History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: February, 1946 Vancouver Medical Association Mar 2, 1946

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 THE    VANCOUVER   MEDICAL    ASSOCIATION
BULLEJTIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests-of the Medical Profession.
Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B.C.
EDITORIAL BOARD:
■'•>£."'; Dr. J. H. MacDermot
Dr. G. A. Davidson Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. xxn
FEBRUARY, 1946
No. 5
OFFICERS,  1945 - 1946
Dr. Frank Turnbull
President
Dr. H. A. Des Brisay
Vice-President
Dr. H. H. Puts
Past President
Dr. Gordon Burke
Hon. Treasurer
Dr. G. A. Davidson
Hon. Secretary
Additional Members of Executive: Dr. R. A. Gilchrist, Dr. W. J. Dorrance
TRUSTEES
Dr. J. A. Gillespie        Dr. A. W. Hunter        Dr. G. H. Clement
Wm       Auditors: Messrs. Plommer, Whiting & Co.
SECTIONS §
Clinical Section
Dr. S. E. C. Turvey Chairman Dr. E. R. Halt. -. Secretary
Eye, Ear, Nose and Throat
Dr. Grant Lawrence. President Dr. Roy Mustard . Secretary
Paediatric Section
Dr. Howard Spohn —Chairman Dr. R. P. Kinsman Secretary
Orthopaedic and Traumatic Surgery Section
Dr. K. J. Haig Chairman Dr. J. R. Naden Secretary
Section of Neurology and Psychiatry
Dr. A. M. Gee .-Chairman Dr. J. C. Thomas Secretary
| STANDING COMMITTEES
Library:
Dr. W. J. Dorrance, Chairman; Dr. F. J. Buller, Dr. R. P. Kinsman,
Dr. J. R. Netlson, Dr. D. E. H. Cleveland, Dr. S. E. C. Turvey.
Publications:
Dr. J. H. MacDermot, Chairman; Dr. D. E. H. Cleveland, Dr. G. A.
Davidson, Dr. J. H. B. Grant, Dr. S. E. C. Turvey, Dr. Grant Lawrence
:j»| - Summer School:
Dr. L. G. Wood, Chairman; Dr. J. C. Thomas, Dr. A. M. Agnew,
Dr. L. H. Leeson, Dr. A. B. Manson, Dr. A. Y. McNatk.
Credentials:
Dr. J. R. Netlson, Dr. H. H. Pitts, Dr. A. E. Trites
V. 0. N, Advisory Board:
Dr. Isabel Day, Dr. J. H. B. Grant, Dr. G. F. Strong
Representative to B. C. Medical Association: Dr. H. H. Pitts
Sickness and Benevolent Fund: The President—The Trustees SODIUM PENICILLIN ■ CONNAUGHT
SODIUM PENICILLIN is supplied by the Connaught
Laboratories in sealed rubber-stoppered vials as a dry
powder which remains stable for at least a year if stored at
a temperature below 10° C. (50° F.). Each vial contains
100,000 International Units.
PHYSIOLOGICAL SALINE, sterile and pyrogen-free, is
supplied in 20-cc. rubber-stoppered vials, permitting of the
convenient preparation of various dilutions of penicillin, e.g.,
by adding 20 cc. of saline to a vial of penicillin a solution
containing 5,000 units per cc. is obtained, or if 2 cc. be
used, a solution containing 50,000 units per cc.
As supplied by the Connaught Laboratories,
Sodium Penicillin is of high quality and
is free from irritating substances.
CONNAUGHT  LABORATORIES
University of Toronto Toronto 5, Canada
DEPOT FOR BRITISH COLUMBIA
MACDONALD'S PRESCRIPTIONS LIMITED
MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. VANCOUVER HEALTH DEPARTMENT
STATISTICS—DECEMBER, 1945
jotal population—estimated :  311.799
npanese Population—Estimated  Evacuated
:hinese population—estimated               _ »o«
r. r r . ;        6,3^5
Iindu population—estimated _     »«*
Rate per 1,000
Number Population
Total deaths                               32q 12 1
Chinese  deaths                            12 22 1
Deaths   residents   only . .               274 10.3
BIRTH REGISTRATIONS:
Male,  310;   Female,  241 .     551 20.8
INFANT MORTALITY:                                                              Dec.} 19945 DeC., 1944
Deaths under one year of  age \ {       24 16
Death rate—per  1000 births       43.6 30.2
Stillbirths   (not included above         8 3
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
November, 1945       December, 1945 Jan. 1-15, 1946
Cases      Deaths      Cases      Deaths      Cases      Deaths
carlet Fever g       31             0              43             0 23             0
)iphtheria . .         2             0                 7             0 3             0
)iphtheria  Carrier         0            0               15            0 0            0
:hicken  Pox 121             0             161             0 0            0
Aeasles \ d         2            0              10            0 39            0
Lubella         7            0                 6            0 4            0
dumps       46             0               56             0 15             0
Whooping  Cough         0            0                 0            0 0            0
fyphoid Fever 'A         0            0                 0            0 0            0
Jndulant Fever j         0            0                 10 0            0
'oliomyelitis —          0              0                  10 0              0
ruber culosis i       68           21                37-13 0             0
erysipelas         0            0                 10 0            0
ideningo coccus  Meningitis         0             0                  10 0             0
nfectious Jaundice i :         0             0                 0             0 0             0
Salmonellosis -_         5             0                 2             0 2             0
Salmonellosis  (Carrier)         0             0                 0             0 0             0
)ysentery j         0            0                 0            0 10
►yphilis L___     128             0               72             0 0             0
jonorrhoea     237            0             133             0 0            0
Cancer (Reportable)—
Resident =       32             0               28             0 0             0
Non-Resident         7             0               13             0 0             0
B I O G L A N "C"
Prepared separately for male and female*
Composition: Anti-thyroid principles of the pancreas, duodenum, em-
bryonin, suprarenal cortex, tests (or ovary). Each 1 cc. ampoule
contains the equivalent of approximately 29 grams of fresh substance.
Indications; Graves's disease, hyperthyroidism, exophthalmic goitre,
thyrotoxicosis.   The most effective therapy available.
Stanley N. Bayne, Representative
Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING Vancouver, B. C.
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Page 92 A study by Aristid e Ma illol.
Reproduced from the
Hyperion Press Art Book
"Maillol".
<i*Pi
All patients, however
severe or mild their symptoms,
ean he treated effectively with
these orally-active natural oestrogens.
"Premarin" (No. 866) for the most severe
.ymptoms; Half-strength "Premarin" (No. 867)*
when symptoms are moderately severe
and "Emmenin" for mild
symptoms.
2Sw$_
IP"
sssssl
^S^
"PREMARIN"Md"EMMENI\"
conjugated   oestrogens   (equine)
conjugated oestrogens (placental)
NATURALLY OCCURRING   •   WATER SOLUBLE   •   WELL TOLERATED
ESSENTIALLY    SAFE   •    IMPART   A   FEELING    OF    WELL    BEING
*Half-8trength"Premaran"is a new strength for those patients whose symptoms, although
severe, do not require the intensive therapy provided by "Premarin" full-strength.
AYERST, McKENNA & HARRISON LIMITED • Biological and Pharmaceutical Chemists • MONTREAL, CANAD
2 Vancouver    medical    association
Founded 1898    ::    Incorporated 1906
PROGRAMME OF THE FORTY-EIGHTH ANNUAL
SESSION (SPRING SESSION)
GENERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
XINICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
These meetings will continue to be amalgamated with the clinical staff meetings of
the various hospitals for the coming year. Place of meeting will appear on the agenda.
February    5—GENERAL MEETING.   Dr. D. H. Williams:
"Recent Advances in Dermatology."
february 19—COMBINED CLINICAL MEETING—St. Paul's Hospital.
/larch    5—OSLER DINNER—Hotel Vancouver.
Osier Lecturer: Dr. A. L. Lynch.
tfarch 12—COMBINED CLINICAL MEETING—Shaughnessy Hospital.
\pril    2—GENERAL MEETING.   Dr. Carl G. Heller, University of Oregon Medical
School: "Uses and Abuses of the Male Sex Hormone."
_pril 16—COMBINED CLINICAL MEETING—Vancouver General Hospital.
day    7—ANNUAL MEETING.
_______ HHkMk^''-'->'-!'l-'.
f   Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and  stabilizing the tone of its
musculature. Controls the utero-ovarian
^   circulation and thereby encourages a
normal menstrual cycle.
_L -
• MARTIN H. SMITH COMPANY
"&. ISO lAf ATITTI STMIT. NIW  TO«K. M. V-
formula and descriptive
literature on request
Dosage: 1 to 2 capsules
3 or 4 times daily. Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, visible only when capsule is cut in half at seam.
Page 93 DfflOESTM ID. H.
THE NEW SYNTHETIC OESTROGEN
LOW COST — ABSENCE OF TOXICITY
HIGH POTENCY
Dienosstrol B.D.H. represents the successful termination of progressive research aimed at the synthesis of an oestrogenic substance, the full therapeutic
employment of which would be unrestricted by the
high cost of the natural hormone or the nauseating
effects of the older synthetic oestrogens upon susceptible individuals.
Available, at a fraction of the cost of the natural
hormone, Diencestrol B.D.H. may be prescribed freely
even to patients who are intolerant to other synethic
oestrogens. ^
N.B.
Diencestrol   B.D.H.   is  the  most  potent
cestrogenic substance known. In changing from stil-
bcestrol to Diencestrol B.D.H., it may be assumed that
0.3 mgm. of Diencestrol B.D.H. is equivalent to
approximately 1.0 mgm. stilbcestrol.
Dienoestrol B.D.H. is issued.in tablets of 0.1 mgm. and 0.3 mgm.
in bottles of 100, 500 and 1000 tablets.
THE BRITISH DRUG HOUSES
(CANADA) LIMITED
TORONTO
CANADA Ike ZdUv& Paae.
Within the next few years, there are going to be, inevitably, some very considerable
changes in the medical set-up of this province, as there probably will be many changes
in other provinces. A whole series of facts are forcing the coming of these changes,
and it is of the greatest importance that they should come, not in a haphazard and
opportunist way, but as part of thoroughly considered and well-laid plans. We see few
signs at present of any such over-all planning, and this is greatly to be regretted. The
hospital situation, the medical school which is slowly but surely coming into being, the
matter of Health Insurance, which we all know must come, and which will alter profoundly our whole medical practice, and affect deeply the health and welfare of the
whole community—these three major problems and many other important ones, such
is the nursing problem, the matter of child hygiene, the question of mental disease,
to mention only a few, cannot be ignored any longer: and the time is more than ripe
for an earnest consideration of all these things.
Take the hospital question, for example, and we shall at once see how incoherent
and disorganized is the whole matter of hospitals. The need for hospital accommodation is so acute that something will have to be done very soon. But there is no general
plan that one can discover, according to which new hospitals can be built, in such a
way as to meet the need in the most efficient and economical way. We have in the
City of Vancouver, for example, several small groups of hospital beds for sick1 children.
Ine two main hospitals each have a certain number of beds: the Crippled Children's
Hospital, far from both of them, has some more: the Preventorium a few more. The
waste of energy here, the scattering of personnel, the difficulties of securing medical
staffs, are all arguments in favour of centralisation—of combining into one large Sick
Children's Hospital all these units, to the great benefit of all concerned. We see the
idvantage of this in a city like Toronto, whose Sick Children's Hospital is a model to
ill the world—and where, we understand, enormous expansion is to take place along
;hese lines, already laid down. As it is, there is no economy of effort, or time, or money,
n the present set-up.
And when the Medical School is established, of what value to it will all these scat-
ered units be? A single, large, centrally placed Sick Children's Hospital, on the other
land, would be of inestimable value for teaching purposes. Such a hospital should be
i distinct entity, not attached to any existing institution, but on its own ground, with
ts own staff and administration.
And as regards other hospital building for the future. We feel strongly that the
ocation, size, and nature of new hospitals and hospital buildings should be according
:o a design, and definite plans, looking to the future. This cannot be done simply by
:he expansive efforts of existing hospital administrations. It should be done by some
:orm of Hospitals Commission, provincial in scope, and established to deal with these
natters on a long-term basis. Only so can we have a coherent, integrated, planned hospital economy for British Columbia. Now is the time, we believe, for such a body to
>e established, and to begin work, before irrevocable action is taken on individual lines,
:nd before vested interests are allowed to appear, and grow so strong that they cannot,
without injustice, be interfered with. Such a body would have time and leisure to
tudy the whole hospital question. It could employ experts and obtain expert advice,
t would plan for many years ahead—and, having no pet projects, or special alliances,
t could deal with the question, not from the point of view of any single institution,
)ut from the point of view of what would best serve the general economy. It would
•onsider such things as preventive medicine and public health, the medical school and
Page 94 medical education, postgraduate training, nursing and kindred questions, medical re
search and so on.
