History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: June, 1953 Vancouver Medical Association Jun 30, 1953

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 BULLETIN
" jf OF
The Vancouver Medical Association
EDITOR
DR. J. H. MacDERMOT
EDITORIAL BOARD
DR. D. E. H. CLEVELAND DR. J. H. B. GRANT
DR. H. A. DesBRISAY DR. J. L. McMILLAN
Publisher and Advertising Manager
w". E. G. MACDONALD
VOLUME XXIX.
JUNE, 1953
NUMBER 9
OFFICERS 1953-54
Dr. D. S. Munroe Dr. J. H. Black
President Vice-President
Dr. George Langley
Hon. Treasurer
Dr. E. C. McCoy
Past President
Dr. F. S. Hobbs
Hon.. Secretary
Additional Members of Executive'.
Dr. R. A. Gilchrist Dr. A. F. Hardyment
TRUSTEES
Dr. G. H. Clement Dr. Murray Blair Dr. W. J. Dorrance
Auditors: R. H. N. Whiting, Chartered Accountant ,.>v..
SECTIONS
Eye, Ear, Nose and Throat
Dr. W. M. G. Wilson Chairman Dr. W. Ronald Taylor Secretary
Paediatric
Dr. J. H. B. Grant Chairman Dr. A. F. Hardyment Secretary
Orthopaedic and Traumatic Surgery
Dr. W. H. Fahrni, Chairman Dr. J. W. Sparkes _M_Secretary
Neurology and Psychiatry |||1
Dr. A. J. Warren Chairman Dr. T. G. B. Caunt Secretary
Radiology
Dr. W. L. Sloan  -Chairman Dr. L. W. B. Card fe_Secretary
STANDING COMMITTEES
Library
Dr. D. W. Moffat, Chairman; Dr. R. J. Cowan, Secretary:  Dr. W. F. Bie;
Dr. C. E. G. Gould ; Dr. W. C. Gibson ; Dr. M. D. Young.
Slimmer School
Dr. S. L. Williams, Chairman; Dr. J. A. Elliot, Secretary;
Dr. J. A. Irvine ; Dr. E. A. Jones ; Dr. Max Frost ; Dr. E. F. Word
Medical Economics
Dr. E. A. Jones, Chairman; Dr. W. Fowler, Dr. F. W. Hurlburt, Dr. R. Langston,
Dr. Robert Stanley, Dr. F. B. Thomson, Dr. W. J. Dorrance
Credentials
Dr. Henry Scott, Dr. J. C. Grimson, Dr. E. C. McCoy.
V.O.N. Advisory Committee
Dr. Isabel Day, Dr. D. M. Whitelaw, Dr. R. Whitman
Representative to ihe Vancouver Board of Trade:  Dr. J. Howard Black
Representative to the Greater Vancouver Health League: Db. W. H. Cockcroft
Published  monthly  at  Vancouver, Canada.     Authorized  as  second  class  mail,  Post  Office Department,
Ottawa, Ont.
Page 387 Raguterad Trad* Mark
IN   LIVER  DAMAGE
!
tA*1-
M*?*'
*rrf>*
gseTt*8
Supplementation with Memine adds flexibility to the dietary regimen
MEONINE...
easy way to
give added methionine
It is difficult to get a sick person to consume a highly nutritious diet1... and anorexia is a prominent feature of liver
disease.
MEONINE...
reduces work
required of liver
Recent research suggests that excessive
dietary protein may impose a burden on
critically ill patients.2
MEONINE helps maintain the detoxifying activity of the liver, and is an
efficient lipotropic agent.
INDICATIONS: Liver damage due to malnutrition, alcoholism, pregnancy,
allergy, or chemo-toxins.
1. Delia Pietra. A.: New York State J. Med.. 49:263, 1949.
2. Editorial: J.A.M.A.. 144:1566 (Dec 30) 1950.
SUPPLIED: TABLETS MEONINE: 0.5 Gm., bottles of 100 and 500, CRYSTALLINE.
MEONINE for preparation of parenteral solutions, bottles of 50 Gm.
Page 38$
MEONINE
41 —METHIONINE   WYETH HOSPITAL CLINICS
VANCOUVER  GENERAL  HOSPITAL
Regular Weekly Fixtures in the Lecture Hall
Monday, 8:00 a.m.—Orthopaedic Clinic.
Monday, 12:15 p.m.—Surgical Clinic.
Tuesday—9:00 a.m.—Obstetrics and Gynaecology Conference.
Wednesday, 9:00 a.m.—Clinicopathological Conference.
Thursday, 9:00 a.m.—Medical Clinic.
12:00 noon—Clinicopathological Conference on Newborns.
Friday, 9:00 a.m.—Paediatric Clinic.
Saturday, 9:00 a.m.—Neurosurgery Clinic.
ST. PAUL'S  HOSPITAL
Regular Weekly Fixtures
2nd Monday of each month—2 p.m | Tumour Clinic
Tuesday—9-10 a.m 1  Paediatric Conference
Wednesday—^9-10 a.m r Medical Clinic
Wednesday—11-12 a.m. Obstetrics and Gynaecology Clinic
Alternate Wednesdays—12 noon Orthopaedic Clinic
Alernate Thursdays—11 a.m Pathological Conference (Specimens and Discussion)
Friday—8  a.m. Clinico-Pathological Conference
(Alternating with Surgery)
Alternate Fridays—8 a.m Surgical Conference
Friday—9 a.m . . JDr. Appleby's Surgery Clinic
Friday—11 a.m . Interesting Films Shown in X-ray Department
SHAUGHNESSY  HOSPITAL
Regular Weekly Fixtures
Tuesday, 8:30 a.m.—Dermatology. Monday, 11:00 a.m.—Psychiatry.
Wednesday, 10:45 a.m.—General Medicine. Friday, 8:30 a.m.—Chest Conference.
Wednesday, 12:30 p.m.—Pathology. Friday, 1:15 p.m.—Surgery.
BRITISH   COLUMBIA  CANCER  INSTITUTE
2656 Heather Street
Vancouver, British Columbia
SCHEDULE OF CLINICS AND MEETINGS—1953
Every Monday—9:00 a.m.-10:00 a.m Ear, Nose and Throat Clinic
11:45-12:45 p.m.  Therapy Conference
Every Tuesday—11:00 a.m.-12:00 p.m . Clinical Meeting
12:00 noon-1:00 p.m | Therapy Conference
Every Wednesday—11:45  a.m.-12:45  p.m Therapy Conference
Every Thursday—11:45 a.m.-12:45 p.m Therapy Conference
Every Friday—9:00 a.m.-10:00 a.m Lymphoma Clinic
(during February)
10:15 a.m.-ll:15 a.m.  (as of March 6) _ Lymphoma Clinic
11:45 a.m.-12:45 p.m  Therapy Conference
Page 391 *
Ouabaine Arnaud and
*
Ouabaine Arnaud
has been adopted  (1928)  at the National Institute lot
Medical Research, London, as the International Standard!
against  which  all  concentrates  or  extracts  of ordinary
strophanthins are standardized for biological activity and f
toxicity.
ABMUD
and only Ouabaine Arnaud
is the strophanthus glycoside which, as a cardiotonic
agent,
{jf^gp3    (A) is established as a pure chemical entity
fl=HP    (B) is uniformely reproduced
{pgjp (C) is therapeutically constant on a weight — purity
basis
figiF3 (D) is not subject to the error of biological standardization
IJiSF3    (E)   is rapid constant and sure in therapeutic action
ff^3    (F)   does not cause or build up habituation
jj^3 (G) is superior to the more ordinary toxic strophanthins or ouabaines which are often ill-defined
chemically and physically and which vary widely
due to plant sources and manufacturing methods.
{JSP3 (H) is particularly indicated in all types of heart
failure with regular rhythm and
fl=g^ (I) in left ventricular failure; left ventricular failure
in myocarditis or accompanying aortic disease or
hypertonia.
*
Ouabaine Arnaud, along with Digitaline Nativelle, are products of which Laboratoire Nattv^lm
is justifiably proud since both are global standards of purity and uniformity in their respectivtk
fields.
Page 392 VANCOUVER HEALTH DEPARTMENT
STATISTICS—APRIL,  1953
Total   population    (estimated)., j !  390 325
April, 1953
Rate per
Number 1000 pop.
Total   deaths   (by   occurrence) \ 450 13.8
Deaths, residents only 419 12.9
Birth Registrations—residents and non-residents
(includes late registrations)
Male   _	
Female	
April, 1953
 5 01
 479
980
Infant Mortality—residents only
Deaths under  1  year of  age ! . 32
Death  rate  per   1000   live  births I j     43.9
Stillbirths   (not included in above item) i       6
30.1
CASES OF COMMUNICABLE DISEASES REPORTED IN CITY
April,   1952
Cases
_    97
Deaths
Chicken Pox	
Diphtheria j —
Diphtheria Carriers I —
Dysentery       9
Dysentery   Carriers —
Erysipelas       1
Gonorrhoea 109
Infectious Jaundice __ _J     15
Measles 127
Meningitis  (meningococcic)        1
Mumps 294
Poliomyelitis	
Rubella	
Salmonellosis	
Salmonellosis Carriers	
Scarlet Fever	
Syphilis	
Tetanus	
Tuberculosis 1	
April,   1953
Cases Deaths
135 —
2
11
1
37
10
1
7
2
134
178
123
10
2
115
11
46
Typhoid Fever___	
Typhoid Fever Carriers.
Undulant Fever	
Whooping   Cough	
OTHER REPORTABLE DISEASES
Cancer	
11
61
1
11
62
80
52
Mount Pleasant Cf?ap?l
FUNERAL    SERVICE    1
Kingsway at Nth Ave. — .   Telephone EMerald 2161
Vancouver 10,   B.C.
flfot pleasant XHnbertaking Co. Xtb.
Page 393 -C CONNAUGHT >
HEPARIN
Clinical experience in the use of Heparin as a blood anticoagulant has
extended over many years. The product has been administered intravenousM
in very dilute solution.
Recent experience has shown that intramuscular injection of concentrated
solutions is an effective means of prolonging clotting time. This method of
treatment provides an increased measure of freedom for the patient and can
be extended over a period of months on the basis of two or three daily injections.
