History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: March, 1950 Vancouver Medical Association Mar 31, 1950

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Published By
The Vancouver Medical Association
.    EDITOR:
dr. j. h. MacDermot
Publisher and Advertising Manager
OFFICERS, 1949-50
Dr. W. J. Dorrance       Dr. Henry Scott Dr. Gordon C. Johnston
President Vice-President Past President
Dr. Gordon Burke Dr. W. G. Gunn
Hon. Treasurer Hon. Secretary
Additional Members of Executive'.
Dr. J. C. Grimson Dr. E. C. McCoy
Dr. G. H. Clement Dr. A. C. Frost Dr. Murray Blair
Auditors: Messrs. Plommer, Whiting & Co.
. Dr. M. M. MAcPHERSON-Chairman Dr. W. H. S. Stockton Secretary
Eye, Ear, Nose and Throat
Dr. J. F. Minnes Chairman Dr. N. J. Blair Secretary
Dr. J. R. Davies Chairman Dr. C. J. Treffry. Secretary
Orthopaedic and Traumatic Surgery
Dr. R. H. B. Reed Chairman Dr. D. E. Starr Secretary
Neurology and Psychiatry
Dr. G. H. Gundry_— Chairman Dr. G. M. Kirkpatrick—Secretary
Dr. W. L. Sloan Secretary Dr. Andrew Turnbull Chairman
Dr. R. A. Palmer, Chairman; Dr. E. F. Word, Secretary; Dr. J. E. Walker;
Dr. S. E. C. Turvey; Dr. A. F. Hardyment; Dr. J. L. Parnell.
Summer School:
Dr. E. A. Campbell, Chairman; Dr. Gordon C. Large, Secretary;
Dr. A. C. Gardner Frost; Dr. Peter Lehmann; Dr. J. H. Black;
Dr. B. T. H. Martensson.
Medical Economics:
Dr. J. A. Ganshorn, Chairman; Dr. Paul Jackson; Dr. W. L. Sloan;
Dr. E. C. McCoy; Dr. J. W. Shier; Dr. T. R. Sarjeant; Dr. John Frost.
Dr. H. A. DesBrisay ; Dr. G. A. Davidson ; Dr. Gordon C. Johnston.
Representative to B. C. Medical Association: Dr. Gordon C. Johnston.
Representative to V.O.N. Advisory Board: Dr. Isabel Day.
Representative to Greater Vancouver Health League: Dr. L. A. Patterson
Representative to the Board of Trustees for the Medical Care of
Social Assistance Cases: Dr. J. A. Ganshorn Vasoconstriction
combined with
antibiotic therapy in
(brand of phenylephrine)
In upper respiratory tract infections,
topical application of penicillin to the nasal cavity has a decided bacteriostatic action against
typical respiratory pathogenic microorganisms.
To provide clear passage for such therapy,
Neo-Synephrine is combined with penicillin-'
shrinking engorged mucous membranes and
allowing free access of the antibiotic.
Neo-Synephrine—a potent vasoconstrictor—
does not lose its effectiveness on repeated application ... is notable for relative freedom from
sting and absence of compensatory congestion.
Stable • Full Potency
Supplied in combination package for preparing 10 cc. ot
a fresh buffered solution containing Neo-Synephrine hydrochloride 0.25% and Penicillin 5000 units per cc.
New York 13, N. if.    Windsor, Ont.
Neo-Synephrine, trademark reg. U.S. & Canada
£*»c«K**s of oatmeal, matt syrup, P*****?
: „"*"**<*% Prepared for human ose,axft*» <*»"*
2*"* wast, and reduced inm. Pabena is *> f*
Z^^of thiamme and supplies wlri****?
;r**'Wnerafe(i,on,COpp6r,CalciUm.and phosP"^
**<«<* of thorough cooking and diyina *"**
**» <fisea«f. It is patebble. convenient *>
economical to use.
PABENA... precooked oatmeal
specified by physicians
PABENA* is oatmeal, and has the rich, full oatmeal
flavor. Its nutritional qualities and its vitamin and
mineral content are similar to those of Pablum.*
PABENA is valuable for infants and children who
are sensitive to wheat, and is an ideal first solid food.
PABENA, like all Mead's products, is advertised only to the medical profession.
*T. M. Reg.
 , .      . ■ -.-.     — -   -   -   ....:0|s£jg?jjjj^a
"«3«' 1
Hill :%
Brand of Polyamine Resin
Prompt acid neutralization
Effective pepsin inhibition
Alkali nization
Acid "rebound"
Alteration of acid-base balance
of body fluids
Removal of phosphorus or      Iff
sodium chloride
Destruction of important
nutritive factors
Interference with normal bowel
Toxicity  (even with massive
In the treatment of
Gastric hyperacidity
Gastric and duodenal ulcers
Heartburn of pregnancy
Biological and Pharmaceutical Chemists
Montreal, Canada.
Is available as
Tablets (No.. 373)—0.25 Gm.
(4 grains) per tablet.
In bottles of 1 00 and 500.
Powder (No. 375)
Founded 1898; Incorporated 1906
(Spring Season)
MARCH 2nd—SPECIAL MEETING Speaker—Professor F. H. Bentley, Department
of Surgery, University of Durham Medical School, England.
MARCH 6th—SPECIAL MEETING, Lecture by Sir Reginald Watson-Jones,  title:
"The New World of Orthopaedic Surgery."
A. DAVIDSON, HOTEL VANCOUVER Title: "Men of Osier's Time."
MARGH 28th—SPECIAL MEETING—^"Lecture by Dr. Cecil Watson, Professor of
Medicine, University of Minnesota, Title: "Some Fundamental and Clinical Aspects
of the Problem of Hepatic Cirrhosis."
APRIL 4th—GENERAL MEETING—"The Problem of  the-Prostate", Dr.  L. G.
It has been the practice in the past to hold a meeting of the Clinical Section of
the Vancouver Medical Association on the third Tuesday in each month. These meetings
were held at alternate hospitals and owing to this fact, often two Clinical meetings were
held at a hospital in one month. To overcome this situation a plan has been worked
out whereby the members of the Vancouver Medical Association are invited by the
various hospital Directors to attend their Clinical Staff meetings. These meetings will
be held as follows:
Second Tuesday—Shaughnessy Hospital
Third Tuesday—St. Paul's Hospital
Fourth Tuesday—Vancouver General Hospital
Notice and programme of these .meetings will be circularized by the Executive
Office of the Vancouver Medical Association.
All special and general meetings will be held in the Tuberculosis Institute Auditorium.
Publishing and Business Office — 17 - 675 Davie Street, Vancouver, B.C.
Editorial Office — 203 Medical-Dental Building, Vancouver, B.C.
The Bulletin of the Vancouver Medical Association is published on the first of
each month.       HH
Closing Date for articles is the 10th of the month preceding date of issue.
Manuscripts.must be typewritten, double spaced and the original copy.
Reprints must be ordered within 15 days after the appearance of the article in question, direct from the Publisher. Quotations on request.
Closing Date for advertisements is the  10th of the month preceding date of issue.
Advertising Rates on Request.
Page 126
m 1
Sifc 5
£'$!  ii
j|y For prolonged
effective blood levels
300,000 units  procaine  penicillin-G per cc in
oil with aluminum monostearate.
1 cc. TUBEX AND 10 cc. VIALS
For high initial and
prolonged effective blood levels
400,000 I.U. per cc. (300,000 units procaine
penicillin-G and 100,000 units soluble crystalline
penicillin-G in oil with aluminum monostearate.)
1 cc. TUBEX
Total   Population—Estimated
Chinese Population—Estimated
Hindu  Population—Estimated
Total deaths   (by occurrence).
Chinese  deaths j	
Deaths,   residents   only   §	
Rate per
1000 Pop.
(includes  late  registrations) S^S
January,  1950.
Male    j "     448
Female ! 1     442
INFANT  MORTALITY—Residents   only:
January, 1950
Death  rate per   1000   live  births     18.6
Stillbirths   (not included in above item) \ 5
Deaths under  1  year of age.
Scarlet Fever	
Diphtheria   Carriers	
Chicken Pox	
Measles '	
Whooping   Cough   	
Typhoid Fever	
Typhoid Fever Carriers
Undulant Fever	
Infectious   Jaundice     _
Salmonellosis  Carriers ~
January, 1950
Cases      Deaths
Dysentery  Carriers  J&.ljL-±±i
Tetanus 1--.—.
Syphilis 1 -	
Gonorrhoea     ;—■—
Cancer (Reportable)
January, 1949
Cases      Deaths
Page 127 PITUITARY EXTRACT (posterior lobe)
A sterile aqueous extract is prepared from the posterior lobe
of the pituitary gland, and is supplied as a solution containing
ten (10) International Units per cc.
Each   lot  is biologically assayed   in
terms of the International standard.
PURITY "   ;|§ '
The extract is prepared as a clear, colourless, -
sterile liquid with a low content of total solids. -
STABILITY    -        JI ■-. |j
Samples  of  each   lot  are tested  at definite
intervals to ensure that all extract distributed
is fully potent.
the Laboratories in packages of five, as well as twenty-five
1-cc. rubber-stoppered vials.
University of Toronto Toronto 4, Canada
We have received a letter from the B. C. Pharmaceutical Association dealing with
the matter of the sale of antihistaminic drugs. Owing to the widespread publicity given
to these drugs as preventives or even cures of the common cold, in the press and in
certain widely-sold magazines, the public has been demanding that they should be able
to buy these drugs at will. There are certain side-effects, not always mamiffesit, but
occurring with sufficient frequency to constitute a degree of danger—drowsiness, nausea,
and so on. Accordingly, these drugs have, temporarily at least, been put on the list of
drugs which may only be sold on prescription.
We feel that this is perhaps just as well, for several reasons. First, because of these
side-effects, which may lead, and in fact have occasionally led, as we understand, to
regrettable consequences. Secondly, because the value of these drugs, either to prevent,
or even mitigate, the miseries of the common cold, is no means proven. It does
seem, as some medical men have found, that taken early in a cold, there are sometimes
signed that the cold has been aborted—but whether this is post fyoc or propter hoc, is
not at all clear. And there is no evidence, as far as we know, that they have any curative
effect. If taken too long, or without proper supervision, their use may be a bad thing,
as other precautions against more serious involvement are overlooked and a condition
which, if treated properly, might have subsided, may become aggravated and lead to a
more serious illness. Thus we do not think that these drugs should be available for
uncontrolled use, nor be offered freely for sale by pharmacists until more accurate
knowledge is available.
As with so many other medical matters and methods of treatment, we have to put
at least some of the blame for. the present state of affairs on such publications as the
Readers' Digest, and other magazines which make a practice of going off half-cocked
over the newer medical work and discoveries. Almost invariably the articles that they
print are wildly enthusiastic blurbs, showily written, inaccurate and undocumented—
and we wish that there was some way of counteracting some of their effects. It is a free
country, we suppose, and anyone can write anything he wishes, but it is a pity that
we (and here we include such responsible bodies as the B. C. Pharmaceutical Association), do not have some way ourselves of obtaining publicity and giving information
which would be conservative, accurate and safe.
We can think back to other instances of this same sort of thing. One-night cures
for athlete's foot, which ruined at least hundreds of feet; dramatic articles about
thiouracil, the drug which was to end surgery in cases of toxic goitre; ballyhoo of
various sorts about penicillin, and the other antibiolics, each one of which was hailed as
the remedy to end all disease. There is an interminable list.
Writing for medical men, we do not need to labour this point, but it brings us
back again to the need for some better system of public relations, or rather, some system
—for at present we have none. It is a difficult question, and we doubt if it can be done
by us as a profession. Most of our efforts in that direction have been not only feeble,
but futile.
Perhaps a hint of the line we might follow has been given us by the recent actioa
of the Health Bureau of the Vancouver Board of Trade, which recently approached
the Vancouver City Council on the matter of hospital accommodation. It was, we
think, an admirable thing to do. It enlisted the support and backing of interests outside
the medical profession, and made it impossible for anyone to accuse us merely, of self-
seeking or self-advertisement. There are a score of matters of interest and importance, not
only to us, but to the public at large, which might well be dealt with in this way. Dr.
L. A. Patterson, the energetic chairman of this Health Bureau, and his fellows, are to
Page 128
tiira be commended for doing a good piece of public relations work. We hope that this lead
will be explored further—and we think that the whole community could benefit by
further action along this line.
Vancouver  Medical   Association
Honorary Treasurer	
Honorary Secretary	
Dr. W. J. Dorrance
_; Dr. Henry Scott
 Dr. Gordon Burke
 JDr. W. G. Gunn
-Dr. J. H. MacDermot
Library Hours: 1   *
Monday, Wednesday and Friday 9:00 a.m. - 9:30 p.m.
