability of a consultation between clinician or surgeon
and the radiologist, and, finally, the advisability of digital rectal and proctoscopic examination.
Summary
The evolution and methods of roentgen examination of ^the colon are
noted.
The roentgenological syndrome produced by carcinoma of the colon is
considered.
The differential diagnoses of tuberculosis and peridiverticular fibrous
hyperplasia from malignancy are briefly discussed.
Some possible fallacies and pitfalls are mentioned.
BIBLIOGRAPHY.
1. "Webber, H. M.—The American Journal of Roentgenology and Radium Therapy,
vol. xxxi, No. 5, May, 1934.
2. Golden—New England Journal of Medicine, Oct. 4, 1934.
3. Boyd—Surgical Pathology, 1933.
4. Lockhart-Mummery—Diseases of the Rectum and Colon, 1934.
J. Harrison, B. J.—Textbook of Roentgenology, 1936.
Page 103 CARCINOMA OF LARGE BOWEL AND RECTUM
With Review of Records.
By Dr. A. Y. McNair
Pathologist, St. Paul's Hospital.
On account of the increasing incidence of cancer, and the late stages in
which it is being seen for the first time by the consulting physician, it has
become one of the major problems of medicine today. This problem is far
from being solved. High mortality and morbidity, in spite of advances
already made in its treatment and diagnosis, give good reason for grave
concern. It appears that only concerted efforts of the profession and laymen
can accomplish anything which will better our present outlook.
Tonight, in conjunction with Dr. Prowd of the Radiological Department of St. Paul's Hospital, I shall try to bring before you some points in
the pathological significance of carcinoma of the large bowel. This is largely
based on a review of ninety-one cases treated in St. Paul's Hospital over a
period of five years from 1931 to 1935.
It had been my hope in a study of these case records to find some early
clue to the presence of this disease. This, however, was not possible, due to
the late stages of the disease when first seen by the consulting physician.
By this time the disease had progressed to such an extent that the symptoms
then complained of were, in many cases, those of extensive involvement of
the bowel wall, with onset of early obstruction. Many symptoms were those
common to other diseases of the bowel, both organic and functional, of
much less serious character. The late stage of carcinoma anywhere in the
body is incurable.
It has been said that the medical profession is becoming more "cancer-
conscious," but it appears that before further progress can be made a radical
change must take place, and much work done by education and thorough,
systematic, periodic examinations, with re-examination at intervals of all
suspicious cases. Much has been done to improve technically the methods of
treatment of these cases, and with such technical skill available, how much
more can be done for those diagnosed in the early stages! In addition to
education of the layman and physician, let us hope that there will be found
some additional diagnostic aids, serological, chemical, or technical, which
will make possible a realization of this hope.
The average duration of symptoms is stated by Rankin1 to average about
ten months before the advice of the physician is sought. It is true that the
disease was present for some considerable time prior to this, probably several
years. The onset is so insidious, with no symptoms or with what there are
vague and wandering, that there is ample time for the disease to be well
established, with frequently a spread to the lymphatic glands, or even to
the liver, and it is only after the onset of signs of obstruction, hemorrhage
from the bowel, gross blood in the stool, or other alarming signs, that a
physician is consulted. It would appear from this that a vigorous, well-
directed educational campaign, extending over a period of years, is long
overdue.
There is always the alarm spread abroad of the fear of producing a cancer
phobia. It is not so deadly as cancer, and, like the phobia of tuberculosis
Read before the Vancouver Medical Association, November 1st, 1936.
Page 106 twenty years ago, will pass. Our present status of dealing with the cancer
patient, particularly in diagnosis, is comparable to that in tuberculosis
fifteen to twenty years ago.
In this analysis of records, there is a lack of completeness of investigation; diagnosis is made late; final proof of cure is available only in a few
cases. There should be a continuity of record from the start to the final disposition of each case. Our present therapy in early cases has proven, generally, to be adequate. It is only by the study of what we have done, and
careful analysis thereof, that we see what has been accomplished, and direct
our plans for the future. In so doing, let us hope that the lot of the cancer
patient will be, in the not too distaht future, as hopeful as it is in tuberculosis.
Diagnosis.—Since there are no definite early symptoms of this disease,
it is seldom seen in the early stage except when accidentally discovered at
rectal examination or operation. Symptoms of chronic obstruction, palpation of a mass, or bleeding from the bowel, frequently start an investigation.
In this there are several points to be emphasized:
1. The taking of a good history.
2. Careful, complete physical examination, which includes a manual
or bimanual rectal-abdominal or vagino-abdominal examination followed
by rectal and sigmoidoscopic examination, with a biopsy, if necessary, taken
at the time, this only after thoroughly clearing the bowel.