We know that we are not alone in thinking that this should be done. Men whi
have been considering this question from the hospital point of view have expressed th
same opinion. We hope that our medical associations will consider this matter carefulrjj
and give their counsel to those in authority. We are at a crossroads just now: an
what is done now will make all the difference to Medicine in British Columbia for man
years to come—if we plan wisely, we shall save money and effort, and obtain the bea
results—the laissez-faire policy can only lead to ruinous waste of both these things-i
and to economic loss and inefficiency.
(Since writing the above, we note in the press that Dr. Alan Brown of Toront
whom we all know very well, by reputation at least, has said substantially what
have tried to say—that we are now, as he puts it, ^'standing near a precipice.    One fa
step, and we shall be sunk for 50 years."    This vivid way of saying that careful a
deliberate planning is essential, appeals greatly to us, and we agree entirely with hi:
We should also like to say that we must keep an eye on the clock, as time is of thi
essence of the contract, as our real-estate friends say, and if we do not act soon, otheii
will act for us, or instead of us.)
We note with regret, but with not much surprise, that the Greater Vancouver Wate
Board has finally decided to discontinue chlorination of water supplies in this are:
Vancouver has now reverted to the status of village, and is in the proud position
being about the only city of its size and importance in Canada and the United State
which does not chlorinate its water. We cannot feel that the Water Board comes ou
of this well—it has adopted a reactionary and dangerous attitude. At the very least
chlorination was a harmless (and we underscore that word) and inoffensive precautioi
most of the time not badly needed'—but it was really much more than that. In th
opinion of real experts (and we consider Dr. Dolman high on this list, and so do all th
leading bacteriological and public health experts) chlorination is a real necessity, ant
we are not safe without it. We can only hope that no serious epidemics will have ti
spread death and disability amongst us, before we decide to adopt the scientific view oi
this matter. As a great port and cosmopolitan centre, and with our growing pretension
to tourist traffic, it is especially vital that our water supply should be above suspicion
It is a pity that so much heat and bad feeling should have been generated over thi
affair, on both sides of the question. It is really this that defeated chlorination. I
became a matter of feeling rather than a matter of calm, scientific discussion. Botl
sides seem to have lost their temper a bit. After all, chlorination is not a matter o
politics, as one or two well-meaning, but misguided, members of our City Council an^
other city councils, tried to make it—nor is it a matter of wounded feelings or i
desire to get one's own way—it is a matter of cold scientific fact. In our considered
opinion, the forces supporting chlorination had fact and scientific reason on their side
the antis did not. Some day, perhaps, and we hope it will be soon, calmer and mon
rational reflection will allow reason, rather than emotion, to prevail.
Page 95 British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President Dr. A. H. Meneely, Nanaimo
First Vice-President Dr. Ethlyn Trapp, Vancouver
Second Vice-President , Dr. E. J. Lyon, Prince George
Honorary Secretary-Treasurer Dr. L. H. Leeson, Vancouver
Executive Secretary Dr. M. R. Caverhill, Vancouver
ANNUAL BUSINESS MEETING
Members planning to attend the Victory Meeting of the Canadian Medical Association at Banff, June 10th to June 15 th, should note the following points.
1. Members of General Council of the Canadian Medical Association should arrive
\n Sunday, June 9th. Sessions of General Council commence early on Monday morning,
nine 10 th.
2. The Annual Meetings of the College of Physicians and Surgeons of B. C, and
t)f the British Columbia Medical Association will be held on TUESDAY AFTERNOON, JUNE 11th.
__ »*. _L *-\
*p *r *s? *r •
The British Columbia Medical Association Dinner given for members of Grand
Council will be held on Tuesday evening. It is the intention this year that this be a
[nixed dinner.
TRANSPORTATION
All B. C. members attending the Annual Meeting of the Canadian Medical Association should plan to attend the above functions, and should govern their time of
Arrival at Banff accordingly. It is noted that the C.P.R. train leaving Vancouver on
the Monday morning arrives at Banff at 10:00 a.m. on the Tuesday morning. This
Evould allow a leisurely "settling-in" before attending the Annual Business Meetings in
the afternoon.
Condensed C.P.R. train schedules are shown for information.
Leaves Vancouver Arrives Banff
train No. 4  7:15 p.m. daily 5^30 p.m. next day
train No. 8  7:45   p.m.  daily 6:00 p.m. next day
[Train No. 2         10:30 a.m. daily        10:00 a.m. next day
The Committee on Transportation is inquiring into the availability of special trains,
br special cars on the regular trains.   Full details will be published when available.
\Pe are informed by the C.P.R. that they expect to again put into effect low Sum-
|mer fares to Banff and return. When we know that these low fares have been authorized full information will be published.
RESERVATIONS
You are again reminded that accommodation is limited, and if you have not already
made your reservations DO SO NOW.   Applications should be sent to:
Committee on Housing,
Canadian Medical Association,
203 Medical-Dental Building,
Vancouver, B. C.
Page 96 h*
GOLF
Men's Golf Tournament will be held on Thursday
Afternoon, June 14th. Be sure to bring your clubs and
enter the competition for the Trophy of the British Co-j
lumbia Medical Association, as well as for the C.M.Ai
competitions.
THE LIBRARY
Mondays, Wednesdays and Fridays, 9:30 a.m. to 9:30 p.m.
Library Hours: -^Tuesdays and Thursdays,' 9:30 a.m. to 5-30 p.m.
Saturday, 9:30 a.m. to 1:00 p.m.
Since March 4th, the Library has been open three evenings a week—Monday, Wednesday and Friday—until 9:30.   Mrs. L. Briscoe has been appointed Assistant Librarian
and is in attendance during the evening.   It is hoped that those who are unable to make
use of the library during the day will take advantage of the extended hours.
SERVICE TO OUT-OF-TOWN MEMBERS
Members living outside Vancouver who wish to borrow books or journals may do soj
These will be mailed out, on request, and the cost of mailing (within the Province)
will be borne by the Vancouver Medical Association.
I MICROFILM SERVICE I
Members are reminded once again that microfilms may be ordered through thej
Library, and read on our desk projector. Practically any articles appearing in journals not in the Library may be obtained in this way, free of charge, and usually they
are received within two weeks of ordering.
RECENT ACCESSIONS TO LIBRARY:
Pathology of Trauma, 1942, by Alan R. Moritz.
Man Against Himself, 1938, by Karl Menninger.
Surgical Clinics of North America, Symposium on Gynecology and Obstetrics, Philadelphia Number, December, 1945.
Transactions of the Ophthalmological Society of the United Kingdom, Session 1944.]
Medical Clinics of North America,  Symposium on Pediatrics,  Chicago Number,!
January, 1946.
Another new journal has been added to our subscription list—Journal of the Historyi
of Medicine and Allied Sciences.
This is a new publication, the January, 1946, issue being volume 1, number 1. It
will be published quarterly by Henry Schuman, and is edited by Dr. George Rosen.
The purpose of this publication, to quote the introductory remarks of the Eeditor,
*'. . . is to provide another focus for studies in medical history. It will not compete
with but will supplement the Bulletin* We welcome contributions on all aspects of
the history of medicine, public health, dentistry, nursing, pharmacy, veterinary medicine and various sciences that impinge on medicine. It is our feeling also that papers
dealing with limited and specific subjects might well be supplemented by occasional
articles of wider scope that would summarize certain important fields and outline tfe
broad trends in them. From time to time the Journal will request competent investigators to prepare such special review articles. . . .
"Finally we wsih to emphasize that, medical history is now being made. The role
of medicine in World War II, as well as its part in the post-war period, is undoubtedly
of high interest for the student of medical history. We shall also welcome, therefore,
papers dealing with the evolution of these current developments. . . ."
* Bulletin of the History of Medicine, Edited by Dr. Henry E. Sigerist.
Page 97 VANCOUVER MEDICAL ASSOCIATION*
[We submit herewith a series of short papers on cancer, presented in the form of a
symposium. It is hoped that others will be received, and there will be published as
jthey are available.
Dr. Evans, Medical Director of the B. C. Cancer Institute, presents an admirable
review of cases admitted in seven years. These amounted to 229, and certain facts of
[great interest emerge from this Review. One is that cancer of the breast is more common in unmarried than in married women of similar age. And why should the left
breast be more commonly affected than the right?
Sixty-six per cent of cases consulted a doctor within twelve months from the time
|they first noticed a lump. The public still needs education, it is certain: but we feel
ithat this number is a great improvement on conditions 25 or 30 years ago.
The method of choice is surgery followed by X-ray therapy, and in this the Institute's opinion is in line with such leaders as Harrington of the Mayo Clinic, and other
I well known authorities.
The number of 5-year cures is still disappointing, 22.5%.   This is not good enough.
Dr. Hardie's contribution, dealing with Research on Breast Cancer, is also of great
interest, especially as regards hormones and the factor present in milk. Hormone action
is of tremendous significance, it would seem, and the delaying effect in women of
male hormone administration, and vice-versa, is now, we believe, sufficiently proven to
suggest many worth-while paths that may be followed. Dr. Hardie does not mention
this, and perhaps we are rather over-sanguine1 about it. But the suggestion that mothers
with a tumour history in their ancestry refrain from nursing from birth is a startling
one—though the originator of this suggestion, Ludwig Goss, most certainly must know
what he is talking about.
A graph accompanies this paper, which we regret we cannot reproduce.
Dr. H. H. Pitts gives a brief but comprehensive review of the pathology. He quotes
authorities whose opinion rather seems to discount Ludwig Goss* advice, referred to
above; they state that the incidence of cancer is greater in women whose children have
not been suckled, and that only 8.5% of women with cancer of the breast give a
normal nursing history. Yet unmarried women have a higher incidence than married.
It is rather confusing. Dr. Pitts gives a useful classification of breast cancer, but is
not fussy about minutiae. In this we applaud him. "It is enough she died, what reckls
it how?" For us as practitioners, only one rule can be safely adopted: "Every lump
in a breast is cancer, till the pathologist pronounces it benign."
The methods of spread, the relationship between mazoplasia, cystic hyperplasia or
cystic mastitis and carcinoma, are discussed, and Dr. Pitts, wisely, we think, takes the
pessimistic, rather than the optimistic, view, and sees potentiality of cancer in all these
abnormal conditions.]
2j- *$• 5£- Si-
BRITISH COLUMBIA CANCER INSTITUTE
REVIEW OF CASES ADMITTED |
A. Maxwell Evans, M.D., Medical Director.
Review of cases of cancer of the breast admitted from November, 1938, to December, 1945* with notations showing the difference between these figures and statistics
published elsewhere.
Number of cases ., j  2 09
Married    207
Single    .     22
(Statistics show that cancer of the breast is more common in unmarried women than
in married women of similar age.   One per cent of the cases occur in males.)
Known history of cancer in the family, equally divided on
male and female side \     82
Page 98 (The usual incidence is that cancer is twice as common on the female side of the
family as on the male side.)
Patients who had children  168
Known complications during lactation ■. 39
(Normal lactation has no detrimental effect in relation to the subsequent development of cancer of the breast. Complete failure to suckle is met with more frequently
in a series of cancer cases than in a control series of cases.)
Ages of patients: 20-80 years—
20-29  ! l       3
(Statistics show that the greatest incidence is between 50 and 60 years and the
number between 40 and 50 is greater than the number between 60 and 70. The youngest reported age in literature is 14.   Most deaths occur between 50 and 65.)
Number of cases before menopause     36
Number of cases during menopause     27
Number of cases after menopause .,  166
Site Situation in Breast
U. O. Q  77
Right breast   118 L. O. Q.   61
U. I. Q.   30
Left breast      98 L. I. Q.   22
Whole   19
Both breasts 13 Unknown  20
(The left breast is usually considered to be the most common site.
As with other figures U. O. Q. is the most common location in the breast.
The nipple area is the most favourable site.)
SYMPTOMS COMPLAINED OF BY PATIENT IN ORDER OF FREQUENCY
Lump—most common complaint.
Pain.
Retraction of the Nipple,
Discharge from nipple.
Alteration in shape of breast.
Swelling in axilla.
CLINICAL STAGE — STEINTHAL
I. Tumour localized to breast—skin not involved—no glands     54
II. Tumour localized to breast—skin or axillary glands involved     98
III. Tumour diffusely involving  breast—skin and deep structures,
involved, metastases to glands, lungs, bones     69
Not staged .       8
(The most important point regarding stage and prognosis is the stage of the disease
when the patient is first seen.)