HOW SUPPLIED
Solution of Heparin—Distributed in rubber-stoppered vials as sterile
neutral solutions of heparin prepared from purified, dry sodium salt of
heparin containing approximately 100 International Units per mg. The
product is supplied in the following strengths:
1,000 International Units per cc.
10,000 International Units per cc.
Heparin (Amorphous Sodium Salt)—Dispensed in 100-mg. and 1-gm.
phials as a dry powder, containing 100 International Units per mg., for
the preparation of solutions for laboratory use.
Recent References:
Stats, D., and Neuhof, H.: Am. J. Med. Sci., 1947, 214:
159.
Walker, J.: Surgery, 1945, 17: 54.
Cosgriff, S. W., Cross, R. J., and Habif, D. V.: Surgical
Clinics of North America, 1948, 324.
De Takats, G.: J.A.M.A., 1950, 142: 527.
CONNAUGHT   MEDICAL
University of Toronto
RESEARCH   LABORATORIES
Toronto, Canada
Established  in  1914 for Public Service through  Medical  Research  and the  development
of Product* for' Prevention or Treatment of Disease.
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S    PRESCRIPTIONS   LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C.
Page 394 We had the privilege recently of hearing a' talk by Dr. J. D. Hunter, General
Secretary of the Australian Medical Association, Division of the British Medical
Association. He described the system of Health Insurance now in vogue in Australia—
and gave us the history of the development of this scheme. From the outset the
Australian medical profession, in all discussions of health insurance, have insisted on one
point—that they would not agree to any scheme in which the .government would have
any control of their actions. Another point on which they have made their stand very
clear, is that there must be no alteration in the doctor-patient relationship. They would
not agree to salaried positions, or to the per capita system of payment or panel system
of practice.
Some of us will remember the visit of Sir Earle Page, of Australia, last year, when
we met him at a dinner given for him by Dr. G. F. Strong. He told us then of the plan
fhe had for a health insurance system which would satisfy both doctors and the public.
This plan is now in operation, as Dr. Hunter told us. It is apparently working well,
and we are sure that all of us who have heard this description, were convinced that this
plan deserves our serious study in Canada. It seems to have gone a long way toward
finding an answer to the problem of medical service on a collective basis.
As we see it, there are several important issues at stake in this question of Health
Insurance on a national basis. From the public's point of view, the main issues are
first, that complete and universal medical care be made available to all, and second, that
it be provided at a cost that all can afford, or better still, at no cost. Naturally, the
public wants the best in medical care, but the experience of Great Britain and many
other countries where Health Insurance is in existence, would seem to shew that the
qualities of cheapness and universality are more important, in the final analysis, than
the quality of the medical care received. Half a loaf that they don't pay for is better
than a whole loaf for which they cannot afford to pay, or do not want to pay.
We, as medical men, feel that this can lead to a system of medical care which is
first very poor in quality, and secondly, very far from cheap as far as the taxpayer is
concerned—in fact, our more exact knowledge tells us that it is really very costly, as
well as being very inefficient.
From the point of view of the medical man, the main points for which we strive
and shall continue to strive, are, first, the ability to give good medical care, according
to the highest possible standards. Secondly, we demand a proper physician-patient
relationship, and do not want to work, either on a salary, or on a per capita system.
Thirdly, we want to be paid for what we do, on a reasonable and adequate basis. And
lastly, we want to have control of the number of patients we have to see, the kind of
service we want to give, and that our medical conscience demands of us.
There are many other minor matters but these are vital.
Now, in the type of service given in Great Britain and some other countries such
as Denmark, Norway, New Zealand, and others, this better type of medical care is,
we believe, impossible. Medical men are overloaded, underpaid, unable to give adequate
care to half the patients that they are compelled to see. When one reads and is told
that in some areas a medical man may have to see as many as a hundred patients a day,
even fifty or sixty, we are shocked and disturbed. We know that this can only mean
very poor service. The system is' faulty and grossly abused by those who are its beneficiaries—and we cannot contemplate with equanimity or indifference the prospect of
such a state of things in this country—nor, we believe, would our people want it.
Australia, however, seems to have solved many of these problems. In the first place,
the system is not compulsory, but it is so attractive that nobody can afford to stay out.
Page 395 (We believe it is correct to say that there is an income limit for those in the scheme.)
The government pays 40 % to 45% of the cost into a fund—the Benevolent Funds and
other carriers, through payment by members, pays an equal quantity. Under no circumstances can the Fund pay more than 90% of the doctor's bills. These are paid
direct to the doctor by the patient on the basis of a schedule of fees, which is very
detailed and with which the Australian profession is apparently satisfied. There is no
disturbance of the doctor-patient relationship—the government has absolutely no part
in the administration of the Fund.
The fact that the patient can only recover 90% at the most from the Fund, and
that he himself must pay 10% is one of the good features of this scheme. It helps
greatly to prevent abuse or overuse of the plan, and the patient has a definite interest
in the amount of the bill. He can only recover when he has a receipted bill from the
doctor.
This feature is, we believe, also present in the Swedish scheme of Health Insurance,
which has been described as one of the best in Europe. There the patient, we are told,
has to pay more than 10 %- of the total.
It would seem that our Australian brethren can teach us a great deal in this matter.
We hope that this plan will be thoroughly studied by those who are working on this
question of Health Insurance. It is very difficult to devise a perfect plan of course, but
there is plenty of food here for serious thought.
Library Hours
Monday to Friday  9:00 a.m. - 5:00 p.m.
Saturday ___ 9:00 a.m. - 1:00 p.m.
Recent Accessions
Antibiotics:   A Survey of their Properties and Uses by the Council of the Pharmaceutical Society of Great Britain, 1952.
Poliomyelitis by W. R. Russel, 1952.
Psychiatry and Medicine by L. A. Osborne, 1952.
The Old Egyptian Medical Papyri by Chauncey de Leake, 1952.
The History of Medicine in Ireland by John Fleetwood, 1951.
The History of the Royal Medical Society 1737-1937 by James Gray, 1952.
William Smellie by R. W. Johnstone, 1952.
Medical Clinics of North America, May 1953.
Canada Year Book, 1952-53.
The Conquest of Fear by Harley Williams, 1952.
Medical Research Council Report number 80, Toxicity of Industrial Solvents, 1953.
A Textbook of Mental Deficiency (Amentia) by A. F. Tregold, 1952, eighth edition.
Medical Philosophy of the Eighteenth Century!
When people's ill, they come to I,
I physics, bleeds and sweats 'em,
Sometimes they live, sometimes they die,
What's that to I? I lets 'em.
—Anonymous.
Page 396 British Columbia Ittufsfoit
Canadian ffltbxtal Association
1807 West 10th Ave., Vancouver, B.C.      Dr. G. Gordon Ferguson, Exec. Secy
OFFICERS-1952-1953
President—Dr. J. A. Ganshorn-
President-elect—Dr. R. G. Large.
Vice»-President and Chairman of General Assembly—Dr. F. A. TurnbulL
Hon. Secretary-Treasurer—Dr. W. R. Brewster	
 Vancouver
.Prince Rupert
 Vancouver
Members of the
Victoria
Dr. G. Chisholm
Dr. E. W. Boak
Nanaimo
Dr. C. C. Browne
Prince Rupert and Cariboo
Dr. R. G. Large
New Westminster
Dr. J. A. Sinclair
Dr. W. R. Brewster
Yale
Dr. A. S. Underhill
Dr. C. J. M. Willoughby
Board of Directors
Vancouver
Dr. F. A. Turnbull
Dr. A. W. Bagnall
Dr. F. P. Patterson
Dr. P. O. Lehmann
Dr. G. C. Johnston
Dr. Ross Robertson
Dr. R. A. Gilchrist
Dr. J. Ross Davidson
Dr. R. A. Palmer
Kootenay
Dr. J. McMurchy
-New Westminster
Standing Committees
Constitution and By-Laws.
Finance	
Legislation-
Medical Economics-
Medical Education-
Nominations	
Programme and Arrangements-
Public Health	
Chairmen
 Dr. R. A. Stanley, Vancouver
 Dr.  W.  R. Brewster, New "Westminster
 Dr.  J.  C.  Thomas,  Vancouver
 Dr. P. O. Lehman, Vancouver
 Dr. T. R. Sarjeant, Vancouver
 Dr. J. A. Ganshorn, Vancouver
 Dr. Harold Taylor, Vancouver
 Dr.  G. F. Kincade, Vancouver
Special Committees
Arthritis and Rheumatism-
Cancer	
Civil Defence	
Hospital Service	
Industrial Medicine—
Maternal Welfare	
Membership	
Pharmacy	
Public Relations	
.„Dr. F. W. Hurlburt, Vancouver
 Dr. Roger Wilson, Vancouver
 Dr. John Sturdy, Vancouver
-Dr. J. C. Moscovich, Vancouver
I Dr. J. S. Daly, Trail
 Dr. A. M. Agnew, Vancouver
 Dr. E. C. McCoy, Vancouver
 Dr. D. M. Whitelaw, Vancouver
 Dr.  G. C. Johnston, Vancouver
| ROVING THOUGHTS %.
The General Assembly of the C.M.A., B.C. Division, was held May 23, 1953, at
the Academy of Medicine Building. This was a most interesting meeting and a report
of it will be sent to you through Dr. Ferguson. Frank discussion of various problems
was encouraged and several people got things off their chests that must have been bothering them for a considerable period of time. I think the chairman, Dr. Frank Turnbull,
deserves great commendation for having held the meeting together, kept people to the
subject under discussion, yet encouraged a really full and open airing of many grievances.
I recently attended a gathering where several business men were complaining
bitterly about doctors in general, in the carelessness of appointments. Their thought
Page 397 was that when we make an appointment for a certain time we should keep it—that
their time is just as important as ours, and that it is definitely wrong for us to continue
our present policy of expecting people to wait long periods in our outer offices. Several
told me they had changed doctors two or three times because of this factor. It would
certainly be a simple point in public relations to try and at least improve in this regard.
Perhaps we should check our receptionists a little more thoroughly.
*_ *t. *s.
-C *r nT
Remember the annual meeting of the CM.A., B. C. Division, in September, the!
21st to 25 th inclusive. Why don't you plan on a little holiday to meet old friends and
generally enjoy this meeting?