3. Laboratory tests, such as examination of stool for gross or occult
blood, pus, mucus, character of the stool with microscopic examination.
Complete blood examination and Kahn test should be done.
4. X-ray examination, to consist, if possible, of a barium series, with
a barium enema with fluoroscopic study. This method is probably one of the
most important in the diagnosis of carcinoma of the large bowel, but in the
rectal and lower sigmoidal areas it should always be combined with sigmoidoscopic bimanual methods of examination, if necessary under anaesthesia.
5. If these fail, and one is still sufficiently sure to warrant it, exploratory laparotomy should be done with biopsy at the time.
In examining a patient for suspected carcinoma of the large bowel, there
are certain things which must be remembered. The colomis development ally
and physiologically divided into two parts; first, the right, which includes
the caecum, ascending, hepatic flexure and right half of the transverse colon;
second, the left, which includes transverse colon from the midline, splenic
flexure, descending and sigmoid flexures to the recto-sigmoid junction.
The rectum, which is entirely separate, will be considered with the left
colon. The right colon receives the bowel contents in a fluid form. There is
absorbs much of the fluid, some food and salts, and passes the remaining
contents on to the left side in a semi-solid form. Here the bowel movements
are slow and occasional, and the bowel acts largely as a receptacle. It is
subjected to chronic infections with frequent delay in passing of the contents, effects of putrefaction, and numerous other disturbances. Here, too,
polypi and papillomatous growths are more common than on the right side.
The rectum, on account of its being a fixed tube, is subjected to greater
trauma and irritation than any other portion of the bowel. Tumours of the
right colon and caecum often attain very considerable size, and are palpable,
and exhibit symptoms wandering in type, and rather vague; obstruction is
usually late, and of the more chronic type, while on the left side obstruction
Page 107 is usually earner, but is seldom complete. There is usually a small opening
left through the centre of the mass which permits the passage of gas and
liquid contents. In the cases where sudden obstruction occurs, it is usually
due to an impaction with faeces, which can frequently be dislodged by an
enema properly given.
Diverticulitis, while relatively more common than is usually supposed,
may be extensive, with massive involvement of the wall, or localized, producing an annular type of lesion. There is usually little or no ulceration in
diverticulitis, with varying degrees of stenosis. Diagnosis of malignancy at
times in these cases can only be made by microscopical study of sections
taken from various portions of the mass.
Pathology.—The vast majority of malignant lesions of the large bowel
are due to adenocarcinoma. This develops in small localized lesions in the
nature of small microscopical adenomata, or in a polypus which is much
the same type of growth. These undergo growth, and finally malignant
degeneration takes place with the onset of a more active phase of proliferation with subsequent invasion and extension. Two types of lesion are seen.
(Here Dr. McNair shewed slides.) Type one is annular in shape, and involves
the bowel wall from within outwards, spreading through the submucosa
and muscle to the serous coat, invading frequently the lymphatic glands,
or even the blood channels. This type is definitely scirrhous in character, and
often involves a small portion of bowel. Ulceration is usually seen with
inflammatory infiltration of the base and surrounding tissues. Growth is
relatively slow with glandular enlargement, with occasionally glandular or
hepatic metastases. Lockhart-Mummary2 states that this glandular enlargement in the high percentage of cases is due to inflammatory rather than
metastatic involvement. The local inflammatory reaction in the growth is
an important factor in producing fibrosis with subsequent stenosis.
Type two is a proliferative type, is more adenoid in character, fungating
and very soft. It grows into the lumen of the bowel, gradually filling and
distending it. Ulceration and inflammatory reaction are usually seen, and
with this the formation of large, crater-like ulcers with ragged base and
soft, papillomatous over-hanging margins. The growth appears to remain
localized for a relatively long time, and although there is usually extensive
glandular enlargement in a considerable number of cases, there is no metastatic spread. Combinations of types one and two are occasionally seen, and
it is difficult to assign them to either one type or the other.
Malignancy of the Growth.—The malignancy of the growth is the chief
determining factor in the rapidity and extent of spread. Undoubtedly, constitutional diseases do permit of a more rapid growth in older individuals.
As a general rule the younger the individual the more malignant the tumour.
The size of the tumour does not indicate its degree of malignancy. Broder3
has shown by investigation that the malignancy depends on the inherent
characteristics of the individual cancer cell and the degree of cellular differentiation; and he has graded malignancy according to these characteristics. He has checked this clinically4 and found it to be true; the more malignant they are the earlier they metastasize, and the lower percentage is seen
of five-year cures. He has graded these characteristics of malignancy in
grades one to four, grade four being a very high degree and grade one a low
degree of malignancy. Frequently we see small primary growths with extensive secondary involvement of glands and liver. On the other hand we
occasionally see large, apparently inoperable lesions, with little or no local
Page 108 extension, and no glandular metastatic involvement. It has been my observation that type one is somewhat more malignant than type two.