Tuesday and Thursday 9:00 a.m. - 5:00 p.m.
Saturday  . 9:00 a.m. - 1:00 p.m.
Recent Accessions
Authority and the Individual, by Bertrand Russell, 1949 (Historical and Ultra-Scientific \
Diseases of Children, vol. 2, edited by Paterson, D., and Moncrieff, A., 4th edition, 1949.
Essentials of Public Health, by Shepard, W. P.; Smith, C. E.; Beard, R. R., and Reynolds,
L. B.
Integrative Action of the Nervous System, by Sir C. Sherrington, 1947^
Office Gynecology, by J. P. Greenhill, 5th edition, 1949. ^
Regional Ileitis, by B. B. Crohn, 1949.
Renal Origin of Hypertension, by H. Goldblatt, 1948.
Sir "William Gowers, by Macdonald Critchley, 1949   (Nicholson Collection).
Sterility and Impaired Fertility—Pathogenesis, Investigation and Treatment, by Lane-
Roberts, C; Sharman, A.; Walker, K.; "Wiesner, B. P., and Barton, M)
Taylor's Principles and Practice of Medical Jurisprudence, vol. 2, edited by Smith, S.,
with legal aspect by Cook, W.'G. H., and the chemical aspect by Stewart, C. P.
Technique of Pulmonary Resection, by Overholt, R. H., and Lariger, L., 1949.
The following specialized journals are taken in the library of the Vancouver Medical
Association and copies can be obtained by members upon request to the librarian:
Eye, Ear, Nose and Throat
American Journal of Ophthalmology
Annals of Otology, Rhinology and
Neurology and Psychiatry
American Journal of Psychiatry
Archives of Ophthalmology ^
Archives of Otology
The Laryngoscope
Journal of Nervous and Mental Diseases
Archives of Neurology and Psychiatry    Journal of Neurology, Neurosurgery and
Journal of Mental Science ,
Journal of Neurosurgery
Journal of Neurosurgery
Public Health
American Journal of Public Health
Page 129
Mental Hygiene
Quarterly Review of Neurology and
Canadian Tournal of Public Health In response to our notice in the November issue of the Bulletin for copies of the
British Medical Journal, vol. 2, 1947, to replace our missing volume, all except five
copies have been donated by Dr. H. C. Rogers, of Nanaimo, B.C., and the following
is the letter sent to bim by the Library Committee:
February  15th,   1950.
Dr. H. C. Rogers, Medical Officer,
Nanaimo Indian Hospital,
Nanaimo, B. C.
Dear Doctor Rogers;
On behalf of the Library Committee may I thank you very much for your kindness
in donating to the Library the copies of the British Medical Journal for the second half
of 1947 in response to our request in the Bulletin.
It is extremely difficult for us to replace volumes when they are lost, especially
British publications, and your generosity in sending us these copies is deeply appreciated
by the Committee.
Yours very truly,
(signed) E. France Word, M.D.,
Secretary, Library Committee.
*c »<• *s" -r *£•
The five missing copies of the British Medical Journal ar£ for *August 23, September
6, October 11, 18 and November 1, 1947, and if any members have copies of these
issues together with the index to vol. 2, 1947, that they do not wish to keep, the
V. M. A. library at 203 Medical-Dental Building, Vancouver, B. O, would appftciate
receiving them.
May 29th to June 2nd, Inclusive—Hotel Vancouver
Dr.  A.  L.  Chute—Pediatrician—Sick Children's  Hospital  and Associate  Professor,
Banting and Best Dept., of Medical Research—University of Toronto.
Dr. Howard P. Lewis—Professor of Medicine, University of Oregon Medical School,
Portland, Oregon.
Professor J. Chassar Moir:—Nuffield Department of Obstetrics and Gynaecology,
Radcliffe Infirmary, Oxford, England.
Dr. R. L. Sanders—Associate Professor of Clinical Surgery, University of Tennessee,
Memphis, Tenn.
Dr.  Myer Wiener—Honorary  Consultant  Ophthalmology,  Bureau of  Medicine &
Surgery, United States Navy, Coronado, California.
Fee, $10.00.
Information, Dr. G. C. Large, 203 Medical-Dental Bldg.
Combined Medical Offices and Apartment to rent
Good residential district in Vancouver; Small premium for nucleus
of practice.
Phone: CEdar 6121 — Evenings.
Page 130
ji4{,i £','.
fill ill
♦''ft* IVk
1949 - 1950
 Dr. J. C. Thomas, Vancouver
Dr. Stewart A. Wallace, Kamloops
 Dr. H. A. L. Mooney, Courtenay
 Dr. J. A. Ganshorn, Vancouver
Honorary Secretary-Treasurer	
Immediate Past President Dr. F. M. Bryant, Victoria
We are publishing hereunder a few of the highlights of the Income Tax Regulations
as they affect niedicd men. A fuller account is being published in the March issue of
the Canadian Medidal Association Journal. Doctors would be well-advised also to
consult a competent accountant in making out their returns. His fees will be many
times repaid by Ins knowledge of the Income Tax Regulations.—Ed.
1. There should be maintained by the doctor an accurate record of income received,
both as fees from his profession and by way of investment income. The record should
be clear and capable of being readily checked against the return filed. It may be maintained on cards or in books kept for the purpose.
2. Under the heading of expenses the following accounts should be maintained and
records supported by vouchers kept available for checking purposes: hMM
(a) Medical, surgical and like supplies; f^S
(b) Office help, nurse, maid and bookkeeper; laundry and malpractice insurance
premiums. (It is to be noted that the Income Tax Act does not allow as a
deduction a salary paid by a husband to a wife or vice versa. Such amount,
if paid, is to be added back to the income};
(c) Telephone expenses;
(d) Assistants* fees;
The names and addresses of the assistants to whom fees are^paid should
be furnished. This information is to be given each year on Income Tax form
known as Form T.4, obtainable from your District Income Tax Office;
(e) Rentals paid;
The name and address of the owner (preferably) or agent of the rented
premises should be furnished (see (i) ) ;
(f) Postage and stationery;
(g )  Depreciation;
Effective with the taxation year 1949, a very significant change has been
made with respect to the method of computing annual depreciation charges
on capital equipment. This new method is termed Capital Cost Allowance
and is outlined in P.C. 6385, dattfed December 21st, 1949. All previour
information published to the profession pertaining to depreciation on both
medical equipment and motor cars and on residences used for both dwelling
and office purposes should be disregarded.
Only that portion, of the total automobile expense, incurred in earning
the income from the practice may be claimed as an expense and therefore the
total expense must be reduced by the portion applicable to your personal use.
Sundry expenses (not otherwise classified)—the expenses charged to this
account should be capable of analyses and supported by records.
Claims for donations paid to charitable organizations will be allowed up
to 10% of the net income upon submission of receipts to your Income Tax
Page 131 Office.   This is provided for in the Act.
The annual dues paid to governing bodies under which authority to
practice is issued and membership association fees, to be recorded on the return,
will be admitted as a charge. Registration fees for license to practice or other
registration or entry fees, and the cost of attending post-graduate courses
will not be allowed.
"Effective January 1, 1948, the reasonable expenses incurred by members of the
medical profession in attending the following Medical Conventions will be admitted
for Income Tax purposes against income from professional fees:
1. One Convention per year of the Canadian Medical Association.
2. One Convention  per year  of  either a  Provincial Medical Association or a
Provincial Division of the Canadian Medical Association.
3. One Convention per year of a Medical Society or Association of Specialists in
Canada or the United States of America.
The expenses to be allowed must be reasonable and must be properly substantiated;
e.g., the taxpayer must show (1) the dates of the Convention; (2) the number of days
present, with proof of claim supported by a certificate of attendance issued by the
organization sponsoring the meetings; (3) the expenses incurred, segregating between
(a) transportation expenses, (b) meals and (c) hotel expenses, for which vouchers
should be obtained and kept available for inspection.
None of the above expenses will be allowed against income received by way of
salary, since such deductions are expressly disallowed by statute.
ATOMIC MEDICINE, edited by Chas. F. Behrens, M.D., Captain M.C., U.S. Navy.
Director Atomic Defence.Division, Bureau of Medicine and Survey, Navy Dept.,
Bethesda, Md., pp. 416.  Thomas Nelson & Sons.
This book, written by a group associated with atomic research in the U. S. Army
and Navy, is an attempt to co-ordinate some of the problems of atomic energy related
to medicine that are unfamiliar to the medical profession. This book will be of particular
interest to the specialist in the field of radiation. The introductory chapters deal with
the physics of atomic structure, atomic piles, fission and the biology of ionizing radiation,
*nd although they are quite elementary, they could be even more explanatory for fuller
understanding by the average reader. The sections on the pathology of body irradition,
the hematology of ionizing radiation, atomic disaster planning and radio active isotopes
'hjjak- of more practical interest to the general physician and surgeon and are worth
perusing. gsr'i
The remaining sections deal with the technical laboratory problems in handling
active materials and are of more interest to the researcher in this phase of medicine.
—P. H. S.
MEDICAL DOCTOR as Executive Secretary of the B. C. Division
Canadian Cancer Society. Applications should be directed to:
The President,
B. C. Division,
Canadian Cancer Society,
2676 Heather Street,
Vancouver, B.C.
and should state qualifications, experience, and salary expected.
Page 132 k'V;S-
Professor of Medicine and Head of the Department of Medicine, University of Minnesota;
Chief of the Medical Service, University Hospitals, Minneapolis.
MARCH 27th - 31st, 1950
8:30 to 10:00 a.m.—Ward Walk, Ward
"A". Dr. D. S. Munroe, Dr. T. K.
MacLean, Dr. H. Scott.
12:15 p.m.—Surgical Clinic. Dr. J. R.
Neilson, Chief, Lecture Hall, Main
2:00 p.m.—Conference with the Resident and Assistant Residents re material for clinical meetings.
6:30 p.m.—Private Dinner.
8:30 to 10:00 a.m.—Ward Walk, Ward
"B". Dr. W. W. Simpson, Dr. J. C.
Moscovich, Dr. J. A. G. Reid.
10:30 to 12:00 noon—Staff Meeting of
Cancer Institute. Arranged by Dr.
A. M. Evans. Conference Room,
Cancer Institute.
12:15 p.m.—Luncheon. Faculty Club,
University of British Columbia. Arranged by Dr. M. M. Weaver, Dean of
the Medical School.
2:15 p.m.—Clinical Conference. Dr.
Cecil J. Watson. Subject: "Pulmonary Infarction." Lecture Hall, Main
6:00 p.m. — Dinner with Executive
Committee, Vancouver Medical Association, Salon "E", Hotel Vancouver.
8:15 p.m.—Special Meeting, Vancouver
Medical Association. Dr. Cecil J.
Watson. Subject: "Some Fundamental and Clinical Aspects of the Problem of Hepatic Cirrlosis." Auditorium, British Columbia Institute of
9:00 a.m. to 10:00 a.m.—Clinical Pathological Conference, Chairman: Dr. R.
E. McKechnie, Pathologist: Dr. H.
K. Fidler. Discussion opened by Dr.
Cecil J. Watson. Lecture Hall, Main
^ji Building.
Page 133
Wednesday, March 29th—Continued:
10:30  a.m.—Medical Clinic.   Chairman:
Dr.   M.   M.   Baird.     Lecture   Hall,
Shaughnessy Hospital.
11:30 a.m.—Pathological Conference.
12:30   p.m.   —  Luncheon,   Shaughnessy
2:15   p.m.—Clinical   Conference.    Dr.
Cecil J. Watson.   Subject: "Pigment
Metabolism."     Lecture    Hall*   Main
Building. ^p
6:30 p.m.—Private Dinner.
9:00 a.m.—Medical Clinic, Dr. Cecil J.
Watson, Visiting Chief. Lecture
Hall, Main Building.
10:30 to 12:00 noon—Joint Clinical
Conference, Department of Tuberculosis, Department of.Venereal Disease
Control, Lecture Hall, Main Building.
12:30 p.m.—Luncheon. Health Centre
for Children. Arranged by Dr. Donald Paterson.   Afternoon free.
8:15 p.m.—Special Meeting, Attending
Staff, The Vancouver General Hospital. Dr. Cecil J. Watson. Subject:
"The Problem of the Bedside Diagnosis
of Jaundice and Liver' Disease."
Chairman: Dr. D. S. Munroe. Auditorium, British Columbia Institute of
9:00 a.m.—Paediatric Clinic, Dr. J. R.