# * *
o   _
Remember the elections. Think carefully and then vote in order for whom youi
want. Remember our ballots work differently in that every number counts so choose
your men in order of preference, voting 1-2, etc., as far as necessary, to give every
candidate a vote.
F. L. S.
iSf ' ANNUAL MEETING   ■ J»-
Vancouver will be the meeting place for most B.C. medical men in September
when the provincial branch of the Canadian Medical Association holds its annual convention. Once a year outstanding doctors from Canada are invited to address local men.
and present new findings in disease and advances in treatment.
Public relations will form an important part of the conference and a public meeting on "Health Insurance" will be sponsored by the group.
A medical round table will discuss the present status of cortisone and Sir Charles
Symonds of England will give some pointers on closed head injuries. Visiting men will
also speak on toxic effects of antibiotics, perforating stomach ulcers, surgery in toxic
goiter and advances in surgery on cancer of the colon. A Seattle opthalmologist will
lecture on eye injuries.
Dean Myron Weaver of the medical school here will describe some of the pitfalls
encountered during the organizational years of the school, and Dr. John Eden of the
Vancouver General Hospital will discuss fluid balance and intravenous electrolytes in
general practice.
Generally speaking, the meeting will be directed at the doctor who must be responsible for the complete care of the patient in small centres throughout B.C.
As in Victoria last year there will be an entertainment room for liquor and conversation; and a golf tournament on Thursday afternoon. Mart Kenney will play for
a gala supper dance at the H.M.C.S. Discovery and a sparkling speaker will highlight
the annual dinner on Friday.
The ladies will enjoy a fashion show and luncheon at the Hotel Vancouver, a sherrjfcj
party on registration day, a tea at the Art Gallery and free TCA flights over the city.
September 23, 24, and 25 should now be ticked off on the calendar for this outstanding meeting in Vancouver.
J|. HOBBY SHOW      f|
There will be another Hobby Show in conjunction with the Annual Meeting of
the B. C. Medical Association in September 1953.
No matter what your hobby is, we would like you to display your work; metal
work, paintings, sketches, photography, aquariums, antique collections, model trains,
boats and so on. This year, we are also having a display for gardeners and hothouse fans,
to show off their flowers and plants. All displays must be sent to the Bell Captain of
the Hotel Vancouver by Monday, September 21st, 1953.
The Hudson's Bay Company have kindly consented to set up the Hobby display.
Page 398 Hi All work will be unpacked and tallied by professionals and we will be responsible
for repacking and mailing the various pieces to those from out of town. There will be
a guard on duty at all times during the display. Engraved small trophy cups and the
Birks Annual Cigarette Box will be awarded as prizes.
Would you please let me know if you will be displaying your work and roughly
how much space it will occupy. Don't be ashamed to send a sample of your work, it
may give other doctors an idea.
A. C. Gardner Frost,
Chairman, Hobby   Show.
PUBLIC HEALTH AND MENTAL HEALTH NEWS
G. F. AMYOT, M.D., D.P.H.,
Deputy Minister of Health, Province of British Columbia
A. M. GEE, M.D.,
Director, Mental Health Services, Province of British Columbia
PLAN FOR HANDLING POLIOMYELITIS PATIENTS
Jl IN BRITISH COLUMBIA ' ||g||      §      §
During the year 1952 the management of poliomyelitis presented certain difficulties
in this province. These difficulties were in the main due to the tendency of physicians,
hospitals and public health authorities to have all cases of poliomyelitis admitted to the
Vancouver General Hospital regardless of the severity of the case or of transportation
difficulties.
In regard to transportation, the R.C.A.F. has given an outstanding service. In
certain instances flights under dangerous conditions have been made by R.C.A.F. personnel to transport cases of poliomyelitis which could have been treated in the local area.
It was therefore felt this matter should be thoroughly reviewed.
This review was carried out by a committee made up of members of the Poliomyelitis Committee of the Vancouver General Hospital and members of the Health
Branch, Department of Health and Welfare, Province of Province Columbia. The
recommendations herewith presented have been thoroughly discussed with the Health
Unit Directors throughout the province and in the metropolitan areas of Vancouver and
Victoria. Further details and the necessary forms A, B and C may be obtained from your
local health authority.
1. Cases suspected of having poliomyelitis should be reported immediately by the
attending physician to the local medical health officer, as prescribed in Part III of the
Regulations for the Control of Communicable Diseases. The Medical Health Officer
follows the Regulations in reporting to the Department of Health and Welfare.
2. The local medical health officer should ascertain whether cases are bulbar or bulbospinal with respiratory insufficiency. Such cases should be reported by him, using the
fastest means of communication, to the Vancouver District Office of the Health Branch
and he should make arrangements to send the patient to a designated poliomyelitis centre
for treatment.  Vancouver Island cases may be sent to Victoria for such treatment.
3. Cases with complications such as bladder involvement, abnormally high fevers
(103-104°F.), persistent vomiting or paralytic ileus, all of which may prove fatal,
should be hospitalized locally, or, if the attending physician prefers, arrangements may
be made by the local medical health officer to send the patient to a designated poliomyelitis centre for treatment.
4. Uncomplicated cases should be hospitalized locally or treated at home. Transportation of uncomplicated paralytic cases over great distances should be discouraged
and nursing care should be arranged with due regard given to maintenance of paralyzed
muscles in proper anatomical position.
Page 399 5. The local medical health officer should have "Poliomyelitis Form A" completed
by the attending physician and copies should be sent to (1) Department of Health and
Welfare in Victoria, and (2) Vancouver District Office of the Health Branch.
6. Any patient transported to a designated poliomyelitis centre for treatment must
be accompanied by the copy of Form A destined for the Vancouver District Office of
the Health Branch.
7. The local medical health officer should have "Poliomyelitis Form B" completed
by the attending physician 30 days after the filing of Form A and copies should be sent
to the Vancouver District Office of the Health Branch.
8. No case of poliomyelitis in the acute phase may be transported from one municipality to another without permission of the local medical health officer (Sect. 88,
"Health Act", R.S.B.C., 1948).
9. Application for the movement of patients to a designated poliomyelitis centre
shall be made by only the local medical health officer to the Vancouver District Office
of the Health Branch, or on Vancouver Island to the Department of Health and Welfare.
10. The Poliomyelitis Transportation Screening Committee  (Drs. Elliot, Murray!
and Ranta) shall decide whether a patient shall be transported and shall determine the
mode of transportation. On Vancouver Island, Drs. Gayton and Taylor will serve in
the same capacity for cases designated for Victoria.
11. Where essential, air transportation will be initiated by the Vancouver District
Office of the Health Branch.
12. The Medical Officer of the R.C.A.F. in charge of air evacuation will determine if air transport is possible. If it can be done, air transport will be undertaken. If
it cannot be done, the Medical Officer will inform the Vancouver District Office of the
Health Branch and the Poliomyelitis Transportation Screening Committee will arrange
alternate transportation or otherwise advise on the handling of the patient.
13. Application for the movement of post-poliomyelitis paralytic patients to a
designated poliomyelitis centre for rehabilitation shall be made by the local medical
health officer on "Poliomyelitis Form C" which should be sent to the Vancouver District
Office of the Health Branch.
Jl NEW T.B. MENTAL UNIT
On May 5, 1953, the Kennett Construction Company was awarded the contract
to construct the North Lawn Building at the Provincial Mental Hospital, Essondale, B.C.
This new unit has been specially designed to provide facilities for caring for
mentally ill patients with tuberculosis, with smaller areas set aside for the isolation and
treatment of other infectious diseases.
This new building will contain 228 beds and will cost $1,517,000.00.   A federal^
hospital construction grant has been authorized by the Department of National Health
and Welfare.
It will be a three storey building of modern design constructed of reinforced concrete and incorporating a sun deck on the roof to be served by an elevator.
Well trained CANADIAN GRADUATE WANTED to take over long
established general practice in City on Coast. Doctor retiring. Good
hospital, good offices and residence available—for sale or rent. Good
opportunity for surgery. Equipment only for sale. Good terms to
right man. Reply to: The Bulletin of the Vancouver Medical Association.   675 Davie Street.   MArine 7729.
Page 400 THE TREATMENT OF CARCINOMA OF THE LOWER LIP
by
A. Maxwell Evans, M.D.C.M., D.M.R.E.
Director,
British Columbia Cancer Institute
Paper given at the Refresher Course
On Malignant Disease
British Columbia Cancer Institute
October 6, 1952.
This paper is an analysis of 162 cases of squamous cell carcinoma of the lower Up,
of patients treated at the British Columbia Cancer Institute between the years 1938 and
1946.   All are cases which were not treated prior to admission.
The ages of the patients varied between 20 and 91 years. The majority were
between the ages of 50 and 70, and this is the sort of age-grouping that has been
reported in other series of cases. Three cases were in females, so it can be seen that by
far the largest number occur in the male sex. This is not so, however, in carcinoma of
the upper Up, and the incidence here, is about 9 males to 1 female. W^
Carcinoma of the lower lip is a slow-growing disease—the average length of
symptoms, from first appearance to that of treatment is about 13 months, but the
time of first appearance to treatment varies all the way from a few months up to
twenty years. Over half the patients in this group^86 out of 162, gave a past history
of some significance. That is, they gave a history of smoking, or had frequent cold
sores on their lips, or had irritation from jagged teeth, or smoking a pipe, or getting their
lips chapped. The typical history of the beginning of a carcinoma of the lower lip, is
the formation of a small nodule, an ulcer or a crack. Either one of these grows slowly
over the years and ulceration will eventually occur in all cases. Regarding the situation
in the lip of the primary tumour—-of these 162 cases—54 were situated on the right
side, 60 on the left side, 23 in the centre of the lip, 12 on the right side and centre, 6
on the left side and centre, and 7 involved the whole lip.
At this Institute we have used the following method of staging cancer of the Up.
Stage I—The primary growth is limited to the lip and is not greater than 3 cms. in
diameter.   There are no palpable lymph nodes.
Stage II—The primary growth is confined to the lip and not greater than 4 cms. in
diameter with no glands palpable in the neck.
Stage HI—The primary growth as in Stages I or II, but a node or multiple discrete
nodes are present in the neck on the same side as the lesion.    These nodes are not
fixed.