Review of Records.—These and the following remarks are based on a
review of ninety-one cases of carcinoma of the large bowel treated over a
five-year period, 1931 to 1935. There will be no attempt at technical discussion of types of operation or therapy given, etc., but I will simply point
out some of the interesting features.
Figure I shows the incidence of malignancy of the large bowel studied
for a five-year period. During this period 7,732 specimens were received
and examined, of which 615, or 7.9%, were malignant. Of these, 58, or
9.9%, were from the large bowel and rectum. Thirty-three cases were not
submitted to microscopical study, and of these, 16 were not operated on,
and were treated with radium or x-ray. The total malignancies of the large
bowel in this series were 91, or 14.7% of the total malignancies.
SURGICAL—1931-193 5.
FIG. I.
Number of Surgical Specimens	
Malignant: Total Number	
% Malignancy of Total	
Number of Large Bowel Malignancy Sectioned
% Malignancy of Large Bowel Sectoined	
No. Malignancy Not Sectioned	
% Total Malignancy 	
Figure II: Age and Sex. The fifth, sixth and seventh decades showed
the greatest number of cases, with the highest percentage in the fifth and
sixth, relatively few before the fourth, and only two in the third decade.
The youngest was 26 and the oldest 78, both were male. The greatest incidence in the series was seen in 1933. The ratio of male to female was 52:39,
or 4:3.
CARCINOMA OF LARGE BOWEL—1931-193 5
FIG. II.
20-29
30-39
40-49
50-59
r
60-69
0.
7.
20.
16.
1.
8.
18.
7.
1.
IJ.
38.
23.
1.1
16.5
41.7   |
25.3
70-79
Symptoms.—The analysis of symptoms for which advice was sought
differs with the location of the tumour in the bowel. Eighty-two per cent of
the cases showed symptoms of early or chronic obstruction. The outstanding symptom apart from this was "an alteration from the usual intestinal
habit.'* Duration of symptoms prior to consulting the physician varied from
Page 109 two days in acute obstruction to two years with vague abdominal pains,
indigestion and a feeling of heaviness in the lower abdomen. The most frequent symptom was crampy pains in the lower abdomen, coming on several
hours after meals, in recurring attacks, increasing in frequency and severity,
with apparently normal intervals between the attacks. Alteration in the
usual intestinal habit necessitating cathartics was a very common symptom.
Irregularity in bowel movement was more marked in the left abdominal
lesions than in the right. Pain varied in character from sharp colic, to
crampy pains, vague, wandering pains, a feeling of pressure or dragging
aches, with or without distention. The greater the degree of obstruction,
the more severe were the symptoms. Loss of weight, strength and appetite,
and tiredness were present in 75%, and average duration four months.
Definite bleeding or gross blood in the stool was not mentioned in any of
the right-side lesions, but was a very common complaint on the left side,
and indicated presence of ulceration. The colour of the blood passed depended
largely on how long it was retained in the bowel before it was passed.
Tenesmus, frequent stools, mucus, muco-pus or muco-blood were present
in all rectal cases, associated with rectal pain or pain over the sacrum.
Anaemia was well marked in 50% of all cases. A palpable mass was present
in six of the thirteen caecal, and in practically all the rectal lesions. Enlarged abdomen was complained of in six cases. These were among those not
operated on.
Methods of study showed a marked predominance of x-ray examinations.
Seventy per cent of the cases were x-rayed and diagnosed as carcinoma.
Stool examinations are recorded in twenty, blood examinations showed three
cases of positive Kahn test. Sigmoidoscopic and proctoscopic examinations
were carried out in 32 cases, and of these 8 had rectal biopsies done at the
time.
Figure III. In this small series the location of a large percentage of the
tumours occurred at the two extremities of the bowel, and brings up the
question of stasis and trauma as a possible etiological factor in the production of new growth. Of the 91 lesions found, 71 occurred in the rectum,
recto-sigmoid and sigmoid regions, easily accessible to digital, proctoscopic
and sigmoidoscopic examinations in the majority of these cases. Diagnosis
by visualization alone was possible in over 50 per cent of the series. As to
the types of lesion, the annular type was more common in the sigmoid and
recto-sigmoid, while the proliferative type predominated in the two extremities of the bowel; caecum 11, and rectum 26. Taking both types into
consideration they are about equally divided; 44 annual to 47 proliferative.