HISTOLOGICAL LTYPE |f
Simplex ! _ 69
Medullary or encephaloid—spheroidal cells in scanty connective tissue anaplastic  ; ;  25
Scirrhous—spheroidal cells in a varying amount of fibrous tissue  21
Adenocarcinoma—cells arranged in tubular fashion™-  17
Page 99 Intra-duct—arises in medium and small ducts (comedo-carcinoma).- 7
Papillary carcinoma—papilloma in a large duct or cyst, other names
—papillary cystoma, intracystic papilloma, cystadenocarcinoma_ 4
Mucoid—(myxomatous, gelatinous  and colloid)   main feature is; a
mucoid tissue in the stromace  1
Tagefs Disease   1
Unknown because no biopsy or operation  84
\ CLINICAL TYPE
Scirrhous—commonest.   Age 50-60, slow growth—most malignsint
of all in spite of fibrosis (corresponds to histological type)  126
Atrophic scirrhous—age 60-70—fibrosis is the main feature     10
Encephdoid—soft—rapidly growing—age  40-50.   Adenocarcinoma
or medullary        8
Acute    j       3
Unknown (no relevant history or operation prior to admission)     80
TYPE OF TREATMENT IN ORDER OF FREQUENCY
Surgery followed by X-ray therapy  35%
X-ray therapy only   24%
Surgery only  2 0 %
Pre-operative X-ray, surgery, post-operative X-ray—.  10%
Surgery, X-ray and radium  3%
No treatment  I  8 %
Number of patients admitted to Clinic with breast amputated—
93: 40% of total.
Surgery followed by X-ray therapy would appear to be the most satisfactory method
i)f treatment if the case is operable when first examined. In cases where the axillary
glands are involved the survival rate is increased by 10% if post-operative X-ray
therapy is given. X-ray therapy only was given to inoperable cases and to cases where
the general condition or age precluded operation.
Surgery as the only treatment was confined pricipally to those cases where no glands
were found at operation.
Pre-operative X-ray followed by surgery and X-ray were given to cases which be-
:ame operable following the pre-operative X-ray.
Radium was used in the breast and for skin recurrences. Skin recurrences appear
usually in 1 - 2 years after operation. Supraclavicular glands in 2 - 3 years and sternal
recurrences in 3 - 5 years. Metastases have been reported as long as 40 years after the
appearance of the primary tumour.
According to Delbet 82 - 84% of breast tumours are malignant. It is difficult by
plinical examination alone to tell whether a tiftnour in the breast is malignant or not.
It would appear logical to assume that all are malignant until proven otherwise by the
pathologist.)
DURATION OF TIME FROM FIRST SYMPTOM TO TIME OF CONSULTATION
One month to 10 years 66% in first year
(These figures substantiate the well-known fact that most women even when they
ire aware of a tumour in the breast delay going to a doctor.)
DURATION OF TIME FROM CONSULTATION TO TREATMENT
One week to 6 years 70% in first month
5-YEAR CASES — NOVEMBER, 1938, to NOVEMBER, 1940   f
Number of cases (all stages)      40
Alive 5 years and over ____      9 — 22.5%
Stage I        2
Stage II         6
Stage III          1
Page 100 RESEARCH ON BREAST CANCER
Dr. D. M. Hardie
A great deal of experimental work aimed at the elucidation of the etiology of
cancer has dealt particularly with breast cancer. Gye, Professor of Experimental Pathology, at the Royal College of Surgeons, summarizes the factors which must act in
simultaneous co-operation to produce mammary cancer.    There are:
1. an inheritable tendency.
2. an hormonal influence.
3. a factor present in mothers' milk.
These three factors have been demonstrated in experimental mice.
With regard to the first, i.e. the inheritable tendency, 5% of female mice develop
cancer of the breast spontaneously. It was found after years of investigation that
female mice with a cancer ancestry were three times as liable to cancer of the breast
as mice whose mothers and grandmothers were known to be exempt. Increased liability
was present in all age periods. By process of breeding it was found possible to obtain
strains of mice of with 80 to 90% of females developed and died of mammary cancer.
These strains are called "high tumour" or cancer strains. This inheritable tendency is
organ specific and was thought to be sex linked through the mother until the milk
factor was discovered.
With regard to the role of hormones, Nathason in the December, 1944, New England Journal, makes a review of the contributing experimental data. Surprisingly its
origin goes back 25 years—when it was first shown that castration of female mice of
a strain in which mammary cancer was frequent reduced the incidence of the growth
and delayed its appearance. The younger the age at ovariectomy, the lower the incidence of the tumor. This work has been fully verified by the work of the present
day. The reverse also has experimental support—namely LaCassagne produced unexpected mammary cancer by providing an excess of ovarian secretion (oestrin). This
was readily achieved for mice of high tumour line but for resistant strains massive
doses were necessary over a long period. The experiments have been extended to male
mice and in susceptible strains it has been possible to produce cancer of the breast by
the injection of oestrogen. This was not possible for mice of low tumour line unless
they were made into high tumour line by suitable foster nursing. The obvious conclusion from these experiments is that cancer of the breast depends partly on the action
of oestrin on the mamary epithelium.
The third factor is present in mother's milk. Bitter of Bar Harbour discovered this
factor and his work has been substantiated by many other investigators. His experiments consisted in exchanging litters between mice of high and low tumour stocks.
The accompanying diagram summarizes the results of his experiments. "A" stock
has a high incidence of breast cancer arid the litters from this stock were left, some
with their own mothers; some removed immediately after birth were suckled by lac-
tating females of a moderately low stock (C.B.A.); and a third group by lactating
females with low incidence (C 57). It is important that these mice be removed immediately after birth, before suckling at their own mother. The subsequent incidence
of cancer in these mice is that of their foster mothers. The converse experiment
has the same result—mice born of parents of low cancer stock and fostered by mice
of high stock again develop the same cancer incidence as their foster mothers, and not
as their biological mothers. Further experiments show that this newly acquired characteristic persists in the next generation. From these experiments, it is urged that
this type of agent is extra-chromosomal, is vehicled by the milk and like many viruses
may remain latent in the body for long periods. Based on Bittner's work, one observer at least (Ludwig Goss) has made the recommendation that human breast cancer
could be substantially reduced if women with any tumour in their ancestry were to
refrain from nursing their progeny right from birth—to stop from one generation, he
believes, would break the chain.
Page 101 The discovery of the milk factor is hailed as indirect evidence of the virus theory.
Its properties regarding infectivity are in harmony with all the information available
concerning viruses in other tumors. Alone it is incapable of acting pathogenically.
Conditions must be just right and the complixity of these conditions is difficult to
unravel. Further, it must be emphasized that the virus is once again playing the part
of the immediate cause of cancer, the hormone and heredity being predisposing or
remote causes.
BIBLIOGRAPHY
1. Cancer Research, May, 1944, Ludwig Goss.
2. Practitioner, July, 1945, Gye.
3. New England Journal of Medicine, December 7,  1944, Nathason.
4. Recent Advances in Pathology, Hadfield and Garrod.
PATHOLOGY OF CANCER OF THE BREAST
Dr. H. H. Pitts
As this symposium deals solely with cancer of the breast, the various other pathological processes affecting this structure will not be included in this presentation.
One might first mention a few general facts in respect to cancer of the breast:
(1) It is one of the commonest malignant tumours in women and has its greatest
incidence in the involution period, i.e., the years before and just after the menopause.
Moore lists the incidence as follows: 26% before the age of 40, 42% between the age
of 40 and 5 years after the menopause, and 32% more than 5 years after the menopause. It is rare before the age of 20 although I have seen one case in a 17-year-oJd
girl with diffuse metastases. One has also seen a considerable number in the 20-30
age group.
(2) It is commoner in nulliparae and some authorities claim that there is a
greater incidence in women whose children have not been suckled. Adair states that
only approximately 8.5% of women with cancer of the breast give a normal nursing
history. The increased incidence of cancer of the breast in nulliparous women in in
sharp contrast to the high incidence of cancer of the cervix in parous women.
Classification of Breast Cancer
For practical purposes these may be grouped under 5 headings: (a) Scirrhous, (b)
Mdullary, (c) Adenocarcinoma, (d) Dust carcinoma, (e) Paget's disease. Some pathologists, and amongst this group, myself, use further divisions, viz.: "Simplex," intermediate between scirrhous and medullary and papillary. Some of these groups derive
their terminology on the gross, some on the microscopic appearance, or both, and I
believe that in the microscopic differentiation of breast carcinoma the personal equation
is no small factor, and especially is this true in deciding between the scirrhous and
simplex types. "Whether one or other diagnosis is made probably does not alter the type
of treatment or prognosis, and consequently it might be more advisable to adhere to the
more commonly used and probably more descriptive term, at least from a macroscopic
standpoint, of scirrhous carcinoma.
There is no point in minutely describing the histological picture of the various types
but it might be well to describe them in a broad sense. The most" frequent type is
the scirrhous, which, as the name implies, is a very firm, usually relatively small tumour
of almost fibrocartilaginous consistency. Generally situated in the upper outer quadrant,
which is the commonest site for all breast carcinoma, it may cause dimpling of the skin
above it. If near the nipple it may produce retraction or even inversion of that structure. Axillary lymph node involvement is relatively early, which would seem rather
paradoxical in view of the histological picture of abundant almost hyaline stroma with
only small cords and nests of cancer cells.
The medullary cancer is more apt to be a larger tumour, softer, probably with some
tendency toward encapsulation, and microscopically showing a great preponderance of
epithelial cells over stroma, yet despite this cellular structure it is not as prone to early
Page 102 metastasis as the scirrhous.    The so-called acute carcinoma usually seen during lactation is more likely to be of medullary type.
Between these two lies the simplex, both grossly and microscopically showing a proportionately equal distribution of stroma to epithelial elements.
The adenocarcinoma and duct carcinoma arise apparently from the lining epithelium
of the acini and ducts respectively, and these tumours, which from a clinical standpoint
cannot be definitely distinguished from the foregoing—i.e., by palpation, etc.—show
a tendency to reproduce acini and ducts although definitely aborted and immature,
and, as is true in tumours in other parts of the body which show attempts at differentiation, they are of a lower grade of malignancy, but unfortunately they are of much more
infrequent incidence than the previously mentioned types. Discharge from the nipple,
either serous or sanguinous, is relatively common in duct carcinoma.
Papillary cancer, I believe, has a place in this classification, as one has seen a number
of instances where there is a definitely papillary type of structure apparently originating within dilated ducts or cysts, probably primarily an intraduct papilloma, the ramifications of the growth infiltrating out into the adjacent breast tissue. These tumours
are of relatively low malignancy.
Paget's disease has ,been the cause of considerable controversy for many years, as to
whether the primary carcinomatous process originates in the eczematous lesion about
the nipple and secondarily involves the underlying mammary ducts and acini, or vice
versa, and there is still no definite universal agreement. However, the proponents of the
primary carcinomatous lesion in the duct epithelium and involving the squamous epithelium by intraepithelial spread are in the majority. It is not a particularly actively
growing malignant process, and in fact the eczematous appearing areolar lesion may be
present for many years.
Lymphatic spread is the chief mode of dissemination of breast cancer, the axillary
lymph nodes being involved, it is said, in from 55-60% of cases when they finally
present themselves for treatment. Supraclavicular lymph nodes and the higher cervical
mediastinal group, especially from those tumours situated in the medial quadrants.
Pleural and peritoneal metastases are fairly frequent and blood-borne metastases involve
the lungs, liver and kidney, femur, vertebrae, ribs and humerus, skull, dura and brain.
One is frequently asked as to the relationship between mazoplasia, cystic hyperplasia
or cystic mastitis,—call it what you will,—and carcinoma of the breast, and again one
is confronted with a controversial issue. On the one hand cystic hyperplasia, etc., is a
very common condition during the period in which carcinoma has its greatest incidence,
and therefore the presence of the two conditions should evoke no particular wonder.
But, on the other hand, the breast reflects endocrine function in the cyclic dilatation of
ducts and acini, and the proliferation of the lining epithelium of these structures
and the cystiv hyperplasia, etc., is probably an index of endocrine, chiefly ovarian, dysfunction. We know further that the injection of excessive amounts of ovarian hormones, particularly folliculin, will produce mammary carcinoma in experimental animals, often of a highly resistant strain. Therefore it seems reasonable to regard these
cystic changes in the breast as potentially true precancerous lesions.
As to prognosis—Boyd quotes a report of Janet Lane-Claypon to the British Ministry of Health on the basis of a very searching and exhaustive survey, that the average
duration of life in untreated cases is 3 years; of those treated by radical operation
50% are alive and well after 3 years; 30% after 10, and of those who, at the time of
radical operation, showed no evidence of metastatic spread, 85% were alive and well
at the end of 10 years.
So here, as with carcinoma elsewhere in the body, early diagnosis and treatment are
of paramount importance, and I feel that all tumour masses in the breast, regardless of
the patient's age, or how clinically innocent they may appear, should be excised and
examined microscopically. The old adage, *'A watched kettle never boils" does not
hold true in tumours of the breast, for the nodule that is kept under observation by
the physician for periods varying from weeks to months may boil over into a full-
Page 103 blown carcinoma, and the delay may mean the difference between a good and bad prognosis. A small surgical scar early is better than loss of a whole breast or even a life
later.
SURGERY OF CANCER OF THE BREAST
By G. H. Clement, M.D.