Stage IV—(a) Where the primary growth is more advanced than Stages I and II;
(b) Where the lymph nodes showed evidence of spread beyond the capsule, or
there are bilateral lymph nodes, even if they are mobile, and
(c) Where there are remote metastases.
The 162 cases fell into the following stages:
Stage I—148 cases
Stage II—7 cases
Stage III—4 cases
Stage IV—3 cases
The diagnosis is easily made in most cases, on the clinical appearance alone, but
all cases should have a biopsy, and histologically the tumour is found jo be a squamous
cell carcinoma, showing varying degrees of malignancy. In our cases, the histological
grading was as follows:
Grade 1   —72 cases
Grade 1-2—16 cases
Page 401 Grade 2 —51 cases
Grade 2-3—18 cases
Grade 3   — 2 cases
Two patients out of the 162 had no biopsy—that is, 160 were verified histologically.
The method of treatment in these 162 cases was the following—radium needles
were inserted into the lip in 105 cases; 17 cases had a radium mould applied; 32 cases
had x-ray therapy and 8 cases surgical excision. It did not appear to make a great
deal of difference what method of treatment was adopted for the primary tumour, but
it is quite obvious from this survey that treatment by radium either in the form of
radium needles or mould, is an extremely satisfactory method of treatment of cancer
of the lip, and I personally prefer it to that of x-ray therapy. We have been using what
we call high-tensity needles, that is, 10 mgm. needles, anywhere from 4 to 8 and 10
inserted into the lip. These are left in for a period of 4J-4 hours as a rule, and that
constitutes the full treatment. It is a very satisfactory one for patients who come from
out-of-town and do not wish to stay in town very long. The cosmetic result is very
good. The procedure can be done under local anaesthesia and does not reguire
hospitalization. Radium needles are eminently suitable for smallish lesions. If the
tumour involves the whole lip x-ray therapy or some method of beam-directed therapy
is preferable. Surgery is an equally effective method of treatment of smallish lesions, but
I think the tendency, in surgery, has been that not enough of the tumour has been
removed, with the result that the recurrence rate is higher with this form of treatment—
but adequately performed surgery has given just as good results as other forms of
treatment.
Of these 162 patients, 6 of them had glands on admission and 8 developed glands
after admission. An analysis of the 6 cases with glands on admission reveals the
following facts: 1 patient, aged 76, had the whole lip involved, with glands on both
sides. He was a Stage IV case. The primary lesion was treated with radium mould,
and the neck with x-ray therapy. He died within the first year. The second patient
was 85. The tumour involved the centre of the lip. Glands were involved on the
right side, and they were fixed. This was a Stage IV case and he died within the second
year. The third case was 65, the tumour was situated on the left side of the lip. The
glands were on the left side of the neck, clinically a Stage III and he died within the
first year. The fourth patient was aged 61. Primary tumour was on the left side.
Glands were present on the left side and later on the right. He at first was classified
as Stage I and he died within the first year. The fifth patient was aged 46. His primary
tumour was in the right lower lip. Glands were fixed on the right side. He was a
Stage IV case and he died in the second year. The sixth case was aged 64. The tumour
was in the centre of the lip. Glands were involved on both sides. He was a Stage IV
case. He died in the second year. All these patients receivd x-ray therapy to the
secondary nodes, and histologically all the tumours were Grade 2. Only two of the
cases—that is the two cases of Stage III—might have been salvaged by radical neck
dissection.
An analysis of the 8 patients who developed glands after admission reveals the
following facts: The first patient had a tumour on the right side of the lip. It was
treated satisfactorily by a radium mould. Stage I case, Grade 2. He developed a hard
fixed mass on the right side of the neck, six months after admission. He was aged 70.
He received x-ray therapy to the neck, and died within the second year following admission. The second patient had a tumour on the left lower lip. Stage I, Grade 1.
Age 50. The primary tumour was treated satisfactorily with a radium mould. He
developed glands^ on both sides of his neck—hard and fixed—nine months after
admission. He received x-ray therapy, and died within the first year. The third
patient had the primary tumour on the left lower lip. Stage I, Grade 1. Age 48.
The primary was satisfactorily cured( with a radium mould. He developed a gland on
the left side 1 year after admission.    This was excised and followed by x-ray therapy
Page 402 and he is alive and well. The fourth patient had the primary tumour on the right
lower lip. Stage I, Grade 2. He was 67 years of age. The primary was satisfactorily
treated with radium needles. He developed a gland on the right side of the neck six
months after admission. This was excised and x-ray therapy was given afterwards.
He is alive and well. The fifth patient had most of the lip involved—we classified him
as Stage II, Grade 2. He was 69 years of age. He had x-ray therapy to the primary
and fixed glands developed on the right side two months after admission. He received
x-ray therapy to the glands, but died in the second year. Case number six had the
primary in the left lower lip. Stage I, Grade 1. He was 70 years of age. The primary
was satisfactorily treated with radium needles. He developed a new lesion in the sixth
year in the right lower lip and then later, glands in the right side and died within the
sixth year. Case number seven had the primary tumour in the left lower lip. Stage I,
Grade 1. He was 91 years of age. The primary was treated satisfactorily with x-ray
therapy. He developed fixed glands in the left side of the neck, one and a half years
after admission—these were treated by x-ray therapy unsuccessfully, and he died within
the second year. Case number eight had the primary tumour in the left lower lip—
Stage I, Grade 1. He was 74 years of age. He had the primary treated by x-ray
therapy satisfactorily. He developed glands two years after admission. The glands were
on the left side—not fixed. He was given x-ray therapy, but died within the second
.year. All the primary tumours in these eight patients were satisfactorily healed, none
of them received a radical neck dissection for varying reasons. However, our policy
is that when glands are in the neck, the primary is cured and glands are technically
operable—that is, they are not fixed—a radical neck dissection should be carried out.
The survival figures are of interest in this group of cases.
Alive and well five years and over 128 cases
\ Died of disease within 5 years  14 cases
Died of intercurrent disease before 5 years with
no cancer present  15 cases
Untraced     5 cases
The 5-year survival figure is, therefore, 79%. This is what is called the crude
survival rate. If one wishes to take into account the probability of not dying (probability figure—.84)—that is, deducting these cases which would normally die anyway
from other diseases, one arrives at a figure of 94% 5-year survivals. This is called the
corrected survival rate.
SUMMARY:
(1) A review of 162 cases of cancer of the lower lip has been presented. It is a disease
of men—principally between the ages of 50 and 70. Slow-growing, and a disease which
can be adequately and effectively treated by radium or x-ray therapy.
(2) 8% of the patients developed glands. They either have them On admission, or will
develop them within a short period of time. The curative treatment of metastatic
lymph nodes in the neck is a radical neck dissection, provided there is no evidence of
extra capsular extension, the primary is cured and there is no contradiction to surgery
on medical grounds.
(3) The crude five-year survival figure is 79%.   The corrected survival figure is 94%.
COMPETENT BOOKKEEPING
CONFIDENTIAL AND REASONABLE
Phone: CEdar 0857—EVENINGS
Page 403 INJURIES OF THE CHEST
G. D. SAXTON, M.D.
Minor Chest Wall Injuries—
This group comprises those strains, sprains and contusions that are ordinarily of
little importance. But in the chest wall the duration of pain or discomfort is often out
of all proportion to the degree of injury. The constant slight movements of the chest
wall seem to exert an irritating effect on nerve endings. Weeks after a trivial injury
considerable pain may be persisting. A reflext arc is established, pain, spasm, irritation,
pain, etc. Often the arc can be broken at the point of tenderness by a simple novo-
caine injection. This may be in the outer chest wall muscles or in the intercostal
muscles. If no definite spot of tenderness can be detected, an intercostal block may
produce the same effect. The patient, who may have been apprehensive of some
deeper disease in hear or lungs, is grateful for the demonstration that the origin is in
the chest wall.
Costal Cartilage Fracture or Dislocation
This is not a common in the absence of other chest injuries. If there is no overriding, and pain is of significance, an attempt may be made at open reduction with
suture of the fragments by a heavy silk suture. If seen later and considerable prominence is present, the projecting cartilage may be excised. The dislocating tip of the 9th
costal cartilage rarely gives symptoms. If pain is present, a simple excision of the tip
of the cartilage can be done.
Simple Rib Fracture
The fracture of a single rib produces pain in relation to the nervous stability.
Frequently no treatment is required. If the patient has a cough, or is leading an active
life, adhesive strapping may be applied. But after a few days the irritation of the
adhesive is often greater than the pain of the fracture and the patient is grateful for
its removal.
If several ribs are fractured, intercostal blocks are indicated. They relieve pain
and spasm and the splinting of the entire injured side that is usually present. They
can be repeated several times and give considerable relief. If the patient is seriously
enough injured to be admitted to hospital, they ar a worthwhile procedure. Personally,
I do not feel they should be advocated as office practice by physicians unaccustomed
to the procedure. There is too great a danger of producing a traumatic pneumothorax
in inexperienced hands.
Rib fractures are particularly dangerous in the older age group or those with any
tendancy to respiratory infections. Pain prevents coughing to remove secretions. This
leads to anoxaemia and cyanosis and eventually heart failure. Removal of secretions
by catheter suction or by bronchoscopy, and intercostal nerve injections are frequently
live saving in this type of case.
Complicated Rib Fractures
The complications of haemorrhage or air leak are usually much more important
than the fractures. They may occur singly or any combination of the two may be
present.
Traumatic Pneumothorax
A spicule of bone tears the visceral pleural envelope. This permits escape of air
by" each inspiration into the pleural space. Pressure is built up slowly or rapidly,
depending on the extent of the pleural rent. If small, the collapsing lung will usually
seal the opening before serious distress is experienced. But if larger, the pleural pressure
will increase and the lung will collapse completely. As the pressure becomes positive,
the mediastinum will shift and the opposite lung will be compressed as well. By this
time dysnoea is extreme.