Seven of the proliferative type showed presence of one or more polypi, and
there was definite microscopical evidence that malignancy had arisen in
these. Lymphatic glandular involvement was a very common finding. In
the operative cases 50% had local or glandular metastatic involvement, and
all had some lymph gland enlargement from inflammatory changes. Cases
treated by palliative methods had metastatic involvement, local or regional,
and a considerable number of them in the liver. The number of cases operated on for cure was 40, with post-operative mortality of 5. Thirty-five
were operated on with palliative measures only, such as drainage or colostomy
only, on account of the extensive glandular, local and visceral metastases.
These showed a post-operative mortality of 11. Sixteen cases were treated
by palliative measures such as radium and x-ray only. Total post-operative
Page.M0 mortality in 75 cases operated on was 21.3%, and cause of death in the
post-operative cases: peritonitis, 4; ileus, 2; exhaustion, 4; pulmonary, 2;
myocardial, 4.
OPERATIVE SUMMARY
fig. m.
V
-C
_3
.J
d
f<
0  v
_
u
"3
14
_.
TJ
o «
_>
Q
•2._
Q
C_j
d
_._
o -_
o
o
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__.
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S'_
Caecum | 13
Ascending   | 3
Transverse j 3
I
Descending | 1
Sigmoid  | 2 3
Recto Sigmoid  6
Rectum    42
Total ! 91
13
11        16
Summary.—A series of 91 malignant tumours of the large bowel is
reviewed. The male sex predominates with a ratio of 4 to 3. The highest age
incidence is in the sixth decade. The oldest patient was 76 and the youngest 26.
2. The tumours were located with greatest frequency in both extremities of the large bowel, rectum, recto-sigmoid and sigmoid and caecum,
comprising 96.5%, with 78% in the lower end of the bowel readily accessible to visual diagnosis.
3. There was relatively little difference in the two types of lesion,
annual and proliferative, with ratio of 44 to 47.
4. Post-operative mortality in 75 cases was 21.3%.
1.
BIBLIOGRAPHY
Rankin, F. W\, and Olsen, P. E.—The Hopeful Prognosis of Carcinoma of the
Colon. Surg., Gyn. and Obst., vol. 56, pp. 366-374, Feb. 15, 1933.
Lockhart-Mummary—Diseases of the Rectum and Colon, Ed. II, 1934.
Broder, A. C—Practical Points in the Microscopic Grading of Carcinoma. N. Y.
St. J. Med., 1932, vol. 32, pp. 667-671.
Broder—The Grading of Carcinoma. Minnesota Med., 1925, vol. 8, pp. 726-730.
COLLEGE OF PHYSICIANS AND SURGEONS
OF BRITISH COLUMBIA
Following extracts from the Statutes of the Province are published
for the information of members.
PUBLIC HEALTH ACT. R. S. 15*24.
Members are requested to aid in education of patients and public of
requirements of the Act in regard to contagious and infectious diseases.
Section 83. "Where any householder knows or suspects or has reason
to know or suspect that any person within his family or household . . .
has any contagious or infectious disease, he shall within 24 hours of the time
Page 111 such disease is known or suspected to exist . . . give notice to the Medical
Health Officer or the Local Board of Health."
Section 86 provides that the physician shall report all cases (even suspects) within 24 hours (subject to penalties).
Section 88. "No person affected with smallpox, scarlet fever or diphtheria, and no person having access to any person affected with any of the
said diseases, shall mingle with the public until the regulations of the Provincial Board have been complied with."
Section 90 covers the question of isolation of infected persons.
NARCOTICS
Extracts from the report of the Narcotic Division of the Department
of Pensions and National Health ending March 31st, 1936—an excellent
report which might be read with interest by every physician in Canada.
stThe co-operation with the medical profession has continued to be very
close, and we are greatly indebted to many members thereof for their assistance and co-operation in relation to cases of addiction which, not having
underworld associations, offered reasonable prospects of cure."
"There are now two provinces, Manitoba and British Columbia, in which
amendments to the Provincial Pharmacy Acts have ensured that straight
codeine shall only be sold by retail druggists on medical prescription. This
is a most useful provision."
While it is regretted that the authorities found it necessary to take action
against two physicians, it is a matter of congratulation that two out of a
medical population of approximately 11,000 indicates a fair standard.
DR. J. W. FORD
BORN 1866 — DIED 1937.
TT has saddened many of us to read in this morning's news of the death
■^ of our old friend, Dr. J. W. Ford, of pneumonia.