Davies, Chief. Lecture Hall, Main
10:00 a.m.—Hematology O.P.D. Clinic.
Dr. A. M. Johnson, Lecture Hall,
Main Building.
12:30 p.m.—Luncheon.  Seniors, Attending  Staff,  Department of  Medicinets
Board Room, The Vancouver General
2:30 p.m. — Concluding Lecture for
Resident and Interne Staff. Dr. Cecil
J. Watson. Lecture Hall, Main Building. QUID PRO QUO IN MEDICAL EDUCATION
Dean of Medical Faculty
University of B. C.
The Vancouver Medical Association last year entered upon its second half century
of existence. Its first fifty years have been filled with distinguished accomplishments—
in the service of the community, the medical profession, and the entire Province of
British Columbia. Last year's occasion called for well-justified jubilation and it is the
speaker's personal loss not to have been at that time a member of this group and to
have shared in the happy proceedings. It has been possible, however, to share belatedly
in these pleasures, through the commemorative booklet which was issued as part of the
It was gratifying, indeed, to note the selection of the epitaph on Sir Christopher
Wren's tomb in St. Paul's Cathedral to grace the cover of the Golden Jubilee volume,
"Si Quaeris Monumentum Circumspice"—If you are seeking a monument, look around
you—and this called to mind one tribute to the intellectual energy and scientific curiosity
of this great man which may not be known to all here and which has some bearing
upon the development of modern practice. It was Sir Christopher, in collaboration with
Boyle and Wilkins, who first injected opium and other medicinal substances into the
veins of dogs (1658). This pioneered, if you will, the application for human benefit
of the knowledge of the circulation of the blood which has been elucidated by William
Harvey but a few years previously. Well within a decade, the first successful intravenous
injections were to be made in man. Sir Christopher's venture into biologic science and the
resulting contribution to basic knowledge in medicine should be remembered with no
less respect than his design of the great Cathedral, the fifty churches, and the many
public buildings of London.
Many features of the Jubilee booklet have stirred me to respectful contemplation
of the history of this Association. Among the names of its early members, I found that
of the late Dr. Glen Campbell whose courtly welcome to medical circles in British
Columbia the speaker will never forget. It was shortly after my arrival in Vancouver
last summer that I received a telephone call from Dr. Campbell to suggest that he pay
a call upon me in my office at the University. With no knowledge of the doctor's age,
his health, or the distance he would have to come across the city for this visit, I acquiesced. In retrospect, it is obvious how far more appropriate it would have been had I
visited Dr. Campbell at his home. The doctor chatted for an hour or so, mentioning in
casual fashion that his health had not been of the best, but concentrating upon what I
now realize to have been a special message* he wished to convey. It was that the physicians
of his generation had never allowed the vision to grow dim that Vancouver should one
day be an outstanding centre for medical education in Western Canada. Like so many
ideals, the cherished ambition of such medical leaders as Drs. W. D. Keith, H. W.
Riggs, W. D. Burnett, R. E. McKechnie, P. McLennan, H. H. Mcintosh, and L.
McMillan, as well as Dr. Campbell, had had setbacks over the years. On one occasion,
the boat was missed completely, although this is not meant to detract from the well-
earned good fortune of our neighbours to the East who were able to start their Faculty
of Medicine as a result.
But Dr. Campbell wasted no time in lamenting what might have been. He was
concerned solely that the Medical School of the University of British Columbia shall
proceed to make up for lost time and shall rapidly earn a widespread reputation for the
quality of the physicians it produces, the excellence of the research which must be
carried on in its laboratories, and the contributions it should make in improving medical
care and public health throughout this area.
I envy you the opportunity many of you had to know Dr. J. M. Pearson, whose
interest to have a vital Association was so great that he went from office to office of the
handful of doctors of Vancouver, enrolling them as members, and enlisting their participation in the scientific programmes which are essential for the professional and intel-
Page 134
I lectual growth of a medical society. The mental picture of Dr. Pearson, "trudging
from doctor's office to doctor's office," reminds me, indeed, of the description Dr. Harvey
Cushing has given us of Dr. William Osier's visits to the old Blockley Hbspital during
his Philadelphia period. As we know, Sir William never missed the opportunity to
participate in a post-mortem examination. Eschewing the street cars and without a
personal carriage during that period, he would walk considerable distances across Philadelphia to attend these functions at the Hospital and to teach his students at the autopsy
Interesting indeed it was to me to discover that Dr. Osier subscribed $100 to the
fund for a medical library in Vancouver. This was being planned for a city which he
was never to visit. It is evidence, not only to his generosity to his fellow physicians, but
also to his oft-repeated conviction that without "observing, recording, and tabulating,"
and withovit the opportunity to learn through medical writing about the similar efforts
of other investigators, medicine cannot progress. Our hats should be doffed to Dr.
W. D. Keith who is with us tonight. He assisted Dr. Pearson in his negotiations with
other medical libraries for a nucleus of bound volumes and in his approach to potential
contributors to the library fund.
It would require too much time to pay adequate tribute to the spirit of seryice
which prompted the founding, in order, of St. Paul's Hospital, the Vancouver Treneral
Hospital, and of the other hospitals in this area, or to the services of the many far-sighted.
medical men of Vancouver, other than those I have passed over too fleetingly.   In some"
cases the lives and works of the latter are perpetuated through their physician-sons who
are practicing in this city..
In the fifty years or a little more during which Vancouver has grown from a town
of 24,000 inhabitants to an impressive city of nearly one-half million people, a technological age has flowered. In 1900, a gainfully occupied adult obtained 10 percent of the
things he required through physical labour, 50 percent through the work of domestic
animals, and 40 percent through the output of machines. It has been predicted that by
1960 only 3 percent of the products of men in progressive nations will be through their
physical labour, 1 percent will be obtained through the work of domestic animals, and
96 percent will be the output of machines. With all the changes in our modern way of
life, the profession of medicine has maintained its pre-eminence in the public mind.~
Last year a study was published at the University of Minnesota entitled, "Changes
in Social Status of Occupations."2 Maethel Deeg and Donald Paterson questioned a
group of University students in a fashion similar to that reported by a previous author
twenty-one years earlier. They chose a sample consisting of 475 studentsHfrom various
colleges and divisions of the University, and from local high schools. The results were
sufficiently interesting to justify reproduction here:
Comparison of Social Status Ranks of Twenty-Five
Occupations Obtained in 1925 and in 1946
Rank Order
(counts, 1925)
Banker |  1
Physician  2
Lawyer ||  3
Supt. of Schools 1  4
Civil Engineer  5
Army Captain.—  6
Foreign Missionary ,.—- 7
Elem. School Teacher 1 ... 8
Farmer :  9
Machinist | . _^ 10
Travelling Salesman  11
Page 135
Rank Order
Deeg and
16 Grocer  12 13
Electrician j  13 11
Insurance Agent  14 10
Mail Carrier _ _  15 14
Carpenter I 1  16 15
Soldier |  17 19
Plumber I j  18 17
Motorman I  19 18
Barber I  20 20
Truck Driver _.__  21 21.5
Coal Miner  22 21.5
Janitor  .  23 23
Hod Carrier ; 24 24
Ditch Digger  25 25
The fact seems clear that more of our young people aspire to careers in medicine
than in any other vocation.
What are the opportunities for fulfilment of these aspirations? The situation is
well-known to all present. Each year in Canada and the United States there are something over one hundred thousand applications made for admission to the medical schools.
This past fall (1949) there was 88,810s applications submitted to the medical schools
in the United States. Not less than 10,000 applications were filed in Canada. These
applications represented about thirty thousand individuals, owin£ to duplicate applications. There are approximately seven thousand places to be awarded to first-year students
in medicine in the two countries. This means that about one out of four applicants
could be admitted. Of the disappointed three-fourths of the applicants, a minority,
perhaps ten percent, may eventually achieve admission at a later date.
The situation is far different from that which existed-even just before the wfer
Dr. J. H. Means,4 Jackson Professor of Clinical Medicine at Harvard Medical School,
recently reminisced in the course of a guest lecture about conditions when h)e entered
upon his medical studies. "To get into a medical school, all you needed to do was to
procure an A.B. or S.B. degree,* and then go around the day the school opened, and sign
on. Even on that easy basis my class at Harvard Medical School had only ninety-six
members. At the present time there are here (New York University College of Medicine)
several thousand applicants for one hundred and twenty-five places." The same situation
exists at McGill University and the University of Toronto Faculties of Medicine, as
we are well aware.
It might well be thought time to consider whether a greater output of doctors
should be guaranteed through the opening of additional schools of medicine in Canada
and the United States. It is my understanding that considerable support has developed
in England for offering a medical education to each and every aspirant who has passed
the necessary preliminary examinations. There is no denying that there is a shortage of
..physicians for- some tasks and in some localities. The acute discrepancy between supply
and demand has been alleviated considerably since returned medical officers have resumed
or have entered the practicing profession. However, I am not unmindful of the statement of a former Dean of Medicine5 in the States about fifteen years ago:
"The question of overproduction of doctors is of the greatest importance to medical
students, to the medical profession, to the maintenance of standards of ethical practice
and to the public welfare. I contend that there are already too many doctors, even if
they were properly distributed and even if their services were available to all people,
neither of which contingencies is true nor is likely to be true under modern conditions.
If it is claimed that competition is the life of trade, I retort that competition may be
the death of a profession."
To return to the approximately seven thousand successful applicants to our medical
colleges, a heavy responsibility rests upon the admitting officers of these institutions.
There is the obligation to make the wisest judgement possible about who is properly
possessed of the qualities desirable in a physician, and there must be a thorough inquiry
Page 136
Iti into the strength of motivation for a medical career, stamina, and physical capacities,
as well as the scholastic records of the applicants. From the standpoint of the borderline
candidate, the economic implications of choice are inescapable. Of the two individual
who may appear before the Screening Committee when the last place is to be awarded,
the successful applicant is likely destined to earn a better livelihood than will his unsuccessful classmate. Yet, which will be the more generous person with his professional
services, and will most, faithfully serve the general welfare of his community? Which
will have, in the words of Robert Louis Stevenson, "be thought to have shared as little
as any in the defects of the period, and most notably exhibited the virtues of the race?"
A medical education is expensive to provide, as Dr. F. Cyril James,6 Principal and
Vice-Chancellor of McGill University, pointed out to the assembled Deans of the Medical
Faculties of Canada recently. The cost per year per student to the medical colleges
of the United States ranges from $735 to an almost unbelievable $9,500,. according to the
Chancellor. This is quite apart from whatever the student pays in fees. The average
cost of training a doctor in Canada is somewhere between the extremes which have been
cited, and, in all probability, the Canadian medical colleges apply from their own funds
approximately three dollars for every dollar which is paid in by the registrant in
medicine. The medical course costs the Province and the University from one-third more
to several times as much as the education of a student in law or engineering, ^nd» from
twice to twenty times as much as it does to provide a four-year course in science or the
arts. The medical graduate today leaves his medical school obligated to society, not alone
for the trust and respect to be accorded him, for the relative financial security which
will be his lot, but also for the financial outlay which was made in his behalf. This
will be even truer when, as is almost inevitable, Federal aid to the medical colleges
becomes a reality.
I have a reprint from the pen of a lawyer, entitled, "Justice and the Future of
Medicine,"7 and I have read it a good many times since the article first appeared. My
interest in this lawyer's opinion is not especially related to the fact that he was one of
"the small group of wilful men" who instituted the anti-trust suit of the United States
against the American Medical Association. This occasion, as many in this room will
recall, was a boycott by the Medical Society of the District of Columbia of certain
physicians employed under a group health plan, and the resulting trial reiterated some
legal principles concerned with medical practice.
The Society had expelled one physician, forced a second to break his contract, and
had denied hospital facilities to their patients. There was not any question of medical
orthodoxy or of medical competence. As Mr. Wendell Berge stated, in giving this paper
before the American Urological Association on June 21st, 1944, had theNquestion been
a choice between two out of many ways of organizing medical service, it might have
been hard to make a proper decision about which was the more desirable. The issue
was simply between two rival plans for bringing doctors and patients .together. The
tactics of the one group were illegal in trying to prevent the other group from proving
or disproving its case.