Treatment in the first instance is directed toward the relief of dyspnoea. If the
pneumothorax is small, and there ,is no shortness of breath, no active treatment is
Page 404 necessary. The wound is a tear of healthy lung tissue. Collapse allows the edges of
the fresh wound to fall together permitting them to seal the defect. If the tear is
small, sealing will occur with moderate collapse before dyspnoea is experienced. This
case is better left alone for several days. If X-ray then shows the lung to be re-expanding, nature should not be interfered with. But if the collapse remains the same, a
careful aspiration under manometer control is indicated. If the pressure remains
negative on withdrawal of air, the rent has not re-opened.
If dyspnoea is present, some air must be withdrawn.   The the balance between
opening the rent by reducing intrapleural    pressure, and the amount of collapse the
■patient can stand without dyspnoea, must be found.   Aspirations of moderate amounts
[of air several times at intervals will usually control both leak and dyspnoea.   Then
when air leak has ceased for several days, the lung can be re-expanded by removal of a
larger quantity of air.
If the tear has been a large one, dyspnoea will be severe when the patient is first
seen. Aspirations once or twice will demonstrate that the leak is continuing rapidly.
Thn some method of continual removal of air is necessary. As a temporary measure,
a needle into the intra-pleural space attached to a water-sealed bottle will permit air
under pressure* to be blown off. But the danger of the needle plugging is too great to
trust this alone for long. A small catheter in a high anterior intercostal interspace
leading into a water bottle at floor level is easily introduced through a cannula. As the
hole seals the expanding lung will occupy the pleural space, the air being withdrawn by
the slight suction exerted by the water bottle.
One or other of the above approaches will handle almost all cases of traumatic
pneumothorax. Instances will occur, however, where the tear has been so great and
there has been so much lung destruction that spontaneous healing does not occur. Then
thoracotomy with suture of the tear, or partial or complete lobectomy may be
necessary.
Spontaneous Pneumothorax
At this point it may perhaps be convenient to compare and contrast the behaviour
of a traumatic pneumothorax with that type called spontaneous. While the latter
usually does occur spontaneously, it may occur during straining movements, and not
infrequently as the restul of a minor chest injury. The history of this case is given
as, T bumped my chest but did not think much about it.' There are no broken ribs, no
spicules of bone to tear the lung.
The spontaneous pneumothorax differs from the traumatic one in the character of
the visceral pleural defect. In the traumatic type healthy pleura has been punctured,
the wound edges will seal by contact as the lung collapses. In a spontaneous pneumothorax, almost invariably, a smooth epithelial-lined sac will have given away. The wall
of this sac has epithelium on both aspects. Probably no bleeding has occurred. There
is no clot to form the matrix through which fibroblasts could grow to produce healing.
In addition, a bronchiole of appreciable size may well lead into the bleb which has
been formed by the breaking down of adjoining septal walls. The duration of a
spontaneous pneumothorax is frequently, therefore, much longer than that of a traumatic
one. The patient with a spontaneous pneumothorax quickly adjusts to a collapsed lung.
Frequently one aspiration will relieve dyspnoea. Repeated aspirations, however, tend to
keep separated the edges of the bleb and delay healing. If healing is unduly prolonged,
a thoracotomy with closure of the defect is indicated. In the event of recurring collapses, the induction of a chemical pleuritis by the introduction of a few minims of
10% silver nitrate will frequently prevent recurrence. The produces considerable
pain and constitutional reaction but may save the necessity of a thoracotomy. If this
is done while there is still an air leak, it will be impossible to get the pleural surfaces
in contact and the procedure will fail.
An example of a traumatic pneumothorax is that sometimes produced by needling
a chest.   In the establishment of an artificial pneumothorax the needle may penetrate
Page 405 the visceral pleura and allow the lung to collapse. A similar accident now not uncommonly seen follows the introduction of local anaesthesia to produce a brachial or stellate
block. The collapsing lung may tear a pre-existing pleural adhesion. This may permit
haemorrhage, sometimes of an alarming degree. We had two such cases in hospital
within days of each other, both of whom required 6 or 8 bottles of blood to revive
them. Added to the dyspnoea of insufficient lung is the dyspnoea of insufficient oxygen-
carrying blood and the shock and lowered blood pressure of the haemorrhage. This
patient is desperately ill in contrast to the other who shows a varying degree of distress.
Intrathoracic Haemorrhage
Except for the aforementioned adhesion tear, and the rare instance of damage to
intercostal vessels by an exploring needle, bleeding into the pleural space is usually the
result of injury to the vessels by the sharp point of a fractured rib. If the arch of the
chest is maintained the vessel does not have a chance to retract. Bleeding is of ten considerable, sometimes to an exsanguinating extent. By the time the patient has reached
hospital, he may be in need of transfusion. Having reached the stage of shock and
lowered blood pressure the bleeding usually stops. I have not personally known of a
case where open ligation was necessary. Removal of the blood from the thorax should
be done as soon as possible. The blood clots quickly but the constant movements in
the thorax cause defibrination to occur. This produces liquefaction but the fibrin is
deposited on the visceral and parietal pleurae. Repeated aspirations of the forming fluid
will keep the lung expanded and the fibrin envelope will be thin. The haemothorax
which is neither aspirated at once, nor repeatedly at an early stage, produces the hard
shell of fibrin which binds the lung into a small functionless mass. The contracting
fibrin produces indrawing of the chest wall, and complete loss of movement of both
chest wall and diaphragm. In addition to the loss of functioning alveoli, there is the
shunt of blood through the airless lung. This patient is much more disabled than if the
involved portion of lung were removed.
Prompt and persistent aspiration will, in a fresh case, almost certainly result in
good function. If seen later when fibrin formation is occurring, aspiration may still
be satisfactory. It was in this latter type of case, two to three weeks after the original
injury, that decortication during World War II gave such excellent results. Trypsin
digestion of the early envelope with Tryptar offers excellent chance of avoiding surgery.
This substance liquefies the fibrin which may then be removed by aspiration. In the
later stages, seen several weeks or months after the original injury, nothing short of
formal decortication is of any value. This procedure consists of opening the thorax and
peeling from the chest wall, the lung, the pericardium and the diaphragm an envelope
of fibrin varying in thickness up to an inch or more. A pleural space may be present
containing fluid, or a hard mass formed by the fusion of the two layers may be present.
The duration gives a clue to the ease of peeling. Up to six months fusion of the fibrin
to the pleura is not marked. Later fibrous tissue tends to grow across and the union
may be very firm. Separation is then difficult and bleeding may be considerable. The
lung is expanded by positive pressure and the pleural space is kept dry and airless by
two intercostal catheters attached to a negative pressure apparatus.
Post Traumatic Effusion
A severe contusion of the chest which, at the original X-ray showed no evidence
of fluid, frequently produces within the next days a considerable effusion. This may
be slightly blood tinged but is not a haemothorax. The pleural trauma results in an
outpouring of fluid. A repeat X-ray a few days after injury is indicated so that this
fluid may be spotted and aspirated.
Stove-in-Ches t
Unfortunately the patient who has had a severe crushing injury to the chest frequently has other injuries more likely to be fatal, particularly of the head or spine. The
general condition of this patient does not warrant  any more interference than the
Page 406 removal of intrapleural air and the replacement of blood. However there is the occasional case with the stove-in-chest who deserves a more direct attack. If two or more
ribs are broken in two places the rigid arch of the chest is destroyed. The mobile plate
of ribs and intercostal muscles is drawn in on inspiration and forced out on expiration
producing the condition of paradoxical respiration. In addition to the severe pain produced the functional efficiency of the chest is markedly impaired. Sand bags against the
softened area give some stability but with depression of the plate. The described procedure of placing a screw or hook in one of the ribs and applying traction is a cumbersome and immobilizing method of treatment. Exposing the ribs at the site of posterior
fracture, replacing them in position and holding them by a wire suture gives markedly
increased stability. The procedure need not be a big one, and with due regard for the
treatment of the original traumatic shock, the hazard of this operation is not great.
This patient, 24 hours after surgery, is in much better condition than the one treated
conservatively.
Post-Traumatic Atelectasis
Bronchial spasm, increased bronchial secretion, bleeding into the bronchial tree,
suppression of the cough reflex by the sedation given to control pain, the severe pain
produced by cough all combine to make atelectasis a frequent and dangerous complication of severe chest injury. It must be suspected in every case of injury. Rising respiratory rate, increased pulse rate, developing cyanosis point to this complication. Portable
X-ray confirms it. No length of time should be allowed to elapse before bronchoscopic
suction. It may be permissible to attempt to pass an endotracheal catheter for suction
but this will likely not be successful. The patient cannot cough, otherwise he would
not have developed atelectasis; encouraging him to cough is usually useless. Relief
obtained by bronchoscopic suction is dramatic and often life saving. This type of
atelectasis should be distinguished from that following surgical operation when the chest
is uninjured. In the latter, with an intact chest wall, time can be spent in stimulating
the cough reflex, often with success in expelling the obstructing plug. The patient with
the chest injury who has survived his first few days and seems to be progressing satisfactorily still remains a candidate for atelectasis if an anaesthetic is given for the treatment of other injuries.
Penetrating Wounds of the Chest
The first aid treatment of the sucking wound is the life saving procedure. If the
chest wall wound is blocked the case is converted from an open to a closed pneumothorax. Then all the factors of the closed case are still acting, but this case need not
be as desperate or as rapidly fatal as an open pneumothorax. At hospital, with controlled
respirations under anaesthesia, time can be taken for proper debridement of the wound.
This may entail a lobectomy for damaged lung, or suture of a lung tear; and repair of
the chest wall defect. The loss of considerable substance of the chest wall was previously
a grave disadvantage. But since the discovery of the use of Vitallium mesh, or blocks
of fascia, considerable defects can be satisfactorily covered. A block of fascia lata from
the thigh cut to fit the defect and sutured, smooth side inward, tightly to the edges of
the wound of the bony thorax gives an air-tight closure against which the lung can
expand and move freely. Enough rigidity is achieved to prevent paradoxical respiration.
Skin flaps can be turned to cover the fascia and grafts applied to the donor site.
Mediastinal Emphysema |||;
Increased intrathoracic pressure from straining, or from a blow on the chest such
as would be produced by a man hitting the steering wheel of a suddenly stopped car
may produce the condition of mediastinal emphysema. Alveoli adjoining blood vessels
are ruptured. Escaping air tracks along the vessels to reach the mediastinum in which
it ascends to the neck. It remains enclosed within the pleura and ordinarily does not
rupture through to produce a pneumothorax. Symptoms and signs depend on amount
of air escaping.   This may vary from X-ray evidence of air within the mediastinum to
Page 407 enormous swelling of the neck with compression of veins and interference with venous
return. Aspiration of the air or opening of the soft tissues of the neck may, in rare
instances, be necessary to relieve obstruction.