"J. W.," as he was generally called by those who knew him well,
was one of the landmarks of our medical landscape. He was an unobtrusive man, quiet and unassuming in his manner, but with a gift of
making and keeping friends, and many, outside of his own profession,
will mourn his passing.
He did his share of community service, too, and was very active in
years gone by in matters affecting his professional associations, having
served in most of the offices of the Vancouver Medical Association, including the presidency. Of late, with advancing years, he lived a quiet life,
practising his profession, and playing golf as a recreation. He derived
great happiness and pleasure from this, and played a consistent and
rather good game, being always a good partner and a worthy opponent.
We wonder if anything better could be said of any man.
He had a full life, and rounded out the three-score mark of years.
He did his work well, and gave the community in which he lived the best
hie had in him. That would seem to be as happy a life as one could very
well have, and we may be glad for him that such should have been his lot.
Requiescat in pace.
-_t-_~a_.
Page 112 POET'S COLUMN
Contributed by W. D. CALVERT, M.D., Milne's Landing, B. C.
PHYSICIAN'S DAWN
One hour besets my path with brooding gloom:
Before cock-crow my thoughts are wont to stray:
Whether my footsteps tend to death-bed room,
Or usher new-born to the garish day:
Used, through long years, to face the darkling chill,
Tread ghostless forest or the desolate street,
Persist in efforts of a lonely will
Against discouragement and ageing feet.
If aught can cheer me now, itf is the trees,
Swaying their stately fronds before the breeze,
Kindly and steadfast friends that creak and sing,
Dignify silence, fend the blizzard's sting.
But with the rising splendour of the sun
All demons flee, my day is well begun.
*
*
TO A BRONZE HEAD OF YPNOS IN THE BRITISH MUSEUM
0 God of sleep, behind this brazen mask,
Whose gaze belies the rounded cheek of youth,
Not mine to plead Elysian fields, nor ask
For dreams of heaven, nor a well of truth.
Eyes fathomless beneath a tender brow,
A dusky wing to waft me to that land,
Your pillared temple, where I would be now,
With store of scarlet poppies in my hand.
Grant me, a way-worn leech, your breath today,
Thrice blessed gift of sudden dreamless sleep,
So minutes yield a night-long holiday,
To freshen eyes that weary vigils keep.
1 can no more than offer these my best
In earnest of a grace made manifest.
NIGHT THOUGHTS
Up hearts! This our long last before the dawn,
Souls' flitting time, and when the pulse is low:
But yet gives promise to us, now forlorn,
Who wait impatiently the rising glow.
What if Old Chaos frets as darkly rude
As once before the prime (And may again),
When Fates direct that she who used to brood
The hollow world must shun the race of men?
Not spent are we, nor heartless to our kind,
With ample means to fill life's utmost needs;
Earth teeming wealth, and richer still the mind
Than all the rest, in spite of wars and creeds.
Through doom foretold and vain imagining,
Still lovers meet—and swallows come, and spring.
Page 113 PETROLAGAR
F FIVE TYPES
"Delightfully Palatable"
Your patients will co-operate willingly when delightfully palatable Petrolagar is prescribed in the
treatment of constipation. We suggest that you taste
Petrolagar and note the pleasant flavor. Petrolagar
is a mechanical emulsion of liquid petrolatum (65 %
by volume) and agar-agar.
Samples Free on Request
John Wyeth & Brother, Inc.
3 64 ARGYLE ROAD
WALKERVILLE, ONTARIO
Cocomalt...
Cocomalt is a delicious, easily digested and nourishing
food in powder form, designed to be mixed with milk.
By laboratory analysis Cocomalt contains:
Moisture, loss in vacuo at 65° C.  0.88%
Fat  3.68
Protein (N x 6.25) 13.06
Crude Fibre  0.74
Mineral Matter-Ash  3.33
Carbohydrates (by difference) 78.31
Calcium  0.30
Phosphorus     0.33
Iron, Fe  0.02
Qcomalt
A°EUC10US FOODDR|N,C
CHOCOLATE FLAVOR
(SAMPLES SENT TO ANYONE ON REQUEST)
WESTERN CANADA AGENTS:
SCOTT-BATHGATE CO., LTD.
WINNIPEG      ::     VANCOUVER YEAR
»»»»»»»»»»»»»»»»»»»»»»»»»»»»» • «<««««««««««««««««««««««««««
In 1930, when Emmenin was first announced by Dr. J. B. Collip as an orally-
active water-soluble hormone of the placenta, little was known of the chemical
nature of placental oestrogenic substances or of the important part they
are now known to play in endocrinology.