In 1867 Charles Moore published his paper on the operative methods of dealing
krith breast cancer. He is regarded as the father of breast surgery. Before that time
fhe general practice was to remove the mamma by transfixion and leave the area to
jranulate over, but with the development of the achromatic microscope, Moore taught
ind advised the removal of the breast, pectoral muscles and glands of the axilla. This
pas before the era of aseptic surgery and there was a great deal of criticism.
In 1894 Halsted advocated that a large area of skin and muscles and axillary glands
>e removed, and left a large area to granulte over. It was shown later by Thiersch,
/olkmann and Stiles that the human spread of cancer was through the lymphatics
>f the pectoral muscles and the fascia, and it was not necessary to remove such a
ijrge area of skin. This was also taught by Samson Handley and now this is the gen-
rally accepted teaching and treatment of today. With the advancement of x-ray
herapy the tendency is now to less radical surgery, and it is the generally accepted
act that all of the glands, no matter how careful the dissection, cannot be found and
emoved.
Before going on to the surgical treatment, the commonest age group is between
0 and 50, and the next 50 and 60.    It is equally common in both breasts and the
nost common site is in the upper and outer quadrant of both breasts; 45 per cent,
ive 5 to 10 years following radical surgery, and 55 per cent, live 1 to 5 years.
The two most important things to plan in the surgery of breast cancer are that
nough skin is left to cover the chest wall so that the suture line heals by first intension, and that the use of the arm following the surgery will be 100 per cent. In plan-
jung the incision enough skin around the area of the breast should be removed to
Insure that all the cancerous area is totally excised. The upper incision carries down
[rom the coracoid process to the ensiform cartilage. The lower incision is planned so
hat any indurated area of the breast, i.e. cancerous, is totally removed as well, and
mus joined to the lower end of the upper incision. In making these incisions, they
re carried deep through the fatty layer, taking the pectoralis major and minor and
jascia, removing the pectoralis major insertion from the tuberosity at the head of
the humerus, and the minor from the coracoid process. The whole mass is removed
h toto—breast muscles and fascia. The removal of the pectoralis major and minor
lives adequate exposure to the axilla and the glands can be thus easily dissected off
he great vessels in the axilla. The clavicular portion of the pectoralis major is usually
eft and the dissection is carried down the side wall of the chest to the latissimus dorsi.
thus the whole of the fat and glands in the axilla and the fat on the side wall are
emoved with any carcinomatous glands. If the upper end of the incision is carried
pto the axilla or over the head of the humerus, there is great danger of interfering
»rith the lymphatic drainage of the arm and as a complication, swollen oedematous
rms are generally seen after six months. The careful dissection of the glands of the
ixilla is one of the tedious parts, and great care is to be taken in removing these glands
js they are so often found to be frozen around the great vessels. The axillary vein
f most easily wounded because of its elasticity. The dissection can be carried up the
mper chest wall, below and above the clavicle, from this incision. Suturing of the
fein is done by silk or silkworm gut. Drainage is left in the axilla and brought out
nrough stab wounds, using a Penrose drain.
Post-operative Treatment:    The upper arm   is left at right angles   to the   chest
kail for four days.    This insures freedom of movement of the shoulder muscle and
inn, and precludes any adhesions in the axillary area, thus giving the patient practically
00 per cent, muscular freedom of the arm on the affected side.
Page 104 RADIOLOGICAL TREATMENT OF CARCINOMA
OF THE BREAST f
By Dr. B. J. Harrison, V.G.H.
The subject of the use of roentgen radiation in the care of patients suffering from
mammary carcinoma includes all other phases of tonight's symposium in the same manner as they, too, touch upon it. Naturally some overlapping will occur; it will be
understood, I think.
Many facts, some of greater, some of less importance, have been brought to light
during the investigation of carcinoma in general and of mammary carcinoma in particular since I spoke on this subject some years ago. The one which has interested me
most perhaps is the relationship of mammary feeding to mammary carcinoma in the
mouse—(1) when a mouse of a strain susceptible to mammary carcinoma is suckled
by a mother of a susceptible strain the suckling develops mammary carcinoma; (2)
when a mouse of a strain susceptible to carcinoma is suckled by a mother of a strain
resistant to carcinoma, the suckling does not develop mammary carcinoma (Worst);
(3) a mouse of a resistant strain, suckled by a mother of a susceptible strain, develops
carcinoma (Bifneld).
Translating these three findings into human terms—a process not always strictly
permissible, of course—there seems to be an indication that when a woman, herself with
the genes containing the latent tumour factor of mammary carcinoma, as evidenced by
a family history of carcinoma, gives birth to a child, she probably transmits to it some
genes with the same tumour factor. Neither parent nor child may show carcinoma at
all, and in any case will not show it before the onset of the suitable cancer period.
Should the mother suckle this child, the risk of the child developing mammary carcinoma will be greatly increased; in other words, it would seem that women of families
with a history of mammary malignancy should refrain from suckling their children.
It is probable that the latent tumour factor is present in nearly every woman,, and it
would seem, therefore, that no mother can suckle her child without increasing the
probability of that child developing mammary carcinoma. To the pediatricians, so
many of whom seem to think that they have food formula; as superior to Mother
Nature's as day is to night, the universal application of the principle that the mother
should not suckle her baby would probably be welcome.
Going a little further, we will remember that pregnancy and lactation are considered
extremely dangerous in cases of existing mammary carcinoma, and it is a justifiable
inference that the changes in the breast associated with pregnancy and lactation, and
even with the menstrual cycle itself, are potential factors in the development of mammary carcinoma in any woman.
It will be seen, then, that the female breast is a source of danger not only to the
potential baby but also to the woman herself, and some thinkers may therefore urge
that, in the same way that circumcision has become popular for male babies, so, too,
bilateral mammectomy should become an imperative for the well-brought-up female
child.
Such a surgical procedure, however, overlooks the aesthetic factor of the breast in
the female armamentarium. I must say that some of us still admit the occasional
existence of this aesthetic factor and prefer that it should be manitained. Should some
method of treatment, for example, x-radiation, be found capable of destroying the
secretory function of the breast without destroying its gross anatomy, then the eugenist,
the cancer epidemiologist, the mother and the child, and finally the man in the street,
will all be satisfied. Let us make haste. Do this for but one generation and the
greatest progress in the prevention of mammary carcinoma that the world has ever seen
will follow.
So much for the role of x-radiation in the prevention of mammary carcinoma.
II.    Case Finding
The next most important point in the development of the attack on mammary carcinoma in the last few years.is that which has been stressed by Strang of the Cancer
Prevention Clinic in New York City.    This Clinic is engaged in the examination of
Paee 105 L
ipparently healthy women. The findings indicate that such examinations bring to light
i percentage of unsuspected cases of carcinoma comparable to the percentage of cases
)f tuberculosis unearthed by the mass surveys going on all over the country.
Such case finding will mean a greater percentage of surgically controllable cases
pith the role of roentgen radiation reduced to a minimum.
III.    Clinically Discovered Mammary Carcinoma.
From the radiological point of view we divide these into five groups:
The first is the very early case found more or less accidentally. These cases are
Amenable to surgery and post-operative radiation is not indicated.
Group 2.—This is the group in which surgery plus radiation must be considered,
rfere the vexed question of pre-operative and post-operative x-radiation must be decided.
Hoffmeyer, in Acta Radiologica in October, 1943, presented the history of 50 cases
}f pre-operative radiation. In not one single case was there complete disappearance of
:he cancer cells. Nevertheless all the cancer cells seen showed evidence of degeneration.
Some of these would certainly have been destroyed if a longer period of time had
^lapsed between the time of administration of the radiation and the surgical removal,
but some of them, too, would probably have recovered and continued the cancerous
process. Hoffmeyer found that the results obtained were better (a) with a high dosage
—4,000 units—than a medium dosage—2,000 units; (b) when a period of four to six
weeks elapsed between the radiation and the operation. The thought to be gained from
this investigation would be that from four to six weeks after pre-operative radiation is
the proper time for the surgical removal.
On this continent, two of the best known exponents of pre-operative radiation are
Kaplan of the Bellevue Hospital in New York, and Soiland of Pasadena. On the other
hand, among the most widely known opponents of pre-operative radiation who are at
the same time strongly in favour of post-operative radiation are Adair of the Memorial
Hospital and Popp of the Mayo Clinic. The figures of the end results quoted by these
two groups of authorities, pre- and post-operative radiationists, agree very closely, with
a slight advantage in favour of the pre-operative group.
I feel that we must look beyond the purely medical aspects of this problem to
account for the forcefulness of the statements of these two groups in spite of the fact
that their figures are almost identical. It should be pointed out that the upholders of
the post-operative treatment receive patients referred from widely scattered places in
the country—patients who travel long distances to reach surgical centres, and it is
natural that there should be a tendency on the part of the clinic to complete the whole
treatment, surgical and x-radiation, in the most speedy manner possible,' using a combined technique which may be carried out in one continuous session, as it were. The
post-operative radiation can be commenced practically as soon as the patient has recovered from the immediate effects of the operation and the wound is healing satisfactorily; in short, before the patient is sufficiently well to travel back to her home she is
sufficiently well to begin post-operative treatment. On the other hand, the two advocates of the pre-operative form of treatment draw their clientele from a much narrower
geographic field—Kaplan mainly from the Bellevue Hospital in New York City, and
Soiland mainly from the city of Los Angeles and its surroundings. In the latter or
pre-operative group, one can see that it is almost as simple to carry out the treatment
in two stages, the pre-operative treatment being followed by a pause for recovery,
which in turn is followed by the surgical procedure. Since the patient has neither to
travel back to a distant home-town between the two technical procedures, nor to wait
idly by in the city, she is not unduly inconvenienced^ by the pre-operative method.
Therefore, using our best authorities as a guide, we may say that post-operative
therapy is advisable when the patient comes from a long distance, but that pre-operative
therapy is slightly more advantageous for patients who come from places close at hand.
In passing, a word of warning should be offered: that before accepting any analysis
of medical statistics on this or any other subject, one should always obtain the figures
and analyze them oneself.   I came across an example in hunting up some figures for
Page 106 this paper. A well-known clinic investigated the end results in several hundred cases
of simple mammary tumour and found that in the five to six years subsequent to operation malignancy occurred in 1.8% of the patients. The clinic then pointed out thai
this rate is five times as great as the rate for the whole of the state in which the clinic
is situated, for women of comparable age groups, and the clinic goes on to suggest that
all patients with these simple mammary tumours should be carefully watched aftei
removal of the tumour because of this noticeable increase in incidence. Now, as
matter of fact, an analysis of the figures indicates that the rate incidence for any group
for five years should be about five times the rate incidence of the same group for one
year. The analysis, therefore, tended to prove just the opposite from that which the
analyst indicated; in short, it tended to prove that there was no greater danger of
malignancy on the whole in patients who had had a previous operation for simple mammary tumour. As a matter of fact, a further analysis of the figures quoted did indicate
that, although the general rate remained unchanged, the rate for patients who had been
operated on for chronic cystic mastitis was about twice the average rate. This, if I
remember right, is just in keeping with the ideas which have been prevalent for many
years.
Group 3.—The third group to be considered from the radiological angle is that
containing patients who are frankly inoperable when first seen. They form between 6%
and 7% of the cases referred to us for x-ray treatment. The relief that can be afforded
these patients is a great stimulus to the practising therapist since it demonstrates so
satisfactorily the efficiency of the x-ray against the malignant cell and leads him on
with a constant hope that as he gains greater mastery of technique he may be able to
obtain, routinely, successes such as at present come only irregularly and unaccountably.
I have taken our cases of this class for the last three to five years and analysed them—
superficially, I will admit.    I quote only the facts.
,   1.   All were over 50 years of age—23% between 50 and 60; 28% between 60 and
70; 36% between 70 and 80; and 12% between 80 and 90.
2. For the different age groups, the greatest incidence, absolute as well as relative,
was found to be in the eighth decade—the group 70 to 80.
3. Only 20% of the patients had had biopsy. It was felt, apparently, that the
diagnosis was so clear that the biopsy was not really necessary nor advantageous in most
cases. It is possible, of course, that some of these cases were not primary in the breast.
We have had several cases, as a matter of fact, in which a mass in the mammary region,
apparently the parent mass, proved at autopsy to be a secondary carcinoma.
4. 100% had involved axillary nodes but only 20% had involved supraclavicular
nodes.
5. 40% had either actual or impending ulceration, that is to say, the skin was at
least reddened, tight, shiny.
6. 90% had fixed lesions.
7. 65% were on the right side and 35% were on the left. This would seem to
indicate that a mass in the left breast, would tend to be found earlier than a mass in
the right breast by a right-handed woman, and this finding would suggest that even
more careful attention might be paid, in the ordinary clinical examination, to the right
breast than to the left.
8. 90% of the patients were married; 10% were unmarried. Unfortunately I had
not available the figures showing the relative numbers of married and unmarried women
in the age groups to which these patients belonged, but I would be inclined to say that
the figures are comparable and that the question of marriage does not enter into the
matter.-
9. Only 15% of the patients were in really poor physical condition—really
cachectic.