In the words of Mr. Berge: "As the case went forward, this notion of medicine as
the instrument of the common health was the Government's mainstay. Again and again
we had occasion to recite the public character of the physician's office. There was a
time when an association of doctors acted with the delegated authority of the State
itself. The Royal Society of Physicians held a charter from the English Crown which
conferred upon it the right to license, to discipline its own members, to search for and
to seize illegal drugs, and otherwise act as a corporate body to secure the common
health. When, much later, Congress issued a charter to the Medical Society of the
District of Columbia, it described its rights and obligations in words almost identical
with the charter of the Royal Society. However, it was careful to withhold from the
new medical society all economic power over its members. It refused to confer upon
it authority to fix any schedule of fees for service. And to clinch the matter, it stated
that the privilege accorded was for scientific and education and for no other purpose
Page 137 These are times which are trying to all. It is most difficult to cultivate and maintain the equanimity and imperturability which were prescribed for the profession by Sir
William Osier. The physician is a public servant, by tradition, by legal definition and
through the means by which he obtained his professional education. His is the initiative
to give constructive guidance in the future arrangements for payment of medical care,
and he must accept it. Because of tradition, he has hereto shunned such subjects as
mcdicial economics. Evidence is now at hand that physicians have the ability to provide
the right answers on large, comprehensive projects of medical care as contrasted with
individual physician-patient financial relations.
It will be a remarkable milieu into which our young doctor will graduate five years
hence, compared with that which confronted his father. He will come upon an economic
scene in which it will take the man in the street five minutes or less to earn a pound of
bread, or thirty minutes or so to earn a pound of beef, according to present indications.
In this he will be quite fortunate as a resident of Australia, Canada, or the United States,
since nowhere else in the world will his advantage in breadwinning be so favourable. To
be sure, he will have to work two or three hours out of the day to pay his taxes, but
this situation he can view with a certain equanimity, inasmuch as a considerable portion
of his payment will be a lien against the future productivity of his country when he
retires, is too ill to work, or must leave behind him dependents who cannot fend
effectively for themselves.
However, Mr. Average Citizen will have other problems to deal with besides his
family's budget for food, shelter, clothing, taxes, insurance and recreation. An
important bearing upon the future of the practice of medicine will be how many hours
the man in the street has to work to pay for a visit to his doctor's office, to consult his
specialist, or to have an operation. Something of this fact was contained in the section
on the cost of medical care in your Jubilee volume. It is certainly true that a home, or
office, or hospital call upon a sick patient is ever so much more valuable to that individual
than it usel to be, and that the physician's income, compared to income in the trades or
«ven the more lucretive white collar occupations, is not disproportionately greater than
it was a generation ago. Irrespective of this, it is most important that here are many
people, totalling, perhaps, one-third of the population, who do no command a high wage
scale or a good salary. One of their greatest needs is for an orderly method of payment
for medical care through application of the insurance pinciple. It is the resolution of
the problem of providing medical care for ,this group that one needs firmly to set aside
much of the romantic quality which has been stressed by those who, in the past, have
dealt with the history of medicine.
You are quite familiar, I am sure, with the series of monographs, prepared by the
New York Academy of Medicine, entitled "Medicine in the Changing Order." This
series, recently completed and consisting of fourteen titles, has dealt with such subjcts
as hospitals, health insurance, medical research and medical education. It is from
"Medical Practice in the Perspective of a Century"8 that I quote one statement found
in the preface.
"When the heroes of medicine and the miracles of its achievements are treated outside the frame of their contemporary world, they must perforce appear like meteoric
phenomena. Moreover, such disarticulated treatment is a serious handicap to the earnest
student who seeks in the story of the past illuminations of the present and some guidance
to the future. What is wanted is not a romantic histroy of medicine, but rather an
historical exposition of the reciprocal interplay between the social, technological, and
economic forces and medicine."
A feature of recent medical history which must inevitably be stressed to the medical
students in our Faculty of Medicine is the remarkable development of the facilities to
properly distribute medical care and to arrange to pay for it. The physician-president
of one of our neighbouring universities has summarized the principle which lies behind
this added subject matter in the medical curriculum as follows:
"Medicine, with its age-old concern for the sick—the poor as well as the rich, the
weak as well as the strong—has been an influence for good surpassed only by religion.
Page 138
m The services of medicine, like those of religion, have been largely personal.  While there,
will always be need for personal services, medicine of the future, if it is to progress as a
social as well as a biological science must broaden its outlook and adjust its education
programme accordingly."
1. Vancouver Medical Association Golden Jubilee, 1898-1948, Commemorative Volume under direction
of the Golden Jubilee Committee.
2. Deeg, Maethel E., and Paterson, Donald G., Changes in Social Status of Occupations. Occupations,
January,  1947, Page 205.
3. Guthrie, William S., Summary of Applications Filed for Admission to the Professional Colleges of
Medicine, Dentistry and Veterinary Medicine in the Years 1947, 1948 and 1949. Ohio State University,
June 14th, 1949.
4. Means, J. H., Where Are "We Going and What Do We Have To Do.   Diplomate 21:109, 1949.
5. Lyon, E.P. Sanws Sing Before They Die. Proceedings Annual Congress on Medical Education,
Chicago, February 17th, 1936.
6. Report at the Seventh Annual Meeting of the Association of Canadian Medical Colleges, September
16th and 17th, 1949.
7. Berge, Wendell.   Justice and the Future of Medicine.   Public Health Reports  60:1,  1945.   '      »
8. Stern, Bernhard J.   American Medical Practice  In The Perspectives of a Century.    1945.
Dr. J. C. Thom!as, Dr. Frank Turnbull, Dr. McCoy.
Given Before the Vancouver Board of Trade.
February 15th, 1950
Mr. Chairman, members of the Board of Trade, and Guests:
As the first speaker on this panel today, may I express our appreciation of the
honour you have done us by inviting the medical profession to come here and discuss
what is in reality our mutual interest in the subject of prepaid health care. If members
of our profession seem to be somewhat reluctant to appear as guest speakers, please
remember that it is due to a tradition in our code of ethics which na^ looked with
disfavour upon personal advertising by doctors. However, I can assure you that the
speakers today appear before you without fear of violating these traditions.
It is our purpose to commence with a broad outline of the various kinds of prepaid
health care which have been introduced and continue with a more detailed discussion
of hospital insurance and prepaid medical care. Some plans are referred to as a matter
of history to show the gradual development of our present situation.
In the early days of this province during the years of development and construction,
the need for health services was recognized as a vital part of each project. The camp
hospital and company doctor were and still are, a part of any plan for development in
our own areas. Often this was purely a company project at the beginning and the
cost was met by both company and workmen contributing. As the community grew,
the hospital was taken over and the doctor looked after the employees and their dependents on a contract basis, the remainder being private patients. Premiums were collected
by employee associations or by payroll deductions according to some mutual agreement.
During the early thirties when voluntary hospital boards were faced with mounting
deficits, due to poor collection of accounts, various communities adopted a scheme
of voluntary prepaid plans to obviate these deficits. Blue Cross entered this field selling-
coverage to employee groups with certain restrictions in the length of time benefits
could be obtained and in the extent of coverage. Rising hospital costs made it necessary
to increase premium rates and restrict services paid for by the plans.
About the same time contracts were made by employee groups with certain doctors
for prepaid medical care.  There was a wide variation in the rates charged and in the
Page 139 degree of coverage. Most of these plans were able to operate because they contracted
with one or more of the local doctors and only covered acute conditions. Elective work,
industrial accidents, chronic diseases and those diseases treated by government services
were excluded or paid for by the insured at agreed rates.
Casualty Insurance carriers expanded rapidly by offering sickness and non-industrial
accident coverage together with loss of time benefits. You are all familiar with the
history of these plans and their operations. The benefits offered and the too-often
disputed claims due to waiting periods and exclusions were some of the reasons for
government enquiry into their operations.
Meanwhile in 1936, the provincial government introduced a health insurance bill
under which the terms of service were never agreed to by the doctors. As a result of
this disagreement the bill was not proclaimed nor put into effect.
Today in British Columbia we have in operation several government sponsored plans
for prepaid health services. The Workmen's Compensation Act has provided medical
and hospital care and time loss, benefits for injured workmen for over 3 0 years. This,
as you know, is financed by yearly assessments according to experience rating and is
supported entirely by industry through employer and employee contributions.
The Department of Veterans Affairs provides medical and hospital care for veterans
according to certain rules for eligibility laid down by the Department. This is a department of the federal government paid for from federal tax revenues.
Similarly the Department of Indian Affairs provides for the care of Indians. Both
medical and hospital care are provided by contracting with voluntary hospitals and
physicians in private practice to do this work usually on a part-time basis.
The Department of Health has provided treatment and diagnostic centres for
venereal diseases, tuberculosis and cancer. These services began as a public health
measure in the case of V.D. and T.B. to control spread of infection, thereby hoping to
eliminate them. Today we f\nd cancer clinics being sponsored by the B. C. Cancer
Foundation and financed by public subscription and government grants. Where the
patient cannot pay for necessary diagnostic investigation and treatment, these services
are provided in the same manner as for those who can.
Also we have the public health services provided by our provincial and local boards
of health. Each unit is staffed by doctors, nurses, social workers, sanitary inspectors,
who make sure that the people in their respective communities are protected from such
health hazards as communicable diseases, contaminated food and water supplies, sewage,
unsanitary housing, contamination of our beaches, poor nutrition. This is called preventative medicine. This service carries on an active campaign to educate the people in all
health matters in the home, the school and in industry.
There is also the tremendous problem of mental illness which is handled largely
by the provincial hospital service. Custodial care and treatment facilities are provided
by the provincial government as well as travelling clinics for diagnosis. One gets a
better perspective of the size of this problem when we realize that there are as many
mental hospital beds in Canada as there are general hospital beds.
The most recent plan in providing prepaid medical care is the Social Assistance
Medical Service. By agreement government pay an annual per capita grant to the
medical profession of B. C. for each person receiving any form of social assistance. The
payment for service is carried out by the doctors on a fee for service basis with prorating
of accounts because the capitation fee has been adequate to pay only 65% of the cost
of services rendered. This you will agree is a distinct improvement in the medical care
of the less fortunate whose pride too often kept them from accepting anything but
the most urgent services in the past, although the medical profession has always accepted
this type of care as a part of its responsibility in every community.
This brief description of many forms of prepaid health care will show how far
we have progressed along the road to socialization of health care. One hears the word
"free" used very frequently with regard to health services.   This is very misleading;
Page 140 for we must all realize that these services were not given but merely prepaid either
by the direct beneficiaries, the employer, or from government funds.. The government
is not a producer. The government cannot give you anything. The government can
only give back to you that which it first took away, money is spent in the process of
taking it away, and money is spent in the process of giving it back, so you always
get back less than you gave. Cost is not the only thing we must consider. There has
been a definite doctor-patient relationship which is a vital part of successful medical
care. The introduction of a third party threatens this. In order to control costs information must be supplied to the party paying the bills or some restrictions may have to be
placed on the free choice of doctor by the patient.
Many of you are f amiliar with the statement of policy adopted by the Canadian
Medical Association.   I quote in part:
"It is recognized and accepted that the community's responsibility in the field of
health includes responsibility not only for a high level of environmental conditions and
an efficient preventive service, but a responsibility for ensuring that adequate medical
facilities are available to every member of the community whether or not he ,can
afford the full cost." -J^s
"Accordingly,  the C.M.A.  will gladly cooperate in the preparation of detailed ..
schemes which have as their object the removal of any barriers which exist between the
people and the medical services they need."
"Th C.M.A. has approved the adoption of the insurance principle. '
Applying this to our present situation, I should like to point out that we believe
the medical profession of British Columbia has cooperated and will continue to cooperate
with the people in our earnest endeavour to bring health services to every member of
the community.   Let us proceed by evolution rather than revolution.
A Sister in one of our large provincial hospitals recently remarked that it is easier
to get into heaven than to find a.hospital bed for a patient with chronic disease. The
reverend Sister did not realize the difficulties that some of us might" experience with
admission standards at the Pearly Gates. But she did make her point. Hospital beds are
at a premium.
In the 1930's it was standard hospital practice to regard 80% becl^occupancy as
a full house. Twenty persent of the beds were kept empty to allow an easy turnover, and
to cope with major disasters. Nowadays, bed occupancy starts at 100%. Extra beds
are the rule in most wards.   Some of our hospitals have beds in the corridors.'
The responsibility for general hospital services is divided between provincial and
municipal authorities. In theory the division of responsibility is well defined. In practice it allows a great deal of "passing the buck."
Prior to the introduction of Hospital Insurance the position was reasonably clear.
Private groups or municipalities initiated plans for all new general' hospitals. They
sometimes obtained large grants for construction and equipment from the Provincial
Government. The expenses of operation were a private or municipal responsibility.
Most general hospitals had an annual deficit. The city of Vancouver paid approximately
one-half million dollars annually to cover the deficit of the General Hospital during the
middle forties. The rates that were paid by the patients did not cover the cost of operation by that much.   Tax money, collected by the City, made up the difference.