Over six years have elapsed—striking progress has been made in the study
of endocrine substances—yet the early description of Emmenin is as sound
to-day as it was in 1930. Emmenin enjoys a prestige that only a truly successful
clinical background can create, and the evidence of this clinical background
is found in an extensive bibliography.*
The original claims for Emmenin in the treatment of disturbances associated
with menstruation have been amply confirmed. In symptoms of the menopause,
in menstrual migraine and dysmenorrhoea, Emmenin may be relied on to
produce a high percentage of satisfactory results and the simplicity of
administration permits extended treatment without inconvenience or excessive
cost to the patient.
* Copy on request
»»»»»»»»»»»»»»»»»»»»»»»»»»»»» • «««««««««<«<««««««««««««<«<««<!
EMMENIN
Water-soluble
MENOPAUSAL DISTURBANCES
FOR
DYSMENORRHOEA
Kyrallu-actwQ.
MENSTRUAL MIGRAINE
\bmmenin is now offered in liquid form (original four ounce bottles) and in
tablet form (bottles of 42 tablets) at substantially reduced prices.
f AYERST,  McKENNA & HARRISON,  LIMITED
Biological and Pharmaceutical Chemists
MONTREAL CANADA The "single upright" attached to the inner side of the shoe, provided with a T strap, fastened to the outer side of the shoe and
so arranged that the bar can be detached from the footpiece at
will. This appliance is used as a protection against a recurrence of the sprain in those cases where the injury has been
extensive and has left the ankle very weak and unstable. The
brace is here shown as used in cases where the sprain occurred
on the outer side of the ankle. A. View from the outer side.
B. View from the inner side. C Cross section of footpiece and
joint. D. Shows how the bar slips onto the footpiece. E. Shows
how the bolt holds the bar when the brace is in position.
Doctors...
We can fit your patients with
Made-to-Measure and
Corrective Shoes
Subject to your Prescription and
Recommendation
34 YEARS' EXPERIENCE IN LAST MAKING AND
CUSTOM SHOE-BUILDING
<Pi
LEXIS,
lPuzL
51 WEST HASTINGS ST., VANCOUVER, B. C. u   z   z
S»  f m
•°m
V
_/^X--.-_&=-^^^
lip
ISlElsillitfe
iT
pick out  JVlary  Lou's
■Hki
Ht
e«?s
Mary Lou had  rickets when  she  was   a
baby. Once that might have made her easy
to identify! But now doctors know how to
treat rickets effectively, and they know what
to   do   to   prevent   it.
Promptly treated, rickets
seldom results in bow legs
or   knock   knees.  So the
answer to our puzzle is—
you can't pick out Mary
Lou!
Fewer children with
iron braces! More children
with legs as straight and
handsome as young
saplings! Fewer hollow chests 1 More well-
shaped jaws and pleasing little profiles!
These are some oj the advantages which
modern developments in vitamin medication
—especially vitamins A and D—have made
possible.
Here is something we'd like to have you
mm
. vWSTCROt _
Wte
keep in mind: Problems involving vitamin
have been studied in the Parke-Davis Lai
oratories every day for over twenty years-
a rich background of experience. For yois
young patients or old, it
a sensible precaution i
specify' .Parke-Davis."
Parke-Davis Haliver 0
with Viosterol is supplier
in 5-cc. and 50-cc. vial
with dropper, and in boxt
of 25, 50, 100, and 2£
three-minim capsules.
Haliver Oil is thj
original halibut liver oj
preparation introduced to the meaiqj
profession in February, 1932.
PARKE, DAVIS & CO
WALKERVILLE, ONTARIO
Winnipeg, Man. Montreal, Qu^
t "It is known that evaporated milk forms a fine curd in the
stomach, a curd similar in many respects to that of human
milk:'
—Jeans, P. C, Stearns, G., et al.:
J. Pediat., 8:4, 1936.
THE MILKJTHAT
(ALWAYS FORMS A
FINE CURD
THE heat treatment given Irradiated Carnation Milk in the process of evaporation so
alters the casein that the curd formed in the
infant's stomach is always fine, soft and flaky.
This characteristic is found in non-acidified as
well as acidified modifications, and is a factor of
first importance in the favorable results everywhere obtained from the use of Irradiated Carnation Milk formulas in infant feeding.
The Dionne Quintuplets have been using
Carnation Milk since November,  1934.
Carnation Company Limited, Abbott St., Vancouver, B.C.
Write for "Simplified Infant Feeding," an
authoritative   publication  for  physicians.