Traumatic Diaphragmatic Hernia
A dramatic but rare complication of crushing injuries of the abdomen is a rupture
of the left dome of the diaphragm with herniation of the abdominal contents into the
chest. Symptoms may be delayed for a short time but as the hernia increases in extent
respiratory symptoms increase. A chest approach facilitates replacement of the viscera
and repair of the diaphragm.
TREATMENT OF ANEURYSM OF ABDOMINAL AORTA
WITH CELLOPHANE ft||
*Peter E. Rees-Davbss, F.R.C.S.(£ng.), F.R.C.S. (C).
Osier, writing in the Lancet in 1905, credits Valisneri of Padua with the first
report of operation on an abdominal aneurysm in 1719. This physician correctly diagnosed a large pulsating abdominal tumour. A surgical colleague, whose name is not
mentioned but who was described as unskilful, obliged with the classical operation of
lancing the tumour with catastrophic results.
The first aorta was ligated for aneurysm by Sir Astley Cooper at Guy's Hospital in
1817, the patient living forty hours. Sir Astley stated he was "much abused for this
operation".
The next ligation was done at the Devon & Exeter Hospital by Mr. James in 1830.
The operation report reads: "As soon as the division of the parietes was effected, the
viscera protruded and the efforts of the poor fellow continuing strong, I soon found
myself embarrassed with almost the whole of the bowels, nearly all of the colon and a
great part of the small intestines being pushed out and presently quite distended with
flatus". Added to the insuperable difficulties of such an operation without anesthesia,
he was further handicapped by breaking the wooden handle of the aneurysm needle.
The Lancet tersely commented: "An appalling operation and we hope not to hear of its
repetition".
Between Sir Astley's ligation in 1817 and the year 1940, thirty patients appear to
have undergone surgical treatment for aneurysm of the abdominal aorta and only six
of these survived for more than a year, (DeTakats and Reynolds, 1947). The method
of occlusion, partial or complete, may be classified according to whether the attack is
made on the outside, on the inside, or on the whole of the affected vessel.
Untreated, the period of survival is one to two years from the onset of symptoms.
1. Occlusion of the feeding vessel from without by contracting clamps, rubber
tubes, bands and cotton tape (Matas3, 1940, Morton4 & Scott, 1944). In nearly all
cases the occluding agent has occasioned later damage to the vessel wall and the aneurysm
has ruptured (Reid5, 1924). Even when obliterative aneurysmorrhaphy has been added
to this type of occlusion, erosion and haemorrhage have occurred (Jenkins6, 1948).
Average length of survival, 6-18 months.
2. The insertion of wire into the vessel, with or without electro-coagulation, can
be applied successfully only to the least common saccular form. It appears that nearly
half the patients die within a few days or a few weeks of wiring, though one of
Wheeler's7 (1917) patients lived for four years and eight months after the operation.
Fascia lata has been employed to occlude vessels successfully in the experimental animal
(Reid5, 1924).
*Read before the British Columbia Surgical Society April 30, 1953.
Page 408 3. Attempts to promote fibrosis and contraction around the aneurysm and the
feeding vessel have included painting with irritants, the injection of sclerosing solutions,
cauterization, and other methods of controlled trauma, but most of these have been
shown experimentally to be either too severe or to be ineffectual (Pearse8, 1940).
To. these can now be added the effects of the application of cellulose film. In 1936,
it was observed that this material could be used in the body with the minimum of
tissue reaction, for example, in the repair of defects in the dura mater (Donati9, 1937).
Just the opposite effect was observed in 1939, when, during attempts to produce
experimental hypertension, it was shown that a fibroblastic reaction leading to dense
fibrosis could be produced in animals (Page10, 1939, Graef11 and Page, 1940).
Consideration of these contradictory results led Poppe12 and De Oliveira (1946)
to investigate the reactions of the basic types of cellulose film. Little reaction occurred
with films of cellulose hydrate, polyvinyl alcohol and cellulose acetate. With polythene
film, however, there was a marked fibroblastic reaction in the vessel wall, the lumen
being considerably decreased and the thickness of the wall increased as much as six times.
In some cases the sac became thrombosed and occlusion occurred. Similar results had
been obtained by Pearse8 (1940) using cellophane (DuPont 300 p.t.) soaked in alcohol
or mercury oxycyanide. This experimental work was supported by the report of an
apparent cure of a subclavian aneurysm treated by the application of boiled cellophane
(Harrison and Chandry13, 1943).
It must of course be remembered that it may be most undesirable to invoke fibroblastic reaction on both sides of a cellophane strip, as will be abundantly clear from our
own experience which is recorded below. It should be possible to render one side of a
cellophane sheet innocuous by placing a layer of inert film on the required side. Such a
technique is described in a recent edition of Surgery, Gynecology and Obstetrics, the
patient being alive and well one year after operation. fg*^
Yeager14 and Cowley (1948), from their own experience, and discussion with
manufacturers, concluded that the disparities were due to commercial adulterants. They
found that pure polythene produced no inflammatory reaction whereas polythene
treated with dicetyl phosphate (1 % ) caused fibrosis.
Consideration of the causative pathology and examination of the post mortem
specimens of aneurysm suggests, of the methods available, that the one which leads
primarily to a strengthening of the weakened wall and secondarily to a decrease in
lumen is most likely to prove successful. It is with this object in view that irritant
cellophane is used.
Cellophane may be applied in various ways:
1. The film may be used to encircle the aorta proximal to the aneurysm causing
a constricting fibrosis thereby decreasing the blood flow; this relieves pressure
in the aneurysm and prepares the collateral circulation. A second operation may
follow when ligation can be attempted.
2. Where encirclement is not possible, sheets or strips may be cut to the size of
the aneurysmal sac, fitted round and secured by sutures.
3. A combination of these two methods may be more successful, when possible.
4. Film may be passed round the vessel and a reinforcing band of more rigid
material applied outside (Cooper15, Robertson, Shea and Dennis, 1949).
From the cases that have been reported, it would appear that the average survival
is about fourteen months. The experience gained from these earlier cases suggests that
with improved technique there will be an increased longevity for the more recently
treated patients.
An account now follows of two patients whose abdominal aneurysm were wrapped
with cellophane.
The first, Mr. A. B.—a 64-year-old retired civil servant is of particular interest
because he successfully passed his film per rectum.   He was admitted to hospital in
Page 409 February, 1947.  Two weeks previously he had developed at attack of diarrhoea followed
by vague abdominal discomfort.   He had also complained of pain and swelling of the <
right leg and foot, unrelieved by rest in bed.
On examination, he was a well nourished, healthy-looking man. A mass was j
palpable in the umbilical region of the abdomen about 12x9 cm. in size. Tender on
palpation, it exhibited an expansile impulse and could be obliterated by compression. It j
was oval in shape with its long axis in the line of the abdominal aorta. Although
attached to the posterior abdominal wall, it could be moved from side to side though
not in a vertical direction. A soft bruit could be detected on auscultation. The cardiovascular system was otherwise within normal limits; the B. P. 140/85. The pulses of
the lower limbs were easily palpable and equal on both sides. Haemoglobin was 85%.
Kahn was negative. NPN was 52 mgms. %.
X-Ray examination showed no aortic calcification and no vertebral erosion.
A preoperative diagnosis of arteriosclerotic aneurysm of the abdorninal aorta was
made and laparotomy was carried out in March 1947 by Professor Ian Aird.
Through a paramedian incision a saccular aneurysm of the abdominal aorta was
visualized just above the bifurcation. The aneurysm was mobilized. Five pieces of
cellophane, 15x15 cm. were then wrapped to enclose the whole of the aneurysm except
the aspect in contact with the vertebral column. The divided peritoneum was then
sutured over the cellophane and the abdomen closed.
Sixteen months after operation, he was admitted to hospital with small bowel
intestinal obstruction. This was found to be due to adhesions between the upper jejunum
and the aorta. These were separated and recovery was satisfactory. Two and a half
months later he passed a mass per rectum. This was found, on unravelling, to consist
of five squares of cellophane, four of them being recovered intact and the fifth being
fragmented. It was greatly feared at this time that the contents of the aneurysm might
swiftly follow its wrapping, but happily the distention subsided and, apart from some
stubborn constipation, his condition was much improved.
Seven months later he was re-admitted with obstructive symptoms. Shortly after
admission, he collapsed and died.
Post Mortem Examination—The stomach, small and large bowel to mid transverse
colon was distended with blood. The posterior aspect of the jejunum, immediately below
the duodenal juction was firmly adherent to the anterior surface of the abdominal aorta
to which it was connected by a fistula. In this region the aorta was dilated to form
what was now a fusiform aneurysm, 7 cms. in length. The aneurysm was almost completely filled by firm fibrin thrombus which was adherent to the wall of the aorta over
nearly its whole internal surface. The adjacent loop of jejunum had also largely been
replaced by fibrous tissue. There was a small abscess cavity surrounding the aneurysm
almost entirely. It seemed likely that the abscess had arisen when the cellophane was
eroding through into the bowel.
Case Two—Mr. S. B., aged 66, who is occupied in a pumping station, is also of
particular interest as his aorta was tied twelve months ago, in April 1952. Operation
for inguinal hernia was carried out by his doctor. In spite of this being performed satisfactorily, and without complication, he continued to have abdominal pain. Laparotomy
was done by his doctor and exploration of the abdomen revealed an aneurysm of the
abdominal aorta.
April 19, 1952—He was admitted to St. Paul's Hospital. Examination of the
abdomen revealed a tender pulsatile swelling in the umbilical region. Precise localization
was prohibited by previous midline incision. The cardiovascular system was otherwise
normal for a man of his age. Routine investigation, including Kahn, was negative.
April 24, 1952—Operation was carried out by Dr. L. H. Appleby. The abdomen
was opened through a long left paramedian incision. The abdominal aorta was then
exposed and freed from surrounding organs. The aneurysmal dilatation began just below
the renal vessels and extended down to the bifurcation. Using umbilical tape, clothed
in polythene cellophane, the aorta was tied securely immediately below the renal vessels.