When hospital insurance was introduced the rates were advanced to their true
level. The Hospital Insurance Fund now pays the hospital the full cost of operation at
ward rates for all insured patients. Non-insured patients pay the new full rate . Patients
in semi-private or private rooms pay enough to cover the extra service that they receive.
So, in theory our hospitals are now solvent. The money for their operation still comes
out of our pockets, but travels a different route.
This is the over-simplified point of view that the Minister has advanced on frequent
occasions.  He has taken great pains to point out that the Hospital Insurance Fund was
Page 141 only set up to pay the bills of those who can obtain hospital services. With injured
innocence he disclaims responsibility for chaos that has developed because of increased
demand for services that were already over-strained. Patients who suffer inconvenience
or interminable delay cannot be blamed for assuming that the Provincial Government
which initiated this project should accept responsibility for the provision of service.
Unfortunately, for both the government and the public, there has been a precipitate
increase in the cost of hospital service during the past few years. Most of this increase
in cost has resulted from rise in wages, cost of food, etc. Efforts to control the rising
costs have intensified a trend that seemed inevitable from the start, i.e. more and more
direction and control of hospital activities from H.Q. in Victoria. Indeed, the Minister
has recently threatened, by public speech, that unless certain Hospital Boards mended
their ways, the government would be forced to take over—a sort of protective invasion.'
And now the Plan is in trouble. 'Experts' have been called in, to re-organize administrative activities and advise about future management. A new commissioner has been
appointed. I suggest, with due respect to the Minister, that this would be an appropriate
time to reconsider the conception and structure of the Act itself.
Some of the shortcomings, and also some of the potential advantages, of the
Hospital Insurance Act, become apparent if one accepts it as an experiment in government. Universal contributory hospital insurance with premiums that are estimated to
cover total costs, is a unique venture. The Saskatchewan scheme is universal and contributory, but from the beginning the Saskatchewan government has contributed an
unknown amount from the Provincial Treasury. There are State Hospital Insurance
schemes in other countries, but standards of living, methods of hospital practice, etc.,
are so different that no exact comparison can be made. It is obviously in the best interest
of everyone to work out a plan that fits the local scene. In that sense—the sense of
being untried and unproven, we may regard the Act as an experiment.
The prelude to any successful experiment is a question or a series of questions. One
question that would have suggested itself before this experiment is: "How far can
Hospital Insurance be carried before it becomes too great an economic burden to the
community?" Dozens of other pertinent questions could be framed but let us stop at
that one for a moment.
There is hardly any practical limit to the amount that could be spent on hospital
facilities and operation if unlimited funds were available. Without great difficulty any
enthusiastic hospital planner could set up plans that would double the present cost, and
a really imaginative fellow could go much further.
Let us take just one more question from the pile: "How far can one carry increased
centralization of authority in Victoria without losing the reservoir of voluntary, valuable
service that is now represented by local boards of management?"  Well, how far?
I have brought forward these two questions to emphasize that the introduction
of universal Hospital Insurance.has created a number of new and difficult community
problems. These problems have been obscured during the first year of operation, because
public and official attention has been focused on inefficiencies of business administration.
It is apparent that the new Commissioner and his two senior assistants have been chosen
to achieve business efficiency, and to that end we wish them every success. Efficient
administration, by itself, will not accomplish the full purpose of the Act, nor prevent
it from foundering again.
Hospital Insurance starts with the simple premise that pre-paid insurance against
the costs of hospital care is in the best interest of all. But its application requires the
development of policies and the continuous reshaping of policies that are complex and
that have wide implications. One would have to be an incurable optimist to expect that
a solitary Commissioner could direct this vast business, and at the same time wisely
interpret the desires and needs of the community into flexible and workable policies. Our
late Commissioner did his level best, but the odds against him were too great.
We presume that administration under the direction of a Commission has been
considered, but there has been no public or parliamentary discussion of this alternative
Page 142
I of which I am aware.  Administration by commission would not offer a panacea.   Success
would depend, in part, on how the Commission was set up. |pf|
I suggest that our Hospital Insurance would be better under the direction of a non-
political, part-time Commission, representing those who pay for hospital benefits, and
those who provide the service. The Commission would have access to all pertinent information. They would develop and reshape policies. The chief administrator would
come to them with his problems and be buttressed by their support. The members of
such a Commission would serve for not more than three years. They would be chosen
by virtue of reputation already established as those best fitted to contribute constructive
thinking to an important community problem.
No individual or group can hope to make universal contributory Hospital Insurance
pay its way or to satisfy every demand for service.   By having a part-time Commissics
to share the responsibilities and criticisms, it might be made workable.
In the approximately twelve minutes allotted to me to discuss prepaid medical care-
it is impossible to go into very much detail. However, I shall very briefly attempt to
show you what principal changes have occurred in the last half century in medical care,
making it, as a result, more costly and hence bringing the necessity for some type of
medical care budgeting.
I shall then briefly outline various types of prepaid medical care plans which are
or have been available in British Columbia and shall conclude by giving you a brief
outline of Medical Services Association, the plan sponsored by the doctors of B. C.
on a non-profit basis—to give you prepaid medical care.
I would like to mention to you briefly some of the problems that have arisen in
the economics of medical care. Practically all of these problems have come from the
fact that medical care has increased in quality so rapidly during the first half of the
present century—and this great improvement in the quality has brought; with it new
and weighty problems in the matter of payment for this medical care,
A first well-known factor is that owing to modern advanced methods of treatment
people live longer—and are frequently ill for a longer period of time—e.g., twenty
years ago when a man had a ruptured appendix he very frequently was dead in two or
three days—that was not very expensive. Today, with penicillin, etc^and modern
methods of treatment, he practically always lives but frequently it is a long illness
and thus needs greater medical costs.
Another of the principal ways in which this cost has risen is in the cost of diagnosis.
Forty to fifty years ago there were very few diagnostic aids to apply to a patient other
than those the doctor applied himself with his hands, eyes and ears. Perhaps a blood
count was done or a broken bone X-rayed. X-ray was just coming into its own and
was not very widely used. There were few precise techniques. Very little thorough
clinical laboratory work was done. The cost of clinical diagnosis thirty years ago was
low and added very little to the cost of medical care of the patient.
Another important item in causing an increase in cost is doctor utilization. Thirty
to forty years ago a patient called a doctor only when all their own methods of treatment
had failed and as a result many people saw a doctor only once or twice a year—or less.
Today in many places, as worked out on a statistical basis, an average of one in ten
people see their doctor each month. This is partly due to the fact that doctors are more
plentiful, as during the war years this doctor utilization ratio was considerably lower.
It should be remarked that in the treatment part of the doctor's services there has been
relatively little increase in cost—surprisingly little considering the general increase in
prices and the devaluation of the dollar. The fees charged by doctors today—by and
large—are not much greater than they were twenty to thirty years ago, although their
expenses are doubled. People are prone to think in terms of the over-all cost of an
illness,—e.g., hospital, plus doctor's services, plus diagnostic aids, etc.—and they do not
Page 143 dissect the various components of the cost. Hence doctors are suffering in public
relations because of the over-all increase in the cost of medical care, of which their
own increase is but a very small and unimportant part.
A fourth problem is the increasing demand by patients for specialist care, whether
necessary or not. Specialists, by and large, have trained for a longer period of time in
one particular field and as a natural consequence their fees must be higher than those
of the general practitioner. People are prone to say, "I have a pain in my side—it may
be my appendix. I had better see a surgical specialist in case it has to be removed."
However, it may be a kidney infection that he has or a pleurisy—then the surgeon has
to refer the patient to another specialist and two or more specialists' fees have then
been incurred instead of going to their general practitioner in the first place who might
have saved the extra fees.   This adds to the over-all cost of medical care.
Bearing these four factors in mind, where, as you can understand, the human
element, which varies greatly, plays a large part—one sees some of the complications
facing the setting up of a prepaid medical care plan. It might be compared to going
out and deciding that the heating of homes which is fairly expensive, should be insured
against. As you can realize, if you paid so much per month to someone who guaranteed
to supply you with all the coal you needed, I'm sure many of you would shovel the
coal on the fire a little more often and you would likely demand- the most expensive coal
available. As a result the rates would go up the next year. Thus it is very hard to
estimate the rate in advance as you can see, and it must rather evolve slowly, which
is what we are attempting to do in this province in the matter of prepaid medical care.
I believe we must accept the fact that medical care by prepayment is here to stay.
This has been decided by the people in general and the doctors had very little—or
nothing—to do with that decision. The chief question now about this medical care
prepayment is whether it shall be voluntary or compulsory—free enterprise or socialistic.
Many people feel that on a voluntary basis we cannot cover a sufficient number of the
people. Various figures have "been worked out estimating that somewhere between forty
to seventy-five percent of the people could be covered on a voluntary basis. I believe
the difference in figures depends mainly on the individual interpretation of the word
voluntary". For instance some companies have so-called voluntary schemes—but one
of the conditions of employment with that company is that the employee be covered
under i;he scheme.  This naturally results in a much higher percentage of people covered.
On the other hand, many people »f eel that on a compulsory basis, which usually
implies a Government operated programme that costs become excessive as you then have
a Government administrative staff to pay as well as paying for the medical care. Also
that you tend to get a poorer calibre of medicine practiced—or an assembly-line type
of practice—e.g.: in New Zealand which is now stated to have the highest narcotic
rate in the world—or in England where to make a good living a doctor must—or may—
care for approximately four thousand patients. We feel that a doctor cannot capably
look after more than a thousand patients—and even under their set-up in England, costs
have become so excessive that they are now considering reducing the services.
With this background in mind, let us come down to what we are doing in B.C.
In B.C. and along the Pacific Coast in general, owing to topography and other factors,
prepaid medical care in the form of contract practice has been an accepted fact for well
over forty years, as Dr. Thomas has already mentioned to you. In spite of all the abuses
contract practice encourages, it has provided much better medical care for large percentages of people than would otherwise have been available. With changing times and
the opening up of our country—with modern transportation, etc., we now feel that
better plans of prepayment for medical care than contract practice are feasible, better
from both: 1. the patient's standpoint — offering free choice of doctor and all available
medical aids and 2. The standpoint of those rendering the services—offering a more
equitable return for investment and services. What the people rally want and what
we feel they should be able to obtain is (1) Free choice of doctor when they want him
and, (2) to have his fees paid in full.
Page 144
19 Organized medicine in B. C. placed itself on record in 1935 as favouring some
plan of contributory health insurance which would be fair to all concerned and preserve
adequate standards of service and remuneration. *g£g
During the past ten to fifteen years we have seen the growth and in many cases
the fall, of many schemes in this Province—all on a voluntary basis. A few of these
are so-called contracts which in return for a premium paid in advance pay for the
medical service rendered. Examples of these are M.S.A., B.C. Teachers', Vancouver
Teachers' M.S.A., B.C. Telephone M.S.A., etc These are non-profit organizations and
are approved by the College of Physicians and Surgeons of B.C.
There are many more of the indemnity type of insurance companies or health and
accident associations or societies. They accept a premium and then pay for medical
service according to their own rates or fee schedules. This very often does not conform
with the minimum fee schedule in force in the Province and hence, leads to many misunderstandings and much discontent among the subscribers, but this can be traced
mainly to the fact that people do buy policies without reading or attempting to find
out what they are buying. They know what they think it should cover—but wishjFul
thinking often is far removed from actual fact.
In 1940, as an attempt to answer this demand for pre-paid medical care, the
Economics Committeee of the College of Physicians and Surgeons of B. Cv brought into
being the M.S.A.—registered under the Societies Act of B.C., a non profit organization,
originally backed by the personal bond of a good number of our medical men. This
organization has grown quite rapidly particularly during the last three to four years and
is now recognized as one of the best—if not the best— of such schemes on the North
American continent. At the present time, approximately one in ten persons in B.C. is
covered under M.S.A., and except for two or three very minor exclusions, it offers a
complete medical care coverage at a very moderate rate.
The membership of M.S.A. is composed of three classes—1. Professional members.
Any qualified physician and surgeon registered under the Medical Act of B.C. becomes
a professional member by agreeing to the Constitution and By-laws of the Organization.