CIRRADIA TED
ARNATION MILK
Va_HRKa* \
if   MtDICAl     I
_--?Sss%.    /
A CANADIAN PRODUCT
"From Contented Cows" Em_lmvlw^ I WliEllPi
(Standardised Vitamins A and D)
IN
EFFECTIVE
PROPHYLAXIS
Effective prophylaxis is assured when the measures adopted are based
on sound scientific principles. Radiostoleum promotes epithelial
integrity; thus it fortifies the body's first line of defence against the
inroads of infective organisms. By prescribing Radiostoleum, therefore, the physician provides his patient with an effective safeguard
against infection.
Radiostoleum also possesses the power to counteract deleterious
consequences resulting from any dietary deficiency of the calcifying
vitamin.
Stocks are held by leading* druggists throughout
the Dominion, and. full particulars are
obtainable from
The BRITISH DRUG HOUSES (Canada) Ltd.
Terminal Warehouse Toronto 2, Ont.
Rstm/Can/372
FOR BRONCHIAL IRRITATION PRESCRIBE
Mistura Tussi
Hartz
;ii-iM.i.iiiiiiiiiiiiiiiiliiiiiimiiiiiiiiiiiiiiiiiiiiiii.iii..Mi.iii.._:
E   FORMULA: jj
=           ■_._•_                                         = MISTURA TUSSI, HARTZ, is
s              .bach tluid ounce represents:              r 1     _i        _     •      i    •
2                                                                               : a palatable and stimulating ex-
E   Ammonium Carbonate    10 grains     = g^^ft;   quickly   and   effec-
E   Ammonium Chloride     10 grains      = dvely relieving Bronchial Irri-
E   Marrubium Vulgare  24 grams     E tation without locking up the
E   Diamorphine Hydrochloride 1/6 gram       z seCretions. Its sedative action is
E   Syrup Tolu  __._ 120 minims   E particularly  effective  in  those
=   Syrup Squill    120 minims   jj hard, dry coughs where expec-
|     Dose: One-half to two fluid drachms     S toration is scanty.
E                    as may be indicated.                     E
rillHIIIIUIIMIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIHIIIII? ^_~'
The J. R HARTZ CO., Limited
Pharmaceutical Manufacturers
TORONTO MONTREAL COLONIC IRRIGATION INSTITUTE
Superintendent—_B. M. LEONARD, R.N., Post Graduate, Mayo Bros.
Treatment Room, showing the Irrigation Tab'e.
REALIZING the need for a properly equipped centre where those suffering
from constipation, worms, indigestion, etc., could be assured of modern
scientific colonic irrigation and internal medication, E. M. Leonard, R.N., has
fitted out operating rooms with the most up-to-date scientific equipment. Here
the patient will receive every attention, and proper thorough treatment under
the care of a fully trained nursing staff, at a moderate charge.
Individual   Treatment $ 2.50
Entire Course  10.00
Medication (if necessary) $1 to $3 extra
This treatment is beneficial in cases such as constipation, indigestion, acidity,
rheumatism, arthritis, worms, diverticulosis, colitis, acne, and any condition
which may have originated in the intestinal tract. To ensure comfort, convenience and thoroughness in these treatments, call at the Colonic Irrigation
Institute, either in Vancouver or Victoria, B.C. Registered nurses always at
your service.
631 Birks Bldg.     Phone Sey. 2443.     Vancouver, B. C.
506-7 CAMPBELL BLDG.
Phone Empire 2721
VICTORIA, B. C. A PRESCRIPTION SERVICE . . .
Conducted in accord with the ethics of the Medical
Profession and maintained to the standard suggested by
our slogan:
Pharmaceutical Excellence
MCG'II 6 Ormo
LIMITED V-X
FORT STREET (opp. Times)      Phone Garden 1196     VICTORIA, B. C.
Nunn $c ®I|0ttt00tt
2559 Cambie Street
ancouver
, B. C.
The hypnotic with analgesic properties
WILL PROCURE A QUIET AND
RECUPERATIVE SLEEP
All forms of insomnia are amenable to SONERYL.
DOSE: 1 or 2 tablets half an hour before retiring.
% tablet is sufficient in light insomnia.
LABORATORY POULENC FRERES
OF CANADA LIMITED
Distributors: ROUGIER FRERES, MONTREAL Dial "Cilia
99
Dial calms excited, irritated nerves, and for such occasions as nervous insomnia, mental and traumatic agitation, pre-operative restlessness, etc., it will fulfil all the
requirements of a good hypnotic.
Cibalgine "Ciba"
Cibalgine represents a non-narcotic analgesic and antipyretic worthy of the physician's confidence. It is indicated in the treatment of pain of every description, febrile
manifestations, nervous excitement, insomnia due to
pain, dysmenorrhoea, etc.