10. 90% of the patients had had a recognisable mass for many months and had
only consulted the doctor when some change occurred in this mass.
Page  107 11. The changes complained of were (a) pain in approximately 70% and (b)
ulceration in 30%.
12. The longest time a lump had been known to be present in the breast before
medical consultation was five years.
13. The shortest time a lump had been present was six months.
14. Even after a change in a pre-existing lump occurred, patients still waited before
bonsulting the doctor. The longest period of waiting in this manner was twelve months
and the shortest was one month.
15. 33% of the patients had had a lump for less than twelve months. This finding
jwas quite surprising to me. It emphasizes the necessity of a rapid attack on any suspected mammary carcinoma and any nodule in the breast is suspect until proven harmless. It cannot be too strongly emphasized by us as a body that in less than twelve
months over 2% of mammary carcinomas become inoperable.
16. One male was found in this group: offhand, one would imagine this to be
ilmost impossible.
These patients were all treated by x-radiation, some receiving more, some receiving
[ess. The object of treatment was palliation, and in designing a treatment from this
angle we must remember that the patient comes to the doctor to be relieved of some-
jching. In these cases, according to our figures, 70% visited the doctor primarily to*
be relieved of pain and 30% wanted relief of ulceration. The others came for various
reasons—-some about the lump; some because they were pushed to the doctor by their
Relatives; some because of metastatic deposits; but taking it by and large, these patients
wanted relief from pain and/or ulceration.
This, then, is our clue in therapeutic approach. Can we do anything for these
patients?    Let me quote some excerpts from a few histories.
Cise Reports
Mrs. V. W., aged 67.—Seen in 1942 with a lump of one year's duration which at
the time she presented herself occupied the central portion of the right breast as a hard
irregular mass the size of a grapefruit, attached to the overlying reddened skin, with
marked oedema of the whole of the skin of the breast. An enlarged very hard right
axillary gland was present. Weight was 121 lbs. Patient was irradiated. The tumour
at no time ulcerated. The axillary glands disappeared. The breast mass diminished in
size but always remained quite large. She slowly lost weight and she died in February,
1945.
Mrs. B. C, aged 52.—In February, 1943, had a mass in the left breast 5x7 cm.*
attached to the skin but movable over the fascia with large hard axillary lymph nodes.
After treatment, this patient did not continue to return for follow-up, and she developed, eighteen months after her first treatment, a very extensive deep ulcer some 15
cm. long. She lived for nearly two years and irradiation was later applied to the ulcer.
It was found impossible to heal the ulceration though its extension was controlled, and
when last seen three months ago the patient was put on sedatives, as she was going
downhill rapidly.
Mrs. G. D., aged 63.—Seen originally in 1942 with a history of two years. A large
lesion with half an inch ulceration on the fold under the breast to the left of the
nipple with a large area of surrounding inflammation and large hard axillary lymph
nodes. Her weight was 133 lbs., and she was treated at odd times until March, 1945,
at which time she was 20 lbs. heavier than when she was first seen. In early May of this
year she had no evidence of ulceration. Unfortunately, when she died on May 17 I was
unable to obtain any information regarding the cause of her death.
Mrs. M. B., aged 81.—With a three-year history preceding her presentation. An
ulcerated mass fixed to the muscle but not to the thoracic wall, accompanied by some
axillary lymph nodes. She was seen in March of this year. She weighed 130 lbs. She was
seen two weeks ago, at which time she had no palpable axillary lymph nodes. There
was no ulceration. There was some indefinite thickening in the treated area but no
definite palpable mass; weight 139 lbs.
Page  108 From these stories can we feel justified in continuing our work? The answer is
undoubtedly "Yes," but it must be followed by the query, "How can we improve it?"
(a) Binney (B.J.R.) says that 6 to 10 mgm. of Stilbesterol daily, a dose which
tends to produce only some nausea and menorrhagia, enhances the x-radiation effect so
that the dose required to produce the result can be diminished some 50%.
(b) Sterilization has been on trial for a long period. Wintz of Erlangen emphasized its value very strongly in the period shortly after 1920, and it seems to be gaining
favour again as having usefulness in all cases except the mucoid type. Sterilization is
best carried out by the administration of roentgen radiation because this is the least
distressing, the least harmful, and the least incapacitating method. The sterilization may
be either of the permanent type carried one in one series or of the temporary type carried along for a number of years by the use of repeated doses. Its value appears to be
equally great in the post-climacteric as well as in the pre-climacteric cases. Should any
menopausal symptoms arise they should be controlled by roentgen radiation to the
pituitary gland instead of by exhibition of estrogen because the latter method of treating the symptoms simply tends to defeat the purpose of sterilization.
The ideal roentgen-therapeutic handling of patients of this group 3 therefore is:
(1) heavy local dosage on the ulcerated areas;
(2) cross-fire dosages on large masses;
(3) metastases to be treated as mentioned in group 5;
(4) the subsequent administration of Stilbesterol, 6 to 10 mgm. daily, over long
periods.
Group 4.—Recurrences. The same principles as are used in the inoperable cases
usually govern the care of these patients.
Group 5.—This group is the group in which radiation is used for the treatment of
metastatic deposits.
(1) In the skin—these occur either by direct extension, lymphatic emboli, lymphatic
emboli, lymphatic extension and blood-born emboli. They are quite superficial. If
only one or two lesions are present excision is possible, but as a rule they are numerous
and should be treated by medium voltage x-radiation, care being taken to include a
large area of the skin on the side of the lesion distal from the breast, because every now
and again one sees lesions of this kind heal up only to be succeeded by lesions appearing
still further away from the breast, beyond the area irradiated.
(2) Regional lymph nodes, (a) The axillary—by heavy dosage, especially with
cross-fire method. These lymph nodes may disappear entirely, although they sometimes
seem to be extremely refractory.
(b) Supraclavicular lymph nodes. These often extend through the capsule of the
gland and are therefore more difficult to control than the axillary glands, moreover, they
are also more difficult to treat because of the technical impossibility of administering
satisfactory cross-fire. The attack, therefore, requires totally different technique.
(3) Skeletal metastases.— (a) Palliative. Palliative treatment only should be aimed
at, if these skeletal metastases are growing rapidly or if there is concomitant gross
visceral involvement. It must be remembered that these lesions may be present without
symptoms at the time of the first visit to the doctor or they may appear at late as
twenty years after the removal of the primary lesion, appearing most commonly in the
spine and pelvis. They seem to arise by extension through the venous vertebral pool.
Mainly osteoclastic, occasionally an osteoblastic reaction develops around them. They
occur earlier and more commonly
(1) the higher the grade of malignancy,
(2) the younger the patient,
(3) the more gross the axillary involvement,
but every variety of mammary tumour can spread to the skeleton.   All osseous metastases respond to x-radiation if treated not later than ten months after the onset of
symptoms and the onset of symptoms usually means the development of pain.  Improvement occurs within a month and lasts for a length of time which varies with the degree
Page 109 jof malignancy, the more rapidly growing lesions showing a recurrence of pain earlier.
lit is to be noted that the administration of androgens, testosterone propionate for instance, causes a rise in the blood and urinary calcium when there is evidence of osseous
imetastases in exactly the same way as does estrone, and therefore they should not be
Administered to patients with osseous involvement.
(b) A curative attack upon metastases in bone is satisfactory and gives occasional
brilliant results if the growth is slow and the patient does not show any other extension.
jl have feen patients with the pelvis riddled with secondary malignancy so badly as to
necessitate confinement to bed for months, get up after irradiation and be able to walk
about for six months and more. Here, of course, a double action occurred—the action
on the ovaries as well as the action on the bone.
(4) Lungs, pleura and mediastinum. The only time that these merit irradiation is
when the lesion is mainly pleural and mainly painful.   Intensive radiation is effective.
(5) The abdominal viscera.   These do not respond to irradiation.
(6) The cerebro-spinal system. Here, even when the metastasis is in the brain
itself, an intensive course sometimes produces very marked alleviations.
1 close with a note of hope regarding the future. Increasing refinement of control
of the physical aspects of roentgen radiation opens up new fields for the variation of
technique. The well-known effects ot x-rays on the genes of cells in general maKes it
appear that our next great progressive step in roentgen tnerapy waits on the increase
of knowledge about the cell itseit.
Physical progress is more rapid than biological at the present time, but just as wc
are entering the atomic phase in the mechanical and physical realms of the world, so,
too, we appear, as I have said so often before, to be entering upon the electronic phase
of biology in general and medicine in particular.
May I summarize as follows:
(1) Prevention of mammary carcinoma is a practical possibility.
(2) Pre-operative  radiation is  at least as valuable  as post-operative  radiation.    The
choice of method depends on economic rather than medical basis.
(3) Sterilization appears now to be definitely of value.
(4) 2% of mammary carcinomas become inoperable if left for 12/12.
(5) Left sided-carcinoma mammae is discovered earlier than right sided.
(6) Radiation has especial value in
Recurrences
Inoperable
Metastatic
Mammary carcinomas.
(7) The future is brighter than is commonly thought.
NEWS AND NOTES
We regret to record the passing of Dr. James A. Sutherland of Vancouver, who died
on March 1st.   Deepest sympathy is extended to Mrs. Sutherland and family.
The profession extends sympathy to Dr. W. E. Harrison of Vancouver in the loss of
his father on February 25 th, and to Dr. D. E. Alcorn of Victoria, whose father passed
away.
Dr. and Mrs. A. E. Davidson of New Westminster are receiving congratulations on
the birth of a son on February 21st.
Daughters were born to Dr. and Mrs. A. W. Holm and to Dr. and Mrs. R. E. Page
of Vancouver.
Page 110 The following Medical  Officers  have returned from  service overseas  and  are on|
leave: Major E. S. James, Major R. E. McKechnie, Major F. L. Skinner, Major N. i.
Ball, Capt. Paul Phillips, Capt. D. M. King and Capt. W. E. Austin.
3_b"  '^ J_» 3fr _&
Congratulations are extended to Lieut.-Col. B. B. Moscovitch on his recent promotion, i
Medical Officers who have received their discharge from the R.C.A.M.C. and are in j
practice in Vancouver include the following: Major A. W. Bagnall, Major B. M. Fahrni,
Major E. F. Raynor, Major R. A. Wilson, Capt. D. W. Moffatt, Capt. F. A. Qlacke,
Capt. L. B. Fratkin, Capt. D. J. FitzOsborne, Capt. H. E. White, Capt. J. V. White,
Capt. G. L. Watson. *      *      *      *
Capt. N. F. A. McSweyn has received his discharge from the R.C.A.M.C. and is
now in practice at Prince Rupert.
Major B. FL Cragg has received his discharge from the R.C.A.M.C* and has resumed
practice in New Westminster.
Major Kingsley Terry is now out of the R*C.A.M.C. and with the Department of
Veterans Affairs in Victoria.
*•       *       «.       sj.
Capt. H. E. Hamer, R.C.A.M.C., has returned to civilian life and is in practice at
Revelstoke.
a. sr-
Dr. W. F. Anderson of Kelowna called at the office when in Vancouver recently.
DR. J. A. SUTHERLAND
Obiit March 2, 1946
In the passing of Dr. J. A. Sutherland, of Vancouver, we are left to mourn
the loss of a man who was in the best sense of both words, a physician and a
gentleman. Those who knew him, loved him—and his death deprives us all
of a man we were glad and proud to call our friend.
"Jimmy" Sutherland, as he was known to all his friends, practised a long
time in Vancouver, over thirty-five years at any rate, and did good, honest
work every day that he practised. He was a very competent man at his work*
and even from that point of view, and it was thus he would wish to be judged,
we are the poorer by losing him.
But it is by his most endearing personality that we shall longest remember
him. Quiet, unassuming, gentle, he was still an addition to any gathering of
medical men. He enjoyed himself so thoroughly with others, whether it were
in a game of golf, or in a quiet game of poker, or just quietly sitting together
and talking, that he gave everyone else a good time. Nobody ever heard Jimmy
say a harsh or unkind world about any other man—he was fond of his fellow-
men, enjoyed good fellowship, and contributed very greatly to it himself.
His name was up to be voted on for Senior Membership in the Canadian
Medical Association, and the votes of his fellows would certainly have secured
this honour for him if he had lived. He served the Vancouver Medical Association well and faithfully, in one of its most thankless and laborious Committees, the one on Relief, and he was a Trustee of the Association. We were the
better for his presence among us, and we shall always cherish happy memories
of him.
Page 111 Captains C. C. Covernton, W. H. Perry and G. C. Walsh, following their discharge
ifrom the R.C.A.M.C, are at Shaughnessy Hospital in Vancouver.
*5* ^S* *5" Jf*
Dr H. G. Baker has received his discharge from the Naval Medical Services, and is
associated again with the Metropolitan Health Committee in Vancouver.
Dr. J. J. Gibson, formerly of Prince Rupert, is now associated with the two Doctors
[White, Parmley and Barr at Penticton.