2. Employer members—It is with the employer member of each groups that a master
contract is written. It is his responsibility to maintain coverage of his group at the level
of 75 % or greater—thus assuring soundness to the plan. (If this were not done and
the percentage dropped lower, it is quite conceivable that soon, mainly sick ones would
insure thus giving increased expense to the system and hence increasing costs and thus
raising rates). In most cases the employer contributes 50% of the cost orKbehalf of
his employees. 3. Employee members being those who receive the medical benefits, and
their dependents. There is a board of eight directors which runs the affairs of the Association. This board is composed of two employer representatives, two professional representatives and four employee representatives. These directors serve without
One should make it clear at this point that M.S.A. is a group coverage plan. Only
groups of ten employees or 75 % of the total employees of a common employer —
whichever is greater, may be enrolled. This is necessary to insure an average coverage
as you will all understand, to avoid becoming burdened with individuals or small sized
groups who are poor risks. This is one of the basic requirements of a group plan. Coverage of individuals for prepaid medical care on a voluntary basis is actuarily an entirely
different problem and in my opinion, would require a separate and much more costly
As mentioned previously, M.S.A. is the most comprehensive plan of providing the
services of Physicians and Surgeons of which I am aware. Payment is made for their
services only and medicines are not supplied—refractions are not included. As physiotherapy is usually performed by persons other than physicians and surgeons themselves,
it is not included. Services for injuries covered under the Workmen's Compensation
Act and services supplied by Public Health Authorities are of course not duplicated. On
the effective date of the master contract the employee has immediate coverage. There
are no riders excluding pre-existing conditions—the usual waiting period of nine months
Page 145 for maternity benefits is in effect, of course, but there is also applicable extended maternity benefit. That is, maternity cases receive benefits until confinement, if the pregnancy commenced during the period of contract coverage. Periodic health examinations
are not included.
Hence, as you can see, M.S.A. offers a complete average at a very fair rate. This
rate has gradually been worked out over the ten year period. As you may readily understand, some people tend to take advantage of a scheme such as this, and if a few in a
company start doing so, it is a practice that tends to spread, e.g.—demanding that
the doctor always maks housecalls when the patient could go to the office perfectly well;
or demanding that they see a doctor for every little ache and pain. This in turn increases
the cost of M.S.A. but as the directors felt that it was not fair to punish those who tried
to play ball and who demanded care only as they would have demanded it if they had
been paying it themselves, the system of "experience rating" was introduced. This means
that costs are worked out for each group individually and if one group, or several
members of one group are demanding excessive service then the rates for that group
are adjusted accordingly and consequently if they demand more than average service,
they must pay more than average rates.
In conclusion, you can see that from the foregoing report that we are gradually
evolving a scheme in the Province of B. C. that is good. However, as you should realize,
this must come slowly. M.S.A. has now been operating ten years and gradually improving
and we have confidence that medicine—if given a chance—can find the way out of the
conditions that prevail, and out of the turmoil in which we liv^ today—as it has found
the way for more than three thousand years. On the North American continent at
least, medicine has come today to the highest point that has ever been reached by medicine
in the world—at any time—and we feel that we should do all that we can to maintain
conditions so that this progress may continue.
1/ is with great pleasure that we publish the two following notes on ACTH and
Cortisone, which formed the subject of an address before the Vancouver Medical Association, by Prof. J. S. L. Browne, of McGill, on February 15 the.
The two sets of notes are admirably complementary to each other. Dr. Skinner, of
Vancouver, took full notes of the matter of the address, while Dr. D. E. H. Cleveland
took equally adequate cognizance of tfye manner in which it was delivered. We feel
that our readers will agree with the Editor that this makes an excellent Combination.—Ed.
An address on ACTH and Cortisone by Dr. J. S. L. Browne, Professor of Medicine,
McGill University, was the occasion of a special meeting of the Vancouver Medical
Association in the auditorium of the Chest Institute on February 15 th.
Professor Browne spoke for nearly two hours, and it is less extravagant than trite
to say that he held his audience spellbound. The address, delivered entirely without notes,
was an artistic tour de force. As one of his hearers was later overheard to say, it is
given to few men once in their life-time to hold the intense interest of an audience on
a subject with which none of them are familiar and in which the speaker himself is
thoroughly versed. The speaker's enthusiasm in his subject was infectious and inspired
speaker and audience alike.
Professor Browne outlined vividly the avenues of approach by which the "steroid"
bio-chemists came to the isolation of ACTH and Cortisone and their preparation in
sufficient amounts for therapeutic evaluation. The story was not lacking in dramatic
interest. None could present this subject better, since the speaker has sustained a leading
Page 146
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part for nearly ten years in this field of investigation, although he modestly refrained
from making mention of this. Dr. Browne is a ready hand with the chalk and blackboard,
and his rapidly sketched diagrams, and graphic formulae of steroid molecules, admirably
served their purpose. $^A
Professor Browne is a physiologist, and like all the great physiologists we can recall
he is strongly imbued with the philosophic aspects of his work. For him the values
in steroid chemistry research which transcend all others are the new concepts of disease
which they have imposed upon him. The study of such substances as ACTH, and
Cortisone or its related steroids, which have been found capable of eliciting remarkable
physiological response in such variety of apparently unrelated diseases, has thrown new
light on the significance of adaptation phenomena exhibited by living structure under
the assaults from its environment. This must force one into adopting new viewpoints
for observing the morbid changes which we call disease, and will help in surprising ways
to explain the "What and Why" of disease. It even finds features in the long-derided
humoral hypothesis in which reconciliation with our modern knowledge of microbic
phenomena is possible. As the speaker said with simple profundity, "The tubercle
bacillus is not tuberculosis nor the pneumococcus pneumonia."
Diseases cannot be labelled neatly and slipped into accurately fitting slots.   We
had a partial and discomforting presence of this before, yet laboured vainly to jam
them in.   Now Professor Browne has adumbrated the reasons why our efforts are as<
unnecessary as futile.
Dr. Browne's exposition was lit by flashes of subtle humour—and sometimes not
so subtle. He may dwell on lofty philosophic planes where the mosaics of graphic
formulae are moved about with a deft finger and their dangling side-chains attached and
detached with ease, certainty and astonishing results, but he still has the common touch.
His adaptation of Hamlet's second soliloquy, with which he concluded, was revealing,
and deserves quotation here:
"To be, or not to bei that is the question;
Whether 'tis nobler in the mind to suffer
The slings and arrows oi outraged stresses, %&J
Or by a stroke to end them all, litlPI
To A to C, to T to H.
That is the question."
The audience which listened to Professor Browne was the largestxthat has ever
been present at a Vancouver Medical Association meeting. The applause w^ altogether
unprecedented in its heartiness and prolongation. Among many from whoni the writer
has gathered impressions, including some whose education has been received at great
British, American and Canadian schools, there was a commonly expressed opinion that
the address was the finest which the listener had ever heard. It can truly be said that
it was nowhere lacking in matter or art.
In the course of his remarks Professor Browne took occasion to decry the newspaper
publicity which has unfortunately attended the release of fragments of information
concerning ACTH and Cortisone, and their effects on rheumatic diseases and leukaemia,
among others. He emphasized the harmfulness of such publicity and the cruel raising
of false hopes, which represents these substances as cures, whereas they have not as yet
been shown to be such, while there is not even enough of them available to give
sustained relief, should it be possible, to a minute fraction of all sufferers.
We therefore have much pleasure in complimenting the Vancouver Daily Province
in its issue of February 16th, on an excellent presentation of Professor Browne's views
and admonitions, and the present situation with regard to the promise and the availability
of these substances.
Page 147
Summary of lecture by Dr. J. S. L* Browne, 15 February, 1950
Dr. Browne first gave a brief resume of historical facts. It had been known for
years that if the adrenal cortex was destroyed a condition known as Addison's disease
resulted. Second, it was also known that adrenal extract would protect the patient from
the effect of the Addison's disease. Third, this had led to extracts from the adrenal
which had been fractionated to hunt for different components. Different authors
segregated different parts, and they were called by the order in which they were found
as Compound A, B, C, D, E, and F. Because of a rumor that had stated in .the early
days of war that the Germans were enabling their pilots to fly more capably at
higher altitudes by feeding them large quantities of adrenal extract, considerable
interest in this subject developed in Canada and the United States. There was marked
interest in the research in these parts. The various compounds, A to F, had been previously broken down and formed, but at that time were not able to be formed synthetically.
With the aid of the Merck Chemical Co., who invested about a quarter of a million
dollars in the scheme, compound A was synthesized. This was tried first in Addison's
disease as it was thought it would be of marked berfefit in that case. After considerable
testing, compound A was found to be completely worthless. This would have meant
an end to the entire scheme were it not that Dr. Kendall of the Mayo Clinic managed
to talk Merck's into attempting to synthesize compound E. This compound, he stated,
he knew would be very useful for something but he did not know what use it would
have, but he was sure it would be extremely beneficial. He was sufficiently convincing
that Merck's agreed to put in another several hundred thousand dollars into attempting
to synthesize this. It is noteworthy that this company has invested approximately one
million dollars in this research and so far has received nothing in return. The decision
to attempt to synthesize it was made about 1946, and by 1948 there was a fair amount
of it on hand, and it was decided to try and find of what use it might be.
Next was Dr. Hensh, also of the Mayo Clinic. He had for years been studying
rheumatoid arthritis, and had been always hunting for something new to attempt. He
had noticed that patients who became pregnant or who developed an acute infection
frequently had an improvement temporarily in their rheumatoid arthritis. He was able
to prove that this was due apparently to increased adrenal secretions. Therefore as far
back as 1941, he had been after his associate, Dr. Kendall, for some of this compound E
that he might try it in rheumatoid arthritis. However at that time there was not
sufficient available for any testing. In 1948, when larger quantities became available, it
was decided to try it in a case of rheumatoid arthritis. Since that time, and to avoid any
possible confusion between compound E and vitamin E, as there is no relationship
whatsoever between them, the name compound E was changed to Cortisone.
The first case of rheumatoid arthritis who was treated was one who had been
bed-ridden for several years. The exact dose was unknown. This was the first time it
had ever been tried in a human being. By chance it was decided to giv/e 100 mgm.
The result was remarkable. The patient, who had not been out of bed for years, within
3 or 4 days was walking around free of pain and feeling absolutely normal. This being
so, it was felt that Cortisone itself was far too hard to produce, and that it would be
much more satisfactory if the patient's own adrenal gland could be encouraged to
produce this substance.
It had been known for years, through the work of Collip and others, that the
pituitary gland had certain hormones which stimulated various fractions of the adrenal
glands to secrete their hormone. Several of these pituitary factors had been broken down
and finally one was found which was called ACTH, meaning adrenocorticotrophic
hormone. It takes four hundred thousand hogs to make one pound of ACTH, so that
it is obvious that this will not be readily available at the present time.  Armour Labora-
Page 148
i< I
It tories decided to make an investigation of this, and have spent considerable sums of
money in this regard. It was tried first in rheumatoid arthritis, and in any patient who
had normal adrenal glands it was found to be most helpful. Dr. Browne noted that
this would seem to be re-proving the ancient Greek "Humoral" theory. He went on to
briefly mention the reaction to stresses of the body, giving the adaptation syndrome.
That in these adaptation syndromes or alarm reaction, the adrenal response might
frequently cause a rise of desoxycorticosterone acetate (DOCA). It was known that
giving large doses of DOCA would produce changes similar to those found in periarteritis nodosa, a type of rheumatic fever, or rheumatoid arthritis and similar diseases. These
then were called the diseases of adaptation. $££     £,<■:-
The frequent response to various stresses is large quantities of DOCA. Therefore
if Cortisone was not available in large quantities, and since ACTH was somewhat more
available, more tests have been done with the latter. However, the method of synthesizing Cortisone which first took 8 months has now been considerably shortened, and
it is expected that large quantities of Cortisone will be available at the end of March.
Therefore the National Research Council of Canada, in conjunction with other research
bodies, is very anxious that projects be undertaken to test the effectiveness of -Cortisone
and to study its use in many conditions. That is the purpose of Dr. Browne's present
trip to give us information in this regard.
Talking about ACTH, some of the affects of it when given in 100 mgm. a day
which is the average dose are:
1. Impaired sugar tolerance. ljfl|
2. Retention of water.
3. Retention of chlorides.
4. Increased uric acid in the urine. '%£$$.
5. Marked fall, to zero, of the circulating eosinophils in the blood.
In regard to this last, if there has been pituitary deficiency and the adrenal has not been
receiving stimulation for some considerable time, the reaction may need priming for
some little time before it can take place effectively. This last fall in eosinophils then
has been used as a test of the adrenal cortical activity—the patient is given some ACTH
and then an accurate count of eosiniphils done both before and afterwaride. Also the
uric acid in the urine is measured. These two should tell whether t^fe adrenal cortex^
is working.