CIBA COMPANY LIMITED
_f MONTREAL
-IDount UMeasant THnbertaktno Co. %tb.
KINGS WAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C.
R. P. HARRISON W. R. REYNOLDS STEVENS' SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity for the bag or the office. Supplied
in one yard, five yards and twenty-five yard packages.
ESTABLISHED  NEARLY A
.CENTURY,*
B. C. STEVENS CO.
Phone Seymour 698
730 Richards St., Vancouver, B. C.
BOWELL& SON
DISTINCTIVE FUNERAL
SERVICE
Phone 993
66 SIXTH STREET
NEW WESTMINSTER, B. C.
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and  stabilizing the tone of its
musculature. Controls the utero-ovarian
^   circulation and thereby encourages 2.
.normal menstrual cycle.,Lip §^j
__ ':__^$l     MlP      ' _§IPf$      '. ■.'■     A
» MARTIN H. SMITH COMPANY
__«!       ISO lAf ATITTI STREET, NEW YORK, N. V.    .
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.
>:«-:&;-«_?-.-.&:.-&;:.&:-: I
N ACUTE INFLAMMATORY CONDITIONS, where one of the main objects of treatment is to produce a hyperemia, the physician
will find Antiphlogistine a valuable medium for
this purpose.
It is one of the most convenient ways of applying
prolonged moist heat and through its action it
helps to abate the severity and duration of the
inflammatory attack.
Indicated in cases of
• Bronchitis
Otitis Media
Neuralgic Pains
Sample on request
An.iphl
MADE IN CANADA
The Denver Chemical Mfg. Co.
153 Lagauchetiere St. W.,
MONTREAL Old Way...
CURING RICKETS in the
CLEFT of an ASH TREE
FOR many centuries,—and apparently down to the
present time, even in this country—ricketic children have been passed through a cleft ash tree to cure
them of their rickets, and thenceforth a sympathetic
relationship was supposed to exist between them and
the tree.
Frazer* states that the ordinary mode of effecting
the cure is to split a young ash sapling longitudinally for a few feet and pass the child, naked,
either three times or three times three through the
fissure at sunrise. In the West of England, it is said
the passage must be "against the sun." As soon as
the ceremony is performed, the tree is bound tightly
up and the fissure plastered over with mud or clay.
The belief is that just as the cleft in the tree will be
healed, so the child's body will be healed, but that if
the rift in the tree remains open, the deformity in
the child will remain, too, and if the tree were to die,
the death of the child would surely follow.
•Frazer, J. G.: The Golden Bocgh, vol. 1, New York. Macmillan & Co., 1923
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IN
I tis ironical that the practice of attemprinj
to cure rickets by holding the child in the
cleft of an ash tree was associated with the
rising of the sun, the light of which we no-
know is in itself one of Nature's specifics
New Way...
Preventing and Curing Rickets with
OLEUM PERCOMORPHUM
T^TOWADAYS, the physician has at his command, Mead's Oleum Percomc
-**^ phum, a natural vitamin D product which actually prevents and cue
tickets, when given in proper dosage.
Like other specifics for other diseases, larger dosage may be required f
extreme cases.   It is safe to say that when used in the indicated dosage, Meac
Oleum Percomorphum is a specific in almost all cases of rickets, regardless
degree and duration.
Mead's Oleum Percomorphum because of its high vitamins A and D content
also useful in deficiency conditions such as tetany, osteomalacia and xerophthalm
Mead's Oleum Percomorphum is not advertised to the public and is w
obtainable at drug stores at a new economical price in 10 cc. and 50 cc bott
and 10-drop capsules.
MEAD JOHNSON & CO. OF CANADA, LTD., Belleville, 0|
Please enclose professional card when requesting Bamplea of Mead Johnson products to cooperate in preventing their reachina unauthoriMdP*
II Busy Days
for Doctors
With the many cases of measles
and influenza, besides the more
common ills prevalent at this
time of year, we invite you to
use our service to the limit. Rely
on us in the matter of dependable sickroom supplies, quality
drugs, exacting prescription
work  and  speedy delivery.
SEYMOUR
10501
24
Hours a Day!
I
SEYI050
OI-MAU.
NIOMT
GEORGIA PHARMACY
LIMITED
W.OCOROIA
STREET
(Emter- $c ijamta Hfit
Established 1893
VANCOUVER, B. C.
North Vancouver, B. C.    Powell River, B. C.
PUBLISHED MONTHLY AT VANCOUVER,   B. C.   BY  ROY WRIGLEY LTD.,   SCO WEST  PENDER STREET Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
§5^^-5^_>IES2^5E^&2^-E^S5^^

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