*r 3£» 5^ *£•
Dr. J. R. Parmley of Penticton reports that a local medical society has been organized there, and that it is intended to hold regular meetings, combining professional and
; social interests.
Jj" 5j> *(• S(»
We hope that Dr. Parmley is making a good recovery following his illness.
* *       *       *
A special meeting of the Victoria Medical Society was held on Thursday, January
31st, for the purpose of hearing Dr. A. E. Archer, Consultant on Medical Economics,
C.M.A., discuss Health Insurance. The meeting was well attended and the informal
discussion which followed Dr. Archer's address was both interesting and informative.
At the regular meeting of the Victoria Medical Society held on February 4th, a
coloured moving picture on Inguinal Hernia was shown, following which Dr. W. E. M.'
Mitchell gave a most interesting description of his experiences in Malta.
Or sj- sj- sf-
Wing Commander J. E. Dalton has received his discharge from the R.A.F. and has
opened an office in Esquimalt.
* * * *
Dr. Leonard Bapty has received his discharge from the R.C.A.M.C. and is in practice in Victoria.
i'r SC- :'e :J-
Dr. J. A. Rankine has received his discharge from the R.C.A.F. and has joined
Doctors A. S. Underhill and W. F. Anderson at Kelowna.
•^ •_ *t» _&
We are sorry to hear that Dr D. M. Black of Kelowna is ill ,and extend "best wishes
for a speedy recovery.
»? »? •*■ *r
Flight-Lieut. C. G. Morrison has received his discharge from the Air Force, and is
again practising with the C. S. Williams Clinic at Trail.
* *       *       *
Lieut.-Col. R. A. Palmer of Vancouver is on an extension course at Edinburgh
University.
* *       *       *
Dr. W. S. Barclay of Sardis visited the office when in Vancouver recently.
%■       *       a-       *e-
We learn with regret that Dr. L. M. Greene of Smithers is laid up with a leg injury
(skiing is such a rough sport). Dr. J. B. Snyder of Vancouver is carrying on for Dr.
Greene while the latter is incapacitated.
sfr st *£ *£■
Dr. W. C. Pitts of Port Alberni visited the office when in Vancouver recently.
»$• ?$• *r 3p
We regret to learn that Dr. W. A. Coghlin of Trail is ill. Dr. Coghlin has the
best wishes of the profession for a speedy and complete recovery.
Dr. J. W. Vosburgh of Princeton recently paid a visit to Vancouver.
Page 112 flfoount peasant Unoertaking Co. Xto.
KINGSWAY at llt_ AVE. Telephone FAIrmont 0058 VANCOUVER, B. C.
R. F. HARRISON W. E. REYNOLDS
M
8$F
13 th Ave. and Heather St.
m
Exclusive Ambulance  Service
FAirmont 0080
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
J. H. CRELLIN
W. I_ BERTRAND VANCOUVER HEALTH DEPARTMENT
STATISTICS—DECEMBER, 1945
Total deaths \ 371 13.5
^nese Population—Estimated Evacuated
Chinese deaths 33 59.2
Deaths—Residents only 306 11.1
Rate per 1,000
Population
12.1
22.1
10.3
Number
Total deaths .     320
Chinese  deaths 12
Deaths   residents   only ! 274
BIRTH REGISTRATIONS:
Male, 314; Female, 298     612 22.3
INFANT MORTALITY: January, 1946    January, 1946
Deaths under one year of age       17 14
Death rate—per 1000 live births       27.8 22.3
Stillbirths (not included above)       11 6
CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY
December, 1945 January, 1946        Feb. 1-15, 1946
Cases      Deaths      Cases      Deaths      Cases      Deaths
jtt Fever   43
theria \  7
pheria Carrier  15
ten Pox  161
les  10
lla I  6
jjps .  56
pping Cough  0
oid Fever  0
tlant Fever __. . . 1  1
myelitis   1
rculosis e c i ; _..—-— 37
pelas    j *  !  1
ngoccus  Meningitis . '. . .       1
pons Jaundice ,—,  _ 5  0
bnellosis — _—~-—-'-  2
jnellosis  (Carrier) =—^-.— :  0
p.tery  70
jilis :  72
rrhoea :  133
er (Reportable):
Resident  28
Non-Resident   _.  13
0
58
0
15
0
0
3
0
2
0
0
14
0
2
0
0
193
0
67
0
0
8
0
4
0
0
13
0
2
0
0
84
0
43
0
0
0
0
3
0
0
0
0
0
0
$
0
0
0
0
0
0
0
0
0
3
72
22
0
0
0
1
0
0
0
0
0
0
1
0
0
1
0
0
0
0
5
0
2
0
0
0
0
0
0
0
0
0
1
0
0
117
1
0
0
0
241
0
0
0
B I O G L A N "C"
Prepared separately for male and female.
Composition: Anti-thyroid principles of the pancreas, duodenum, en_-
bryonin, suprarenal cortex, tests (or ovary). Each 1 cc. ampoule
contains the equivalent of approximately 29 grams of fresh substance*
Indications: Graves's disease, hyperthyroidism, exophthalmic goitre,
thyrotoxicosis.   The most effective therapy available.
Stanley N. Bayne, Representative
Phone MA. 4027 1432 MEDICAL-DENTAL BUILDING Vancouver, B. C.
Descriptive Literature on Request
THE SCIENTIFIC HORMONE TREATMENT
Page  113 z.
<M
MAINTENANCE dosage levels of all the required vitainins. Whc|
patient is obese, on a diet, pregnant, aged or adolescent, you will wi
prescribe no less than the daily recommended allowances as specified \
Food and Nutrition Board of the National Research Council, S
Special Formula supplies these full allowances.
EACH    CAPSULE   CONTAINS:
Vitamin A
Vitamin D
Thiamine
.    .    . 5000 units     Riboflavin    .    .    .    .3m
.    .    .    800 units     Niacin 20 m
,    .    , 2   mg.     Ascorbic Acid    .    .    . 75 m
There is no higher standard for maintenance dosage levels of all the indft
vitamins, lack of which has been shown to cause deficiency states comn
occurring in man.
SQUIBB
hm,
VITAMIN   CAPSULES
FOR UTERATURE—WRITE E. R. SQUIBB & SON OF CANAD/
36-48 CALEDONIA ROAD, TORONTO [\NCOUVER      MEDICAL      ASSOCIATION
Founded 1898 :: Incorporated 1906
j PROGRAMME OF THE FORTY-EIGHTH ANNUAL
[ SESSION (SPRING SESSION)    §        j
MERAL MEETINGS will be held on the first Tuesday of the month at 8:00 p.m.
NICAL MEETINGS will be held on the third Tuesday of the month at 8:00 p.m.
These meetings will continue to be amalgamated with the clinical staff meetings of
the various hospitals for the coming year. Place of meeting will appear on the agenda.
ruary    5—GENERAL MEETING.    Dr. D. H. Williams:     „
"Recent Advances in Dermatology."
mary 19—COMBINED CLINICAL MEETING—St. Paul's Hospital.
ch    5—OSLER DINNER—Hotel Vancouver. |
Osier Lecturer: Dr. A. L. Lynch.
rch 12—COMBINED CLINICAL MEETING—Shaughnessy Hospital.
ril    2—GENERAL MEETING.   Dr. Carl G. Heller, University of Oregon Medical
School: "Uses and Abuses of the Male Sex Hormone."
il 16—COMBINED CLINICAL MEETING—Vancouver General Hospital.
1   7—ANNUAL MEETING.
Breaks the vicious circle of perverted
menstrual function in cases of amenorrhea,
tardy periods (non-physiological) and dysmenorrhea. Affords remarkable symptomatic
relief by stimulating the innervation of the
uterus and stabilizing the tone of its
musculature. Controls the utero-ovarian
circulation and thereby encourages a
normal menstrual cycle.
«W • MARTIN H. SMITH COMPANY
Ht, ISO  lAfAYtTU SHUT.  NIW TOM. N. T.
Full formula and descriptive
literature on request
Dosage:   l to 2 capsule.
3 or 4 times daily.   Supplied
in packages of 20.
Ethical protective mark MHS
embossed on inside of each
capsule, risible only when capsule  is cut in half at seam.
Page 114 (ABSENCE OFl|.    HIGH
TOXICITY
POTENCY
Linked Together
FOR BROADEST THERAPEUTIC APPLICATION
DIM0EST10L B.D.H.
THE NEW SYNTHETIC OESTROGEN
Diencestrol B.D.H. combines all the advantages of
both the natural and synthetic oestrogens. It may therefore be administered in full therapeutic dosage in all conditions in which other oestrogens are generally used.
Diencestrol B.D.H. reproduces, at a fraction of the
cost, the effects of the natural oestrogenic hormone and
thus its use in any required dosage is permitted in patients
m all income brackets. Being non-toxic, it may be prescribed freely even to patients who have previously shown
intolerance to other synthetic oestrogens.
N.B. — Diencestrol is more potent than any other
oestrogenic substance hitherto available. In changing
from stilbcestrol, it may be assumed that 0.3 mgm.
Diencestrol B.D.H. is equivalent to approximately 1.0 mg.
stilbcestrol.
Dienoestrol B.D.H. is issued in tablets of 0.1 mgm. and 0.3 mgm.
in bottles of 100, 500 and 1000 tablets.
The British Drug Houses (Canada)
Limited
TORONTO
CANADA ZJUtari.
We are publishing in this number, on one page, a synopsis of the various clinics,
iferences, and meetings that are available for medical men to attend each month in
various hospitals of Vancouver, as well as the regular and clinical meetings of the
ncouver Medical Association.   We shall publish this in each issue.   Not only is it
kided for the benefit of men practising in Vancouver, but it is hoped that it will
»ve of interest and value to medica) men and women visiting us from other parts of
C, or indeed, from any other locality.    There is, as will be seen, a wealth of oppor-
bity for men visiting Vancouver to see what is going on—and we need hardly add
^t everyone who wishes to attend these various clinics, ward rounds, etc., will be most
irtily welcomed.   The large hospitals here have a great deal of clinical material, of
iat interest—and the men acting as leaders are all thoroughly conversant with the
hnique of conducting such conferences.   Keep this schedule handy when you come
Vancouver.   We should like to say that the idea of publishing such a schedule as a
hilar thing came from the ingenious mind of Dr. J. Moscovich, who practises in
pcouver.   He has also prepared a very full schedule of the Out-Patient Department
tivities of all the hospitals and clinics.  We cannot, handicapped as we are by limita-
jns of space, publish this in this issue, but will do so at an early date.   It will be found
contain a surprising amount of good stuff, which must not be allowed to go to waste.
ite outpatient department, as we remember our chief saying to us in interne days, is
place where you really learn medicine and surgery.
The outbreak of smallpox of the haemorrhagic type which has recently occurred in
ittle, with eight fatalities to date, has produced a very notable—we had almost said
narkable—demand for vaccination in this Province.   It is, to us, a matter for great
tisfaction that this should be so: since to all medical men, vaccination is a measure
jat should be universal.   It takes periodical episodes like this to awaken the public to
e necessity for it—but the remarkable thing, to our mind, is the almost complete
sence of protest that, as little as fourteen years ago, when we had our own serious
tbreak, was so vocal and so vigorous. The antis then attacked general vaccination
ry bitterly—and it was necessary for a campaign to be instituted to "sell" vaccination
I the public.  The Greater Vancouver Health League was responsible for that campaign,
hich it conducted with the backing and support of Dr. J. W. Mcintosh, who was then
J.H.O. for Vancouver.   Newspaper space was purchased, and regular advertisements
ere inserted for some two or three weeks.   As a result, a very widespread incidence of
tccination was attained.    This time, no campaign has been necessary: the public has
>cked in thousands to the clinics provided, and to their own physicians, and over
venty thousand have already been vaccinated—and still they come, and Dr. Stewart
lurray has wisely reopened the clinics which his department has  so promptly and
ficiently staffed.
We wonder, perhaps, why this much wiser and saner attitude should now prevail,
hinking it over, we cannot but feel that the greatest part of the credit must go to the
rovincial Health Department, which for many years has preached, and provided, im-
unization against diphtheria, whooping-cough, scarlet fever and so on. The public
is learnt to accept these as the boons they really are—has come to appreciate the value
f them and the protection they afford—and has become immunization-conscious. This
the reward that we are sure the Provincial Health Department will best appreciate,
id the one that will gratify its personnel the most.
Page 115 Vancouver Medical  Association
President \ Dr. Frank Turnbull
Vice-President Dr. H. A. DesBrisay
Honorary Treasurer —Dr. Gordon Burke
Honorary Secretary ——- : ! : __—Dr. G. A. Davidson
Editor . = i m 1—Dr. J. H. MacDermot I
The following have been elected recently and are welcomed as new members of t
Vancouver Medical Association:
Dr. H. L. H. Chambers.
Dr. S. Allison Creighton.
Dr. C. H. Gundry.
Dr. T. R. Harmon.
Dr. H. L. Jackes.
Dr. G. A. Minorgan.
Vol.