ACTH is a protein with a molecular weight of about 28,000. In California it has
been hydrolyzed down to the polypeptide stage of only 6 amino aci6ds and found to be
still more active. If this can be still further hydrolyzed to two or three amino acids
it will be definitely possible to synthesize ACTH, in which case much larger quantities
will be available. An excessive dosage of ACTH will give rise to symptoms indistinguishable from Cushing's Syndrome. Usually ACTH results in increase, excretion
of potassium and may result in increased excretion of sodium, though usually there is~
retention of this.
Dr. Browne next reviewed the result of ACTH as given at a Congress called by
Armour Laboratories where 140 or so scientists who had been working with it gave
10-minute reports on their work.   These then discussed several conditions which we -
will now mention.
Hyperthyroidisms*—ACTH used in 5 cases.   Two cured, three useless.
Malignant Exophthalmos—-Used in 1 case with great help. Gives no help in
ordinary exophthalmos.
Hypoglycaemia—Of congenital type due to overactive pancreas. ACTH gave
marked help and in this case the benefits were consideraibly prolonged after ACTH
was stopped, and in the one year follow-up available there has been no recurrence.
Gout—If people have an acute attack of gout, ACTH will completely arrest the
pain and disability and all symptoms within three hours. There is increased formation
of uric acid by breakdown of proteins and purine metabolism while ACTH is being
given.   This is also markedly increased in urinary excretion so that the blood level^
Page 149 probably goes down. When ACTH is stopped either after an acute attack or even in
people who have a gouty diathesis but no acute attack, there will usually be an attack
of gout resulting shortly after stopping the ACTH, owing to the still large production
of uric acid which is then excreted at only the normal rate.
Blood Pressure—DOCA tends to cause hypertension. Cortisone somewhat neutralizes DOCA. In essential hypertension there is, however, very little result. A slight
lowering of blood pressure followed in some cases. Also hypertension has followed the
giving of ACTH.
Acute Nephritis and Nephrosis—Farnsworth of North Western University did this
work. Two children with acute nephritis—initial effect, increased oedema and raised
blood pressure. However, these all fell and the clinical picture became completely
normal very rapidly. Nephrosis—A child of 5 who had been sick for 3 years with
remarkably raised NPN, high blood pressure and blood cholesterol of 600. On6 ACTH
it wcs found that there was a temporary increase in oedema (as it is seen ACTH tends
to cause water retention). On the 11th day there was sudden diuresis and loss of 20%
of body weight.   In due course there was complete remission of symptoms.
Lymphoid Tumours—Chronic lymphatic leukemia—patient felt better, glands
lessened in size. During the time on ACTH patient felt better, glands reduced in size,
white blood count rose at first then fell to normal. There was, in other words, a
complete remission. The condition, however, recurred after treatment was stopped. In
eosinophilic leukemia there is also marked result during the time of treatment.
Malignancy—There is no evidence of any effect on other malignant tumours.
Arthritis—In rheumatoid arthritis, Still's disease in children, there was marked
Rheumatic Fever and Rheumatic Carditis—seven out of eight the fever and sed.
rate rapidly fell to normal. Pericarditis cleared up. The oedema became temporarily
increased, then improved.
It is to be noted that this tendency to lose potassium may give rise to a potassium
deficiency and this tendency will be aggravated if ordinary dieuretics are given.
In many disease this was tried with a rapid loss of temperature. It was used in
Dermatomyositis, Periarteritis Nodosa, Ulcerative Colitis, and other Collagen diseases,
and was found to be of some help in all of these.
Hypersensitive States—In asthma, 12 were tried. Ten received complete relief of
symptoms. It is noted that during the time these people were on ACTH, they could
be given many times the normal exciting irritant without an attack of asthma. It was
also noted that there was a recurrence of asthma within 4-6 weeks after treatment,
and this seemed to be approximately the same time whether the treatment Vas carried
on 4 or 5 days or 4 or 5 weeks. In the other two of these 12 patients the asthma was
made worse.   It is also useful in penicillin reactions, vasomotor rhinitis, hayfever, etc.
In Disseminated Lupus Erythematosus—ACTH was tried in two cases of acute lupus
who were almost moribund, and within a very few hours both patients appeared absolutely
normal. In other cases less acute the results were somewhat less remarkable. However,
the lupus recurred rapidly after treatment was stopped. ACTH apparently alters the
body response to any irritant.
Cirrhosis of the Liver and Virus Hepatitis—there was also an impression of some
improvement though this was not definitely proven.
Poliomyelitis—No action observed.
Neurological States—in general were found to have little effect. Myasthenia gravis
had an initial effect which was bad, and later improved. Alcoholism showed marked
improvement of the various bad effects. There was shortening of D.T.'s, etc., though
Korsakov sycosis was not altered.
Pulmonary Disease—Lobar pneumonia showed an almost miraculous result. He
stated one case in which an alcoholic was brought into hospital with almost complete
consolidation of one lobe.   He was given ACTH and 18 hours later an X-ray showed
Page 150 absolute clearing. It is noted that bacteraemia frequently results following the use of
ACTH, but apparently does not bother the body. Virus Pneumonia—while on ACTH
the patient felt well, and while taking it the symptoms were controlled completely, but
did not show any change in the lung picture. When it was stopped there was a recurrence of the symptoms and one patient was given five remissions and exacerbations
by giving and stopping the ACTH. ^j|£
Tuberculosis—was used in two advanced cases. Within 36 hours there was marked
improvement. They were kept on it for one month and gained 28 pounds. Temperature
fell to normal, sed. rate fell to normal, and the Mantoux test became negative, though
they were still having positive bacteria in sputum. The lesions in the lung diminished
in density. However, when this was stopped in 24 hours the condition was worse than
previously. Apparently there is a diminution in the growth of fibrous tissue which
is the normal response to the body in attempting to heal T.B., and this allowed marked
There is a psychological effect, and ACTH may cause euphoria which may go on
to hypermania, and occasionally worse. One doctor stated that he thought that a certain
amount of euphoria was to be expected if a patient who had previously been confined,
to bed for 12 years by rheumatoid arthritis were given some Cortisone or ACTTH,
were able to get up and go around to dances and so on. He thought the man would
have some reason to feel good.
Dr. Browne then went on to some of his own speculations in this disease. He drew
a diagram showing Addison's at one end, normal in the center, and Cushing's Syndrome
at the other, and said that this was the idea of the adrenal secretions. Minimum giving
Addison's, maximum giving Cushing's.
Cortisone apparently affects the internal transfers of protein and salt into and out
of the cells. He gave the instance of a pregnant woman in which the foetus will invariably take what it needs from the mother's blood, and even if the mother is not getting
sufficient to eat, her own tissues will be broken down so that the foetus can have all
that is necessary. Cortisone causes a mobilization of protein, so affects protein'metabolism
and apparently also fat and carbohydrate metabolism. In continuing Cortisone or ACTH
in large amounts to animals, there was a very marked depletion of proteins from all
tissues of the body and the animals died more or less in starvation. It is known that
in chronic illnesses there are tendencies for certain cells to store proteins. These, with
some other added features tend to give abnormal tissues. Cortisone reduces protein and
so this abnormal tissue. It acts then as a flux or a valve allowing a flo^^of protein
from the cell back into the normal circulation. The changes which occur are of ten good
but may be quite unfortunate. These things, he felt, show that disease is not a rigidv
thing, you cannot put it into a compartment and say "yes» this patient has this particular
disease." It is all a stage and a question of degree. He drew a picture of an iceberg
showing seven or eight peaks and put the name of one disease at each peak. Then he
drew a water line, which, like an iceberg, covered seven-eighths of the particular one
he had drawn. He said the one-eighth above was the individual characteristic of the
body response to that particular organism, and the other seven-eighths was the body's
general reaction. So that the general reaction is present in any case, and it is only
this final one-eighth of a specific response through which we have finally labelled all
the diseases. He stated that it was shown in many cases that marked psychological
stimulation could cause intense rise in the glucocorticoids in the urine which are the
end products of Cortisone and ACTH. This then he felt might possibly be the way
in which miracle cures have from time to time occured when a patient with marked
psychological stimulation would cause considerable secretion of ACTH and so formation
of Cortisone, with an almost miraculous recovery. He felt that the rise of psychosomatic
medicine was extremely important but that we were tending to fall on the two sides
of the fence which was not there.
Cretinism is of 2 kinds, sporadic and endemic. The sporadic type can occur anywhere in the world and the endemic type is found in the mountainous areas of localities
in which goitre is endemic, i.e. some parts of Switzerland, and Derbyshire and Gloucestershire in England.  There is an equal sex incidence.
This evening we are considering the sporadic type of Cretinism. The onset of this
disease may not be obvious until the child is 3 months of age, or perhaps even a little
later if it has been breast fed.
The severity of the clinical picture varies with the extent of the deficiency of
the thyroid gland, but the description which follows and the accompanying lantern slide
will serve to describe an untreated cretin of 2 years of age. In build he is stumpy and
thickset with limbs that are short in comparison with the trunk. The skin is dry,
rough and may have a yellowish tint. There may possibly be some cyanosis of extremities. The hair is course, brittle and appears to be sparsely parted. The head is large
with wideset eyes and a broad, flat nose, and the fontanel is late in closing. The teeth
are late in arriving and tend to decay early. The tonsils are big and the tongue protrudes
as if it were too big for the mouth. Expression is dull and there is a slow smile. There
is a myxoedematous infiltration affecting the skin of the neck and limbs, and supraclavicular pads of fat are present. The umbilicus protrudes and there may in fact, be an
umbilical hernia. ■.
Progress is slow. The child falls more and more behind his fellows mentally and
bodily. He walks late. His speech is limited to a few words, and it is difficult to stimulate
him to any display of emotion. Sexual development will be absent. He sleeps much,
is placid and his movement are slow and reptilian. It has been said that without thyroid
the fires of metabolism burn low.
The diagnosis of the condition is made very largely on recognition of the clinical
picture, but confirmation may be obtained by an estimate of the serum cholesterol. If
the upper limit of normal is taken as 200 mgms.% it may well be found that in a
cretin the figure may be 400, 500 or even 600 mgb.%. Confirmation may also be
obtained by X-ray of the wrists, in which it will be seen that the bone age of the child
is not as advanced as in a normal child of similar age. The accompanying lantern slide
shows a case of right sided congenital dislocation of the hip which has occurred in a
cretin. The second picture shows the same hip with the deformity now corrected after
20 months of treatment with thyroid extract. No other treatment was given. This
picture is taken from Caffey's textbook of Paediatric X-ray Diagnosis.
A differential diagnosis lies mainfy between Mongolism and achondroplasia, and
the last lantern slide shows a typical achondroplasia, and the last lantern slide shows a
typical achondroplasic. The differentiation between Mongolism and Cretinism is of
very considerable importance in that no drug treatment is of any use for a Mongol, but
a properly treated Cretin can be improved not only in appearance but also in mental
development to the extent that a known Cretin has won a scholarship. Briefly to mention the appearance of a Mongol, the skin is smooth, there is no constipation, the child
is of normal size, happy disposition, he may have a Curved little finger, a small tongue,
and be fond of music. Often there is an associated congenital heart lesion. These children,
while being mentally defective, do not present the problem to their families that an
untreated Cretin does.
Treatment', consists of the administration of thyroid extract daily for the rest of
the patient's life. The dose should be started at grain % daily. The effffect of the drug
is cumulative—a fact which must be remembered when increasing the dose. At least
one week must be allowed before making a further increase in the size of the dose. In
the first instance, the dose can be governed by estimation of his serum cholesterol, but
in the months and years that follow it is perfectly satisfactory to govern the size of the
dose by the pulse rate of the patient and by the number of daily bowel movements. It
must be remembered that the normal pulse rate of a young child is above that of an
adult, i.e., in the neighborhood of 110-120 per minute at birth. Clearly, the possibility
of overdosage of, the drug and production of thyrotoxicosis must be born in mind.
Page 152
Dr. G. A. Greaves has retired from active practice in Vancouver.
Dr. G. W. J. Fiddes, formerly of Hazelton, has moved to Green River, Ontario.
Dr. V. St. John, of Alert Bay, has moved to Campbell River.
Dr. J. E. HM, formerly at the Vancouver General Hospital, has been named
Director of Laboratories at the Sacred Heart Hospital in Spokane.
Drs. L. A. Quirk and Dr. R. D. Thompson are now with the Department of
National Health and Welfare in London, England.
Dr. G. O. Hallman, formerly of Cloverdale, is now in Suva, Fiji Islands.
Dr. J. T. Cruise, formerly of Kelowna, is now practising in Victoria.
Dr. F. N. Elliott has moved from Vancouver to Port Renfrew.
Dr. L. M. Greene has moved from Powell River, B. C, to Prince Rupert.
Dr. J. H. Blair is now practising in Calgary.