Page 410 This rendered the vessel pulseless distal to the ligature. The aneurysm was then dissected
clear of surrounding structures and completely wrapped in polythene cellophane sheets.
The peritoneum was then securely closed over the wrapped aneurysm.
Postoperatively, the lower extremities were warm although no pulsation was
detected in the vessels for forty-eight hours. Pulsation was considerably reduced but
was still present at the site of the aneurysm.
He became ambulant on the second day after operation and, apart from occasional
abdominal pains, had an uninterrupted convalescence.
Re-examination January 20, 1953—Mr. S. B. stated he was able to carry out his
job which entails supervision of the flood prevention in the Dewdney District. He also
has a farm which he manages with his wife. His chief complaint is weakness in the hips
and thighs on exertion.
On examination—Healthy appearance.
Abdomen—There is now no pulsation in the aneurysm area. No pulsation can be
felt in the femoral vessels although the limbs are warm and give him no pain. There
is some wasting of the buttocks and thighs.
April 17, 1953—Re-admitted to hospital with cramp-like lower abdominal pain.
There was no evidence of intestinal obstruction. There was no palpable abdominal pulsation.  Lower limbs were warm and gave no pain.
Sympathetic block failed to relieve the abdominal pain.
Aortogram showed a large aneurysmal sac with an abundant collateral circulation.
There was no evidence of reflux, or leakage.
May 4, 1953—Patient collapsed and died.
AUTOPSY REPORT
On opening the abdominal cavity a large mass consisting chiefly of blood clot was
seen. Approximately 1200 cc. of blood and blood clot were removed.
A large aortic aneurysm could then be clearly identified. The aneurysm extended
from 2 cm. below the renal arteries to the bifurcation of the aorta and on the left side
into the left common iliac, the internal iliac and the external iliac as far as the femoral
ring. Over all the aneurysm measured 19 inches in length and five inches at its greatest
width.
The aneurysm had previously been tied with umbilical tape 1 % inches below the
renal arteries. The vessel was not completely occluded as a lumen of 2 cm. still persisted. The wall of the aorta above the ligature had expanded to three inches in diameter.
Cellophane film which had previously been used to wrap the aneurysm presented itself
as a mass among the blood clot. There was no gross evidence that it had caused fibrous
tissue formation.
On the posterior wall of the aneurysm from the point of ligation to the bifurcation,
there was a linear tear four inches long extending through the wall of the aorta.
CONCLUSION
From consideration of the cases reported in the literature, it can be said that no
satisfactory treatment for aneurysm of the diseased abdominal aorta has yet been suggested. Certain types of plastic materials have the property of promoting a limited degree
of fibrosis in the tissues of the body. When applied to an aneurysm, this leads to strengthening of the wall and eventual occlusion of the lumen of the sac. If a standard film
with a reliable reaction could be found it is concluded that it would decrease morbidity
and might even promote cure. In order to find a film giving constant controlled fibrosis,
further experiments are required. It would be necessary to ascertain the chemical formula, precise details of physical processing and methods of sterilization. The results could
be recorded conveniently as units of fibrosis for various tissues.
The older methods of treatment have been thoroughly tried in all their variants
and found wanting. The results with irritant film are too incomplete to assess as yet
Page 411 but they are based on sound experimental work and from what is known of their
reaction in the body, their use suggests that there is a brighter future for the abdominal
aneurysm.
BIBLIOGRAPHY
1. Cooper, Sir Astley.   Lectures in Principle & Practice of Surgery.   Thomas  & George Underwood,
London 2.67.1825.
2. DeTakats G. and Reynolds, J. T.   Surg. 21.443, 1947.
3. Matas, R.   Ann, Surg. 112.909.   1940.
4. Morton, J. J. & Scott, W. J. M.   Ann. Surg.  119. 457.   1944.
5. Reid, M. R.   J. Exp. Med. 40. 293.  1924.
6. Jenkins, J. A., N. Z. Med. J. 47.349.   1948.
7. Wheeler, W. L. DeC.   Lancet 1.53 5.    1917.
8. Pearse, H. E. Ann. Surg. 112. 933.   1940.
9. Donati, Dino.   Bull D. Soc. Med. Bologna  109. 139.   1937.
10. Page, I. H.   J. Amer. Assoc. 113. 2046. 1939.
11. Graef I. and Page, I. H.   Amer. J. Path. 16. 211.   1940.
12. Poppe, J. K. and De Oliveira, H. R.   J. Thor. Surg.  15. 186.    1946.
13. Harrison, P. w\ and Chandry J.   Ann. Surg. 118. 478. 1943.
14. Yeager, G. H. & Cowley, R. A.   Ann. Surg. 128. 509.   1948.
15. Cooper, F. W. Robertson, R. L.   Shea P. C. Dennis, E. W. Surg. 25. 184.   1949.
ANNOUNCEMENT
MRS. C. T. McCALLUM, widow of the late Dr. C. T. McCallum, radiologist, announces her appointment as a member of the sales staff of the
West Shore Realty Co. Ltd., 1437 Marine Drive, West Vancouver.
Specializing in homes for doctors and business executives, she would
like to draw attention to a magnificent VIEW home in West Vancouver;
Owned by a millionaire oil man, the home, the grounds, and the view
are beyond description, yet the price is REASONABLE.
Fifteen minutes drive from downtown.  Enquiries invited.
Phone: West 848—Days; 2494-L2—Evenings
§ FOR RENT fl.
Two, three or more rooms, doctor's office in a medical-dental building,
away from downtown* area, no parking problem. Laboratory and
physiotherapy machine available for use by all tenants. Also extra
large general reception room, and complete x-ray facilities. Facilities
available for doctors not having their own receptionists.
B.C. Medico-Dental Building, 2695 West Broadway, Vancouver, B.C.
Now Operated by Lefohn Holdings Limited
Page 412 THE TEACHING OF PREVENTIVE MEDICINE
James M. Mather, M.D., D.P.H.
Professor of Public Health, University of British Columbia
(Presented to a meeting of the Vancouver Medical Association, April 7, 1953)
Without making any pretensions to other than ordinary observational powers, I
confidently claim that, if you graduated in medicine before World War II, I can tell
you what your impressions were of your course in public health as an undergraduate and
what memories you retain of that course. You will remember it as just another examination hurdle which has to be cleared on the way to a degree. It was the course where,
unless attendance was taken, you felt relatively safe in skipping classes. Probably your
most vivid memory of field trips was the one to a sewage disposal plant unless, by chance,
it was the one to the brewery. The lecture course was filled with material on environmental sanitation and communicable disease control. You could see little or no application of the material to the private practice of medicine where you were headed. You
swotted it up for the University and Council examinations and then promptly forgot
it and have thought very little about it since. I may be wrong in the details but I'm
willing to wager that I'm not far out on the broad perspective.
The whole picture of the practice of medicine has changed within our generation.
My own particular field has probably changed even more than some of the other branches
of medicine. Even the vocabulary has changed. In most Universities the title of
Department of Public Health has been replaced by a great variety of designations ranging from Preventive Medicine, through Community Health to Social and Environmental
Medicine. We belong to the old school in so far as our title is concerned. We believe
that "Public Health" still covers our functions and obligations when one defines public
health as Sir Wilson Jameson did; that "public health is the health of the public".
Surely, that gives us a wide enough range.
The present day objectives of the teaching of this subject can be summed up very
briefly: we are charged with training the general practitioner of the future to do a
better job through an appreciation of the importance of preventive medicine in his
day-by-day work and through knowledge of the health agencies, official and voluntary,
that may be an aid to him in his own practice. Our whole effort is beamed toward the
practitioner, our effort is to teach preventive medicine in contradistinction to the
specialty of public health.  We feel the latter is a matter for postgraduate study.
If, then, our objective is the teaching of the preventive aspects of the clinical
practice of medicine, is there any justification for the existence of a separate department
for that purpose in the medical school? Ideally, no. There should be no such department, but, after all, ideals are rarely attained in this imperfect world. As an ideal, the
preventive aspects of each subject in the medical curriculum should be an integrated part
of the teaching within each, of the departments. From the practical point of view the
separate department will be in existence for a long time yet. In one school, Johns
Hopkins, formal teaching by this department has been abolished, and the Department
of Preventive Medicine remains as a coordinator to see that each of the departments
incorporate the preventive aspects of each subject into its clinical teaching. There,
.public health, per se is taught to the students by personnel from the graduate School
of Public Health in the same University. It is too early to assess the success of this
type of teaching. I think it is likely that most of us will work out our teaching days
in a separate department but, more and more, our teaching must be integrated with the
clinical departments. Have we any special body of knowledge which makes us indispensable? We do have knowledge in public health or mass health procedures:, these
must, in some degree, still be imparted to the medical student. However, rather than
a separate body of knowledge, I think our most valuable contribution is our attitude,
the attitude that prevention is a most vital and important aspect of all branches of
medicine. Our role is to see that that attitude is cultivated in the medical student and
that he appreciates its application in every field of medicine.   We, in public health, are
Page 413 in a fringe specialty; that, in my mind, has no derogatory implications, rather, it is a
privilege.   We touch and have much in common with every other specialty in medicine. <
No other teacher in the medical field has the opportunity of the teacher of preventive
medicine.   His terms of reference are so broad, his field so limitless, that he can bend i
his efforts toward any aspects of the healing art that will help to improve the health j
of the public.   That, then, is what we consider to be our role in the teaching of thei
undergraduate medical student; to cultivate in him an appreciation of the importance i
of prevention in all fields of medicine, to show him the facilities that will be available!
to him in his community, and to attempt to integrate this preventive concept throughout all the fields of medical teaching and practice.
The-opportunity to be associated with the development of a new medical school
is both exciting and frightening. There are no precedents and taboos handed down from j
those who have gone before.   The whole teaching program must be built right up fromi
the ground.   For a person like myself, transplanted from the field to the academic!
atmosphere, the change and the challenge are terrific.  My choice as head of the Department was, I think, made for several reasons.   I have been a general practitioner; I havei
been a full-time health officer; I have been active in organized medicine.   I would feel j
that  my part-time  teaching  experience  through  the  years  was  the  least  important i
factor in my being chosen.  I would pay tribute to Dean Weaver.   He chooses his men i
carefully, and then gives them a completely free hand to develop their own Department.