5:
6:
547-553
81-116
THE LIBRARY
HOURS: Monday, Wednesday, Friday: 9.30 a.m. to 9.30 p.m.
Tuesday, Thursday: 9.30 a.m. to 5.30 p.m.
Saturday: 9.30 a.m. to 1.00 p.m.
RECENT ACCESSIONS TO LIBRARY:
Nelson Loose-Leaf Medicine Renewal Pages:
Vol. 2:  85-95H    Leprosy, by Frederick Reiss.
2: 219-221K Infectious Mononucleosis, by Ellis Kellert.
Vol. 3:  54A-54E   Hypoglycemia and Hyperinsulinism, by Allen O. Whipple.
Vol. 5:  531-546    Diseases of the Pancreas, by Allen O. Whipple.
Tests of External Pancreatic Function, by Louis Bauman.
Mental Deficiency, by Howard W. Potter.
Subacute  Combined  Degeneration  of  the  Spinal  Cord,  bi
Henry W. Woltman.
Oxford Loose-Leaf Medicine Supplements:
Vol. 1: 744 (1)—744  (27)    Psychosomatic Medicine, by Edward Weiss.
Vol. 3:  1017-1026 (8)    The Pineal Body and Its Disorders, by Arthur Groll-i
man.
Vol. 4: 71  pages   (revision)    Industrial Toxicology,  by Alice Hamilton an<$
Rutherford B. Johnstone.
5: 70  (7)—70  (24)    Chancroid, by Francis M. Thurmon.
5:  386  (1)—386  (26)    Surgical Treatment of Pulmonary Tuberculosis,!
by John Alexander.
5:  379-422   (6-5a)    Fungous Infections or Mycosis, by Frederick T. Lord.
6:  591-616 (9)    Dementia Paralytica, by H. H. Merritt and H. C. Solo-
6:  531-534
Vol.
Vol.
mon.
6:  828 (1)—828  (13)    Scleroderma, by W. T. Longcope.
BOOK REVIEW '•"'.'■
"Clinical Neurology" by Bernard J. Alpers, M.D., Sc.D., Professor of Neurology, Jefferson Medical College, Philadelphia, Cloth, Price: $8.00.    Pp. 797 with 232 illustrations, Philadelphia: F. A. Davis Co., 1945.
This new textbook of Neurology has recently been added to the Library of the
Vancouver Medical Association.   It can be highly recommended both to those interested
Page 116 in Neurology as a specialty, as well as to General Practitioners and Students.. It is
excellently printed and on good paper, and throughout, the author's style is very readable. The author discusses the symptomatology of the various conditions in a lucid and
comprehensive manner and the differential diagnoses are usually excellent. The tables
and illustrations arc better than average.
There are some minor criticsms which might be made but they are not serious ones.
The outline of treatment of Tabes Dorsalis is hardly along modern lines; under the
chapter titled "Etiology" of Multiple Sclerosis, the table quoting the precipitating fac-^
tors must seem rather antiquated to modern Neurologists and, in the mind of jsht
reviewer, little is gained by dividing Multiple Sclerosis into various types; similarly, the
chapter on the treatment of Multiple Sclerosis is highly uncritical in certain instances,.
as when such drugs as sodium cacodylate, quinine and injections of liver are said to be
occasionally helpful, not to mention Vitamin Bl, C, D, and E.
Few will agree with the author that there is any special virtue in Bulgarian Belladonna over any other form of belladonna.
All in all, this textbook of Clinical Neurology is an up-to-date summary of our
knowledge of diseases of the Nervous System and would be a useful addition to any
physician's library.
HISTORY OF THE VANCOUVER MEDICAL ASSOCIATION
;*;-. IV.
The Library and the Reading Room
At the annual meeting of the Society, held in October, 1902, Dr. Brydone-Jack
gave notice of motion as follows: "That this Association form a medical club, for
the purpose of renting a suitable room, furnishing the same, and providing medical
periodicals for the use of its members; also starting a Medical Library and Reading
Room." What seemed uppermost in the minds of the promoters of the plan was the
establishment of a centre where members might gather during spare moments for
social intercourse. It was suggested that members of the Dental profession might join
in the scheme.
The Executive of the Association was at this time much concerned about the small
attendance at the monthly meetings, and supported the plan on the ground that it
might induce members to take a deeper interest in the affairs of the Society, particularly if it included provision for a library and reading room.
The outcome of the motion was the formation of a committee to look into the
matter and formulate a workable plan. This committee reported the following March,
at which time Dr. Glen Campbell suggested circularizing the practitioners of the city
with a view to getting their opinions on the question.
No further action was taken until the autumn of 1904. During the preceding
summer an event of primary importance to the young Association had taken place.
This was the holding in Vancouver of the annual meeting of the Canadian Medical
Association. The local committee of arrangements now made known a decision of the
general committee to hand over to the Vancouver Society surplus funds accruing from
the Dominion meeting. This money, $250.00 in all—was to be used as a nucleus towards the establishing of a medical library.
Here at last was something tangible, but to those promoting it, the scheme must
have moved with exasperating slowness. It was not until eighteen months later, in
February of 1906, that we find further reference to the subject in the Society's minutes. By this time the Executive Committee of the Association, having taken the
matter in hand, had some concrete proposals to make.
Page 117 The committee urged the formation of an incorporated society, either for the
library alone, or in conjunction with the Vancouver Medical Association. It also set
forth in detail an estimated cost of furnishing a library, based on an initial membership
of forty, and placed the annual membership fee at ten dollars. Relative to the suggestion of incorporation, it was pointed out that such a step was necessary, since the
library property might in time become valuable, and that trustees, who might legally
administer such property, would be necessary. It was finally decided to: "Incorporate the Vancouver Medical Association and Library in conjunction, under the Benevolent Societies Act, with provisional trustees, methods of election of their successors,
bylaws, etc" On May 1st, 1906, the Association was duly incorporated, and a formidable document carrying this out was signed by Drs. Undcrhill and Pearson, as representatives of the Society.
The way was now cleared for the organization of a library. To Drs. Stephen and
Keith must go a great deal of the credit for putting matters in a practical form. As
a subcommittee they together canvassed the physicians of the city for contributions
towards a fund to finance the scheme. By the end of March, 1906, a total of $865.00
had been subscribed, and this sum, together with the $250.00 on hand from the
CMA funds, made a handsome total. In the old building which stood on the N.E.
corner of Hastings and Granville streets, a suitable room was found to house the
library at a rental of $12.00 a month. Almost four years after the subject had first
been broached, the library of the Vancouver Medical Association came into being.
Nothing now remained to be done except the working out of a few details. A
library committee was appointed which was authorized to arrange all matters in connection with the library; with power to buy books, lease rooms, etc* The first
committee consisted of Drs. Keith, Stephen, Brydone-Jack, Ross and R. E. McKechnie.
The bylaws were duly revised to take care of the new departure. They provided for
an acting librarian to be appointed from the members of the committee, and directed
the said committee to bring in a report of its activities at each annual meeting of
the Association.
The library was now fully launched, and has since played an extremely important
part in the educational lives of the medical men of Vancouver. During the first
few years facilities for its use were limited to a reading room only, where books and
periodicals might be consulted. None such might be taken home for more leisurely
perusal. The librarian was a member of the Association and his time was given free.
In Octover of 1907, Dr. Keith, who was then librarian, reported that books valued at
$293.00 had been purchased during die year, and that extensive use of them had been
made by members. In his report, Dr. Keith recommended that the library committee
of five, elected annually, should be reduced to four, of whom two should retire each
year.   This method of election is still in vogue.
- In 1908 Sir Wm. Osier made a substantial contribution to the library funds and
expressed keen interest in its progress. About this time Dr. Keith visited New York
where he contacted Mr. Thomas Browne of the Academy of Medicine of that city.
The latter responded with a gift of a complete set of bound volumes of "Lancet,"
covering the entire period of its publication, from the first number issued. This gift
\s~ among the most valuable possessions of the library. From New York, Dr. Keith
went on to London, where he had a most generous response to hints for assistance to the
infant library at home. Sir Lauder Brunton donated a bound set of the "Practitioner,"
covering the period during which he was editor of that periodical. He also presented
Dr. Keith with copies of several books on Me&cine of which he was the author. Both
Sir Wm. Osier and Sir Lauder Brunton were rn^de honorary members of the Association.
*•
(To be continued)
Page lit British  Columbia  Medical  Association
(Canadian Medical Association, British Columbia Division)
President i Dr. A. H. Meneely, Nanaimo
First Vice-President Dr. Ethlyn Trapp, Vancouver
Second Vice-President i Dr. E. J. Lyon, Prince. George
Honorary Secretary-Treasurer Dr. L. H. Leeson, Vancouver
Executive Secretary Dr. M. R. Caverhill, Vancouver
ANNUAL BUSINESS MEETING
Members planning to attend the "Victory Meeting" of the Canadian Medical Association at Banff, June 10th to June 15 th, are reminded that the Annual Meetings of
the College of Physicians and Surgeons of B. C. and of the British Columbia Medical
Association will be held on TUESDAY AFTERNOON, June 11th, commencing at
2:00 p.m.
On Tuesday evening the British Columbia Medical Association will be hosts  at
t Dinner for General Council of the Canadian Medical Association.
Transportation
Condensed train schedules are shown hereunder:
Leaves Vancouver
Train No. 4  7:15 p.m. daily
Train No. 8  7:45 p.m. daily
Train No. 2 10:30 a.m. daily
Numbers leaving Vancouver on any one day will not be sufficient for a special train.
However, the C.P.R. will supply special cars on the regular trains according to demand.
Make your own reservations for space NOW with the C.P.R. and inform the ticket
bffice that you are attending the Canadian Medical Association Meeting.  These reservations will then be placed in the special cars allotted.
It is expected that low Summer return fares will be in effect again. You will be
notified when these are definitely authorized.
Arrives Banff
5:20 p.m. next day
6:00 p.m. next day
10:00 a.m. next day
'•V?*1
? K$£t&'"' lW **^&
__L%Jm,_
W&m
Page 119 College of Physicians and Surgeons
President  Dr. F. M. Auld, Nelson
Vice-President . Dr. G. S. Purvis, New Westminster
Treasurer _Dr.  H.  H. Milburn, Vancouver
Members of Council Dr. F. M. Bryant, Dr. Thomas McPherson, Victoria (District No. 1);
Dr. G. S. Purvis, New Westminster (District No. 2); Dr. H. H.
Milburn, Dr. Wallace Wilson, Vancouver (District No. 3); Dr. E. J.
Lyon, Prince George (District No. 4); Dr. F. M. Auld, Nelson (District No. 5).
Executive Secretary Dr. M. R. Caverhill, Vancouver
Registrar - Dr. A. J. MacLachlan, Vancouver
NOTICE
Problems confronting the profession will be discussed at the Annual Meeting of the College of Physicians and Surgeons of British Columbia being held in
Banff, on Tuesday, June 11th next, during the Annual Meeting of the Canadian
Medical Association.
You are requested to send in your questions to the Registrar in order that
they may be placed on the Agenda.
The following extract from a letter received from the British Columbia Teachers'
Federation Medical Services Association appears for your information and attention.
"Our Associations, the Vancouver School Teachers* Medical Association and the
British Columbia Teachers' Federation Medical Services Association, give hospital as
well as medical coverage. Because we guarantee payment to the doctors first, we
never pay the hospital until after having received complete case forms from the
doctor, who admitted our member to the hospital. In many cases doctors' accounts
have come in months late. In the meantime, the hospitals have been dunning our
office and the member, which has a tendency to act against the value of the teachers'
medical plans, and at the same time destroys the member's credit standing in the
district in which he lives. Therefore, we would appreciate receiving from the members of the medical profession our accounts at the earliest possible date. Such cooperation would greatly assist the prompt settlement of both doctors' and hospital
accounts."
"COURAGE AND DEVOTION BEYOND THE CALL
OF DUTY"
Through the co-operation of Mead Johnson & Company, $34,000 in War Bonds are
being offered to physician-artists (both in civilian and in military service) for art works
best illustrating the above title.
This contest is open to members of the American Physicians' Art Association. For
full details, write Dr. F. H. Redowill, Secretary, Flood Building, San Francisco, Cal.
Page 120
Page Ut b
—(
3
3
Staff Clinical
Conference
9 a.m.
)
r
-t
H
4
;
Medical Ward
Rounds
(Dr. Kincade)
9 a.m.
Staff
Conference
9 a.m.
b
H
HT
H
H
;
H
F
Cancer
Conference
9 a.m.
Skin
Cancer
Conference
9 a.m.
Clinical
Meeting
4-5 p.m.
Radiological
Conference
1-2 p.m.
•
Medical Ward
Rounds
9 a.m.
i
Staff Clinical
Meeting
2nd Tuesday
8 p.m.
Medical Ward
Rounds
(Dr. Baird)
9 a.m.
Neurological
Ward Rounds
(Dr. F. Turn-
bull)
2 p.m.