Dr. J. M. Murray, from Vanouver, is now in New York City Hospital, New York.^
Dr. A. W. Knox, of Kelowna, is now at the Presbyterian Hospital in New York.
Dr. F. W. Arber is at Campbell Rivjsr.
Dr. Leslie Saunders, of Vancouver, is now at the Queen's General Hospital in
Kingston, Jamaica.
Sir Reginald Wat son-Jones and Professor F. H. Bentley have been guest lecturers
from England at the Vancouver General Hospital this month.
Dr. J. A. VenaHes has returned from England to his home in Victoria.
Dr. K. K. Pump has moved to Montreal from Vancouver. ",
Dr. H. P. Swan is now with the British Military Hospital in Hamburg.
Dr. James Nelson, formerly with the Red Cross Transfusion Service in Vancouver,
is with the Tuberculosis Unit in Victoria.
Dr. G. H. Burgess, formerly in the Queen Charlottes, is now at Prince Rupert.
Dr. D. G. Ulrich has moved from Zeballos to Vancouver.
Dr. G. A. Fraser has gone to the Hospital for Sick Children in Toronto from
Dr. A. A. O'NeU, of Vancouver, has moved to Calgary.
Dr. S. W. Baker, from Ladysmith, is now in Vancouver.
Dr. J. S. Spooner is studying Urology at Queen's University.
Dr. C. H. Vrooman is at present in Sidney, Australia, where a conference is bleing
held on Pneumonoconiosis. Eleven countries will be represented at this conference,
and he is one of three Canadian representatives who will take part in the discussions.
Dr. Digby Leigh has been an Honorary F.R.C.S. in London, England.
Dr. W. J. Thompson has been named Director of the Western Center for Physical
Rehabilitation in Warm Springs, Florida.
Dr. D. A. Steele has been named B. C. Director of the Canadian Foundation for
Poliomyelitis and has been in Toronto preparing for this Kinsman Club project.
Dr. Albert Menzies has left the Vancouver General to continue studies at the
Sunnybrook Veterans' Hospital in Toronto.
New fathers include Drs. A. L. Pedlow, G. W. Barnes, and R. Farrish.
Dr. W. Sherman, formerly at the Vancouver General Hospital, has gone to Hawaii
to continue his pediatrics course.
Page 153 M Mh'-- Asthmatic
Eupnogene may be recommended as a cardiotonic to offset dyspnoea and to stimulate
free diuresis. Particularly effective in the treatment of Asthma, Emphysema, Chronic Bronchitis and Arteriosclerosis (non-advanced).
(per teaspoonful)
"^^ZZZZZ^ZZ^^^^^. Caffeine Iodide 0.50 Gm.
' Sodium Benzoate    .    . '^S^S .....      0.08 Gm.
' Tincture of Coffee  .    .     0.25 Gm. ZI^^^^I^^^^IZZ!
Strictly   Ethical   Specialties m
Restoration of normal vaginal pH is frequently
the only measure necessary for successful therapy
in vaginitis and cervicitis, and a buffered acid
jelly is conceded to represent the simplest and
most direct means of effecting such restoration.
Aci-Jel is just such a jelly—misdble in water
and entirely free from irritant qualities even on
prolonged usage. Available in 314 02. tubes, with
or without measured applicator.
Ii hypnotic with mild analgesic action
Hypnotic and sedative with an analgesic
action which may be strong enough to efface
pain as a cause of insomnia in selected cases.
Highly recommended for all types of insomnia.
TABLETS: 0.1 Gm. each, scored to permit easy
SUPPOSITORIES:  0.2 Gm. (3 grains) for adults.
0.05 Gm. (3A grain) for children.
ELIXIR: containing 0.26 Gm. (4 grains) of the sodium salt of
SONERYL per fluid ounce. Pleasant flavour. May be mixed
with milk or orange juice.
2&£i Information and samples upon request.
MONTREAL for the management and control of Jf f|
Cardiovascular disorders
, ■  ■
enteric coated red tablets
enteric coated white tablets
Theobromine Cpd.
compressed white tablets
The suffix ANCA will identify any of our products on a prescription. OSTOFORTE
"Sjb-Ajl brand of high potencylVHamin D Capsules
For  the treatment  of
The treatment of chronic arthritis with massive doses of vitamin D,
while entirely empirical, has proved beneficial in a great number
of cases.
In many arthritics, diet may be restricted for therapeutic reasons or
the appetite diminished due to physical inactivity. Ostoforte Compound capsules supply massive doses of vitamin D and also adequate
amounts of other vitamins, thus making up for dietary deficiencies
of these factors.
S.E.C. No. 671 "Sowf
In each capsule:
Vitamin D      50,000 Int. Units
Vitamin A  1,666 Int. Units
Thiamine HCI  0.67 mg.
Riboflavin  1.0   mg.
Niacinamide..'.  6.67 mg.
Ascorbic acid  15.0   mg.
In average daily
dose (4 capsules)
200,000 Int. Units
6,664 Int. Units
2.67 mg.
4.0   mg.
26.67 mg.
60.0   mg.
For those cases where the
normal diet is adequate in vitamin B factors and vitamin A.
S.E.C. No. 657 "Sot*"
Each capsule contains 50,000 I.U.
vitamin D.
Up to six capsules daily.
Literature and clinical
specimens on request.
Boxes of 50 and 100 capsules.
Ostoforte Compound and Ostoforte should not
be administered to patients with "impaired kidney function" nor to children in repeated doses.
ekank6 &Mod&8c6o.
Stout   brand of *Adiphemne HCI.
«U»*I   brand of Bufoborbital N.N.R.
S.C.T. No. 426 "£»**"
Paxil    50 mg.
Noctinol    15 mg.
S.C.T. No. 425 "Sautf"
Paxil.    75 mg.
1 lo 2 tablets 3 times daily.
Bottles of 30 and 100 tablets.
ethanolester hydrochloride.
# has good antispasmodic effect on
intestine, gall bladder, ureter, bladder and
uterus, as demonstrated on these organs
and on isolated preparations;
# is relatively non-toxic;
# is non-mydriatic when taken orally;
# does not seriously depress salivary
In spastic conditions associated with emotional
instability, generalized vagotonia and certain
other circumstances, the administration of a
small amount of barbiturate is often desirable.
This barbiturate should have a duration of
effect intermediate between the very
short-acting ones, such as pentobarbital, and the
very long-acting ones such as phenobarbital.
Noctinal Cstodaf brand of Butabarbital N.N.R.)
has such activity, and when combined with
PAXIL provides a very useful therapeutic agent.
Complete therapeutic information and
clinical samples available on request.
CANADA Uncle Charlie had -the right idea...
Youngsters are eager fdr candy—and just as eager to take their
medicine when it comes in candy-like Duozine £W<r^/ Tablets.
Every time they gobble down a delicious Dulcet Tablet, they
hardly suspect they're taking a therapeutic dose of sulfonamides. But they are—and the medication is as potent, stable
and effective as in any unflavored, hard-to-swallow tablet.
DuozmeJDK/r*/ Tablets 0.3 Gm., are composed of equal parts
of sulfamerazine and sulfadiazine. More and, more physicians
are prescribing this sulfonamide combination because the
effectiveness of either drug is equal to the total weight of
both, while the danger of crystalluria is reduced to that of
one component alone. ||||1
Duozine Dulcet Tablets are prescription products, available
through your pharmacy. You may obtain dosage schedules
and information on Duozine and other sulfonamide Dulcet
Tablets by writing to Abbott Laboratories, Limited,
SPECIFY Abbott's Sulfadiazine-Sulfamerazine Combination
(Sulfadiazine-Sulfamerazine Combined, Abbott)
©MEDICATED SUGAR TABLETS, ABBOTT. flfoount Peasant Xttnbertakino CoJpLtb.
KINGSWAY at 11th AVE Telephone FAirmont 0058 VANCOUVER, B. C.
^Vzxnon ^J^xzhaxatoxu Cahoot
AGE 7 TO 16
For particulars apply to:—
R.R. No. 2, Vernon, B. C.
Nmrn & ©fjmttamt
2559 Cambie Street,  Vancouver, B.C.
Effective Printing
PAcific 3053
820 Richards Street, Vancouver,B.C. *»<
"Pre mar in"
in terms of actual results at the menopause
Perloff. W. H.: Am. J. Obst. & Gynec. 58:684 (Oct.)  1949.
Fried, P.H. and Hair, Q.: J. Clin. Endocrinol. 3:512
(Sept.) 1943.
Gray, L. A.: J. Clin. Endocrinol. 3:92. (Feb.)  1943.
Harding, F.E.:West.J.Surg.Obst.& Gynec 52:31 (Jan.) 1944.
Sevringhaus, E. L. and St. John, R.: J. Clin. Endocrinol. 3:98
(Feb.) 1943.
Glass, S. J. and Rosenblum, G.:   J. Clin.  Endocrinol.  3:95
(Feb.) 1943.
Freed, S. C, Eisin, W. M. and Greenhilirj. P.: J. din. Endocrinol. 3:89 (Feb.) 1943.
"Premarin" is supplied in tablets of 0.3, 0.625 (with or
without '/j grain phenobarbital), 1.25 and 2.5 mg., or as
liquid containing 0.625 mg. conjugated estrogenic substances
(equine) per teaspoonful.
Biological and Pharmaceutical Chemists. Montreal, Canada.
3017 Cafergone
(EX. 110)
Oral Migraine Therapy
CAFERGONE is the first highly effective oral preparation providing rapid and * sure relief to the
migraine sufferer. Each tablet contains: ||3j
1 mg. ergotamine tartrate
100 mg. caffeine (Free Base).
. . . "Practically all of the patients in this series had previously
used ergotamine tartrate to abort or relieve headache and they
uniformly stated that E.C. 110 was more effective than ergotamine used alone''' . . .
(Horton, Ryan & Reynolds, Proc. Staff Meet., Mayo Clin., 23: 105,1948).
. . . "Although E.C. 110 (CAFERGONE) was developed
primarily for the relief of the migraine attack, it is uniformly
effective and has a much wider range of usefulness in the relief
of headache of all other types, especially typical and atypical
histaminic cephalgia" . . .
(Hansel, Ann. Allergy, 6: 155 — 161, 1949).
. . . "CAFERGONE . . . definitely seems to be an excellent
preparation to use to abort headaches, especially those of the
migraine and histaminic cephalgia types" . . .
(Ryan, Postgrad. Med., 5: 330, 1949).
Literature and samples available on request,
Available in vials  of 25 and 100 scored
50 mg. tablets.
NOTE: To date there is no evidence of toxic reactions with Gravol. However, some individuals may
become drowsy or confused on high or continuous
References: 'i$&&
1. Carliner, P.E., Radman, H.M., and Gay, L.H.:
Science, 110: 215 (Aug. 26, 1949). 2. Gay, L. H.,
and Carliner, P.E.: The Prevention and Treatment
of Motion Sickness. Bull, Johns Hopkins Hosp.,
May, 1949. 3. Beeler, J. W., Tillisch, J. H., and
Popp, W. C.: Proc Staff Meet. Mayo Clinic (Sept.
14,  1949).
And other conditions where
nausea and vomiting are factors
Reports from the literature on
beta dimethylaminoethyl benzo-
hydryl ether 8-chlorotheophyl-
linate (GRAVOL).
"Out of forty-three women
with symptoms from 4-6
weeks, thirty-one (72%) were
completely relieved within 3
hours after treatment. Twelve
women (28%) had no relief."
98.6% effective in prevention
of sea sickness . . . eliminates
symptoms in up to 97.6% of
cases already developed. (2)
Out of 82 patients with moderate to severe radiation sickness, 65 reported good to excellent relief. (3)
Each scored^ tablet contains:
Bet{| dimethylaminoethyl ben-
zohydryl ether 8 - Chlorotheo-
phyllinate  50 mg.
FAir. 0080
NW.   60
When prescribing Ergoapiol
(Smith) for your gynecologic patients,
you have the assurance that it can be obtained only
on a written prescription, since this is the only manner
in which this ethical preparation can be legally
dispensed by the pharmacist. The dispensing of this
uterine tonic, time-tested ERGOAPIOL (Smith) —only
on your prescription — serves the best interests
of physician and patient.
INDICATIONS: Amenorrhea, Dysmenorrhea, Menorrhagia,
Metrorrhagia, and to aid. involution of the postpartum uterus.
GENERAL DOSAGE: One to two capsules, three to four
times daily—as indications warrant.
In ethical packages of 20 capsules each, bearing no directions.
Literature Available to Physicians Only.
Ethical protective mark,
M.H.S., visible only   -
when capsule is cut In
halt at seam..
hew mix UiiJi


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