It is perfectly obvious what his attitude is toward preventive medicine when I tell you
that I have more teaching hours allotted to me, 255 in all, than in any other medical]
school in Canada.   As I have said, I have a completely free hand to develop my own
Department.   I fully expect I will make mistakes.   However, I propose to develop a
teaching program in preventive medicine along the lines I consider to be most valuable to i
the practitioner.  If I fail, it will not be because I have been afraid to try.
The teaching in preventive medicine is offered through the four years of the medical j
course. It is offered in a continuity which coordinates with the student's development!
of medical concepts. Our teaching program is dependent upon the utilization of per- !
sonnel and organizations in the community. Our relations with the Metropolitan |
Health Committee, the Provincial Department of Health and Welfare, and the numerous i
voluntary agencies in the community are-extremely close and their personnel participate j
in our training of medical students. Without their help, it would be impossible to
carry out the instruction in preventive medicine.
In the first year of medicine, we provide 25 hours of instruction. This is, in the j
main, didactic in type but we do use two field visits to show the students the health j
faculties the city and the province offer. These two field visits serve as an orientation
experience and as a framework upon which we can build the subsequent didactic
instruction. The lectures trace the development of the preventive concept, the history
of public health, the present day organization of health facuities, official and voluntary,
at the international, national, provincial, and municipal levels. The emphasis is placed
upon the relationship of the general practitioner to these facilities, how they may aid
him, and what his obligations are toward them. An effort is made to impress upon the
student that the patient is not just a disease entity but a social being, a member of a
family, a member of a community.
During the second year of instruction, a total of 135 hours is allotted to teaching
in public health and preventive medicine. Of these, 40 hours are devoted to parasitology
which is given by instructors from the Faculty of Arts and Science. This lecture and
laboratory course deals with the life history of the parasites of man and the insect
vectors in human infections. The remaining 90 hours are devoted to an exploration
of community health facilities, their relationship to the general practitioner, and to a
basic laboratory course in biostatistics. At this stage in his medical course, the student
is being introduced to disease processes, in preventive medicine he begins to explore the
care of the sick in the community, he sees the facilities that will aid him in his future
Page 414 practice. The pattern of instruction is a field visit, visual in type, done in small groups,
and followed up by a lecture to the entire class by the head of that particular service
to consolidate and oordinate the visual impressions received. There is a great variety of
these field experiences but the general arrangement is the same for all; small groups of
j students seeing health faculties in actual operation;, home visits with the V.O.N, nurse,
home visits with the public health nurse; home visits with the social welfare worker,
j etc. This is the first opportunity the student has had to see his future patients in their
natural environment, in their homes, or at their work. A course of 20 hours in bio-
statistics is given. This is a most difficult course to make interesting to medical students.
We do not feel it is either the sole prerogative or responsibility of preventive medicine
-but it is a responsibility we gladly assume. Our basic objective is to give the medical
student an appreciation of the value of good statistics, a critical attitude toward the
claims of published material, and guidance in any investigation in which he may be
engaged n the future. During this course, the subjects of vital statistics and epidemiology are introduced.
The course in third year is given over a period of 50 hours. Here the emphasis is
on the preventive aspects of acute communicable and chronic diseases, accident prevention, rehabilitation, and problems of the aged. The instruction is carried out by means
of lectures, conferences, field visits, and combined teaching conferences. The field visits
Be primarily concerned with the problems of rehabilitation and are combined efforts
of teachers, not only from the clinical departments, but also from the ancillary medical
fields of psychology, social work, etc. The teaching of the preventive aspects of communicable disease grows more difficult each year with the lessening of available clinical
material. However, we feel that it cannot be neglected since our students may easily
find themselves in areas where these diseases are still major problems.
Our fourth year course has yet to be given and is, thus, still in the planning stage.
However, we do have some definite ideas about it. There will be 50 hours of instruction.
We must present to the students a summary of public health law as it applies to the
general practitioner. We must cover certain public health matters in regard to environmental management and food control. We propose to discuss military medicine, ABC
warfare, civil defence. However, we feel our most important proposal is the use of combined theatre teaching conferences, where, in cooperation with the various clinical
departments and with other schools such as nursing and social work, we would hope
to present the concept of the whole patient rather than the disease.
There are certain other plans for the teaching of the medical student which, even
though they are not the responsibility of the Department of Preventive Medicine, are,
we believe, very important to his training in the preventive concept. It is proposed that
in his fourth year each medical student will, during the academic year, spend a period
of preceptorship with a general practitioner. There are many difficulties inherent in the
selection of preceptors, the supervision of the period of training, etc. However, we feel
strongly that this is the only way that the student can gain a practical picture of the
private practice of medicine in contrast to the teaching hospital atmosphere which, even
though it is obviously necessary, is not a true preparation for the problems of private
practice. This preceptorship, brief as it may be, will be most valuable to the student.
The General Practitioners' Section of the B. C. Medical Association has demonstrated its
interest in improving the standards of general practice. Its participation in training of
medical students would be a practical method of integrating the general practitioner
into teaching and sue ha program would be of mutual advantage to the practitioner,
the student, the University and to medicine as a whole.
Through the cooperation of the Federal and Provincial Departments of Health we
will, this year, have four students who are finishing their third year employed in Health
Units for the summer. The primary purpose of this employment is not recruitment of
future health officers but, rather, to give a certain number of students an opportunity
Page 415 to see the interaction of health agencies and practitioners in a rural environment. We
have been very pleased with the keen interest of students in these appointments.
I have attempted to give you, very briefly, our present program and our future
plans for the teaching of preventive medicine to medical students in the University of
British Columbia. As I said in the beginning, our whole aim is to develop in the physician
of the future a healthy attitude toward prevention, a knowledge of its value to him in
the practice of medicine, and to provide him with an appreciation of and adequate
information concerning health agencies, official and voluntary, in his community. This
teaching is an integrated effort not only of our own Department but also of all other
clinical Departments in the University and a host of agencies in the community. We
hope that, by our efforts, the medic'al student may be better equipped to take his place
in the community as a family physician.
OPENING FOR MEDICAL MAN
General practitioner required in small town on west coast. Mining,
logging and fishing industry. 25-bed well equipped hospital under
excellent management. Splendid opportunity for young graduate.
Good school and living accommodation.
For further particulars apply to Publisher:
675 Davie Street MArine 7729
FOR SALE OR RENTAL
Well established general practice in suburban district in Vancouver.
Owner leaving for post graduate study.  Available July 1, 1953.
Phone HAstings 4234 KErrisdale 5415
or write the "Bulletin"
Canada 5   rvlodt   Ulniaue iKedorl
WALLACE   ISLAND
A glorious vacation adventure awaits you . . . An entire privately-owned
island exclusively your holiday domain. Miles of enchanting trails, colorful
shoreline, hidden coves and lovely beaches ... all inviting exploration.
Deluxe Cottages—privately located. Perfect for families. Safe, sandy beaches for
children. Excellent fishing. Recreational activities. WRITE TODAY FOR
COLOR FOLDER.
Telephone WALLACE ISLAND now for reservations and information
1     W A LLACE    ISLAND
c/o GANGES, B.C.
David B. Conover, Mgr.
\f/z hr. scenic drive from Victoria — Princess Elaine from Vancouver
or direct plane service.
Page 416 Dr. H. J. Muth is now practicing in Trail.
Dr. D. Webb is now practicing in North Vancouver.
Dr. Theo Wilkie will take over the practice on Saltspring Island of Dr. David Boyes
and Dr. Glen Ankenman who are continuing in specialty training.
Dr. John McCarley of North Vancouver was recently severely injured while operating a caterpillar tractor in his leisure time.
Dr. J. L. Danto has recently opened a practice in dermatology in Vancouver at
Granville and Forty-first.
Dr. Gladys Cunningham of Vancouver has been elected a Fellow of the Royal
College of Obstetricians and Gynecologists in London in recognition of her work in
China as a missionary.
Dr. J. R. Bloomfield of the Vancouver General Hospital is now associated with
Dr. H. D. Barner of the Vancouver Victoria Drive district.
Dr. J. M. Kidd of Vancouver will be resident at St. Paul's Hospital in pathology,
next year.
Dr. G. F. Thompson, who spent six months at the Institute of Optholmology London, has opened a practice in Victoria.
Dr. W. A. McElmoyle of Victoria is on a trip to England.
Dr. F. M. Bryant addressed the Victoria Medical Society at the Annual Memorial
Oration dinner in May. Out of town guests were Drs. J. Ganshorn and E. C. McCoy
of Vancouver, A. H. Meneely and C. C. Browne, Nanaimo, and J. W; Neville, Lady-
smith.
Dr. Bruce Lee of Vancouver will take surgery training at Shaughnessy next year.
Dr. Ian MacDonald of the Vancouver General Hospital will continue at Essondale
next year along with Dr. Ted Jordan and Dr. Norman Jones.
Dr. N. T. McPhedran will be associated with Dr. H. A. Mooney of Courtenay for
the summer months.
BIRTHS
Born to Dr. and Mrs. J. Moyer of the Vancouver General Hospital, a daughter.
Born to Dr. and Mrs. Bruce Gates of Vancouver, a son.
Born to Dr. and Mrs. P. M. McLean of New Westminster, a daughter.
Born to Dr. and Mrs. T. R. Osier of Vancouver, a daughter.
Born to Dr. and Mrs. S. W. Civkin of New Westminster, a daughter.
Born to Dr. and Mrs. W. D. Panton of Powell River, a son.
MEDICAL MAN
URGENTLY NEEDED, CHRISTIAN DOCTOR, MARRIED OR SINGLE,
to assist in general practice. Must be capable and have references.
Minimum salary $400.00 net and possibly a good deal more. Send
particulars directly to Dr. H. A. McLean, Ceepeecee, B.C.
Page 417 CANADA'S FIRST AND FOREMOST
PROFESSIONAL PHARMACY
Iflacdo
Medical Dental Bufldin^
icriplions
PA. 4141
*jrree C-//tt cJjeliveru and *srree [-Provincial f-^odt
aae
r
Page 418

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