Surgical Ward
Rounds
(Dr.  Huggard)
11 a.m.
Clinical Pathological
Conference
12.45 p.m.
0
3rd Wednesday
Combined
Clinical and
Staff Conference
Friday,
11 a.m.
Pathological
Conference
►J
H
M
0
Medical Ward
Rounds
8.30-9.30 a.m.
(Dr.   Strong)
Surgical Ward
Rounds
12.30-1.30 p.m.
Medical Ward
Rounds
9.30-10.30 a.m.
(Dr.  Desbrisay)
Staff Clinical Meet.
4th Tuesday
each  month
Clinical
Pathological
Conference
9-10 a.m.
Orthopaedic
Ward Rounds
8 a.m.
Medical Clinic
9-10 a.m.
Medical Ward
Rounds
8.30-9.3 0 a.m.
(Dr.  Turvey)
Paediatric
Ward  Rounds
9-10 a.m.
Radiological
Conference
9-10 a.m.
g
0
M
H
o
0
1st Tuesday
of Month t
Regular   Meeting
8 p.m.
3rd Tuesday
Clinical   Meeting
For Location, see Office
-
AVCIMOJY
Avasarxx
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AV<3SHflHX
Avaraj
Avcraaxvs Vanx&uAJ&i Qene/uU cttoAfUtaJ, Section
DISSEMINATED LUPUS ERYTHEMATOSUS
By N. C. Chtvers, M.D.
(Senior Interne in Medicine, The Vancouver General Hospital)
First described by Biett in 1828 and Hebra in 1845, Lupus Erythematosus was given
its present name in 1851 by Cazenave. Osier, in 1895 initiated modern investigation
•f the syndrome but only during the past twenty-two years, since the work of Libman
and Sacks stimulated interest in the condition, has the clinico-pathological picture been
thoroughly worked out.
Although it is a disease with widespread manifestations it has usually been diagnosed
by the skin eruption and so has tended to be less familiar to the internist than to the
dermatologist.
Lupus Erythematosus occurs as two main types:
1. The common discoid variety (which will not be discussed in this paper)  seen, as
erythematosus or seborrhceic types, and
2. The disseminated variety, which may be ACUTE, accompanied by grave con-
stitutional symptoms which may develop as such or be engrafted on the discoid type, or
SUBACUTE, with or without constitutional symptoms.
The etiology is obscure. Blood cultures are negative unless there is an intercurrent
infection. No endocrine disease has been identified nor a vitamin deficiency. As in
Rheumatic Fever and Rheumatoid Arthritis, infection is probably responsible. If this
statement is correct, there must obviously be a constitutional predisposition. It affects
primarily the endothelium-lined structures, capillaries, synovial and serous membranes.
There are no characteristic gross lesions. When, as occurs in about twenty-five per
cent of cases, there is an associated verrucous endocarditis on the mitral or tricuspid
valves, the entity is usually referred to as "Libman-Sacks Syndrome."
Microscopically, the lesions are particularly marked in the blood vessels, widespread
in many organs. Unlike periarteritis nodosa, the lesions are mainly degenerative rather
than inflammatory, and affect primarily the arterioles and capillaries. The basic lesion
is a widespread fibrinoid degeneration of collagen to which may be added a minor
degree of reactive inflammation.
Heart: flat, warty vegetations of Libman-Sacks type extending onto the mural endocardium. Microscopically, the basic lesion is fibrinoid degeneration of connective tissue
of endocardium, myocardium and pericardium.
Kidney: characteristic microscopic lesions in glomerular tufts—
1. So-called "wire-loop" capillaries.
2. Focal necrosis of the tuft.
Vascular lesions are most common and severe in the kidneys, but may be present in
any organ. In advanced cases, there may be complete fibrinoid necrosis of all coats of
the arterioles. Marked thickening of the intima may cause great narrowing of the
lumen. A fulminating necrosis may call forth an inflammatory cell reaction (lymphocytes, plasma cells, a few polymorphs).
In the skin, fibrinoid degeneration occurs in the upper layer of the corium, involving
both collagen fibres and ground substance. The arterioles and capillaries show the usual
changes.
Although the clinical picture is varied, the following features should make the diagnosis possible:
1.   Preponderance of females in the age group from puberty to menopause.
Page* 122 2. Prolonged irregular fever with tendency to remissions of variable duration—weeks,
months, possibly years—with persistently negative blood cultures.
3. Recurrent involvement of serous and synovial membranes, particularly polyarthritis
with pains involving the muscles and bones as well as the joints.
4. Loss of weight and prostration.
5. Depression of bone-marrow function—leukopenia, hypochromic anaemia, moderate
thrombopenia.
6. Clinical evidence of vascular alteration in the skin, kidneys and other viscera. Urinary findings suggestive of acute glomerulonephritis eliminates rheumatic fever as a
diagnosis.
7. Thinning hair with no apparent local cause.
8. Occasional abdominal pain and distension and tenderness may be due to peritoneal
serositis. When fever is high, the heart may have gallop rhythm. The electrocardiogram reveals little except low voltage. A soft systolic murmur may be due to fever
or anaemia or indicate Libman-Sacks* Syndrome.
At the onset or later, vascular lesions of the face appear as erythmatous macules or
patches tending to become confluent, first on more exposed parts of face, bridge of nose
and cheeks, above eyebrows, upper lip, chin and pinnae, also the V-shaped exposed area
of the chest. They may be characteristically located on the ends of the fingers and
around the nail beds, or as erythematous macules on the thenar and hypothenar eminences, palms, ends of toes and balls of feet. Areas of skin subject to trauma may be
affected, such as the elbows and knees. In older rashes, minute telangiectases may be
scattered in the midst of the macules—evidence of more permanent vascular change.
They may be purplish due to extravasation of red blood cells and plasma. Small groups
of petechias and macules of brown pigmentation persist in remissions.
Sometimes there is a history of exposure to sun immediately before the onset or an
exacerbation. Others who suffer with low-grade fever and migratory- arthralgia for
months, expose themselves to sunlight during convalescence and develop the rash.
There may be progressive renal damage but the blood-pressure is usually normal.
There may be transitory oedema. Discrete enlargement of lymph nodes is common.
There may be evidence of vascular injury in the eye-grounds.
Prognosis: Symptoms may continue for months with exacerbations and remissions.
The average duration of the disease is eighteen months.  Most die, owing to
1. Toxaemia.
2. Renal insufficiency.
3. Intercurrent infection.
No effective treatment has been found—irradiation of the ovaries, testosterone and
iodine are listed among the therapies that have promised and failed.
It is remarkable that, although the diagnosis of Disseminated Lupus Erythematosus
has been recorded only ten times during the past ten years in The Vancouver General
Hospital, we have been able to present four cases at Medical Ward Rounds in the space
of two months, three of them simultaneously. From a study of these ten cases, the
following significant features are correlated:
Nine were females; nine were between the ages of eighteen and thirty-nine. In all
cases there was a pyrexia of unknown origin, leukopenia and mild anaemia, the charac-
istic rash. In nine cases there were albuminuria, microscopic urinary findings and negative blood cultures. Arthritis was found in eight, abdominal pain in six. In five cases
there was a history of light-sensitiveness, and in four, petechial eruptions occurred. A
striking feature we have noted in two of our cases—rapidly thinning hair—is not mentioned in the file histories, nor is the mild euphoria which has characterized all four of
the present cases. It should be emphasized that in quoting the number of cases which
have shown what are usually considered significant findings in the disease, complete
records were not always available so that the actual proportion exhibiting a particular
symptom or sign might well be higher.
Page 123 The duration of the disease in nine cases ranged from four to thirteen months, but
two of our recent cases are still alive, and follow-ups on three are not available. The
history of one case, probably an acute exacerbation of a chronic discoid type, may have
gone back to thirty months before her death. Five are known to be dead; of these, only
two have come to autopsy.
A typical case history is that of a twenty-nine-year-old woman, a street-car conductress, who was admitted to this hospital on November 12th, 1945, with the following
complaints:
1. Recurrent skin rash for more than a year.
2. Recurrent joint stiffness and pain for more than six months.
3. Fever and chills for two months.
Her only past illnesses were:
1. Growing pains at the age of thirteen which necessitated six months' bed rest.
2. Measles at the age of twenty-one.
The family history is irrelevant.
She was perfectly well until the summer of 1944 when she was severely sunburned.
After the burn had subsided, she was left with a hard red, itchy welt in a butterfly distribution across her nose and cheeks. Several doctors tried various medications through
the winter months without effect. In June of 1945 oral iodine therapy was instituted.
The rash had disappeared by August and she discontinued the medicine.
In May she noticed a stiffness of the hands, wrists and knees which interfered with
her work. Salicylates did not help but the symptoms had disappeared in two or three
months. They recurred in September in the knees, flitting to the wrists, hands, feet and
shoulders.    Her feet and wrists swelled noticeably.
She stood up to tiring work all summer, feeling well, but in the first week of September she began to run a high temperature. She went to bed, being so weak that she
fainted every time she got up.   Thereafter she felt herself "going downhill" consistently.
As her arthritis recurred and the chills and fever developed, the skin rash flared up.
This time it started as a red line on the forehead close to the hairline and gradually
spread over the face. The more ill she became, the more prominent the rash became..
Her hair commenced to fall out. For a while her mouth was sore and her gums bled
when irritated. She developed anorexia, lost twenty pounds in less than two months.
Other symptoms were a dry, hacking cough, nocturia with burning micturition, men-
orrhagia, emotional instability.
Shortly after admission her temperature was 104, pulse 100, respirations 20. She
continued to run a septic type of fever with peaks up to 105 until her death on December 14tb.
Her skin was smooth, pale and dry. There was an erythematous confluent macular
scaling rash on the forehead and face. The butterfly distribution had an atrophic appearance. Small lesions were present on the elbows and knees. The ends of the fingers were
affected with lesions which were darker than elsewhere, more atrophic and combined
with petechia;.
There were scattered, enlarged, discrete, tender lymph nodes in the cervical and
apical regions. No abnormalities of the heart and lungs were detected. Blood pressure
was 90/40. The abdomen was diffusely, slightly tender. There was minimal oedema of
the ankles.
Laboratory Findings were haemoglobin 63%, red blood cells 3,200,000, white blood
cells 3,350; sedimentation rate 20/98; platelets 126,000; nonprotein nitrogen, bleeding
and clotting times were normal. Urine showed normal fluctuation of specific gravity
albumin plus 2-3, occasional erythrocytes. Electrocardiogram: slightly low potential in
limb leads. Radiograph of the chest: a moderate degree of pleural thickening along
both major interlobar planes.   Two blood cultures were negative.
Page 124 The course was one of progressive deterioration without complications. Iodine, liver,
[vitamins and blood transfusion had no effect. Her haemoglobin was 56% just before her
death. A feature which has been noted also in our other cases was a mild euphoria
hvbich persisted to the end.
REFERENCES
1. Baehy, George—Textbook of Medicine, Cecil: VI edition.
2. Cannon, A. B.—Arch. Derm. & Syph., 51: 26-31, Jan.,  1945.
3. Blount, S. G., and Barrett, J. T.—Ann. Int. Med., Aug., 1945.
4. Stokes, T. H., et al—Am. J. M. Sc. 207: 540-549, April, 1944.
5. Cluxton, H. E., and Krause, L. A. M.—Ann. Int. Med.  19: 843-872, Dec, 1943.
6. Ormsby and Montgomery—Diseases of the Skin.
MODERN TRENDS IN NURSING SERVICE DEMANDS
R. A. Seymour, Assistant Superintendent, Vancouver General Hospital
It is interesting and profitable to speculate on the changing demands for nursing
service. Looking back many years these changes have been gradual but none the less
evident. The demands for changes have arisen from the public, from the Medical Profession and, much to their credit, from the nurses themselves.
In 1840 the nursing service consisted of courageous women who volunteered to
render help to the sick and dying. Since that time this nursing service has developed
until it is well organized nationally and internationally. It has advanced along with
the progress in Medicine. As the practice of nursing became a science as well as an art,
schools of nursing were started. For instruction and knowledge they were largely
dependent on the medical profession, and the place for their work and teaching was in
the hospital. Hospitals are necessary for the Schools of Medicine and likewise hospitals
are necessary for the Schools of Nursing. The Nursing Schools have evolved over the
years, to be no longer so dependent on the Medical Profession. They have developed their
own teachers and lecturers, they themselves have created their own text books and have
such a large body of specially trained personnel that they could continue to carry on at
the present time alone. Not alone, of course, without hospitals. Hospitals will always
be necessary for both Schools of Medicine and Schools of Nursing.
The profession of nursing, being thus recognized and so organized, is protected by
the laws of the country and this requires the setting up and maintenance of standards.
As a result, the Nursing Act states that Nurses must be qualified according to certain
standards after definitely prescribed instruction, and must be registered before gainfully
practising their profession.
In early years most hospitals were staffed with student nurses and the wards and the
students were supervised by graduates. Much of the routine labor of housekeeping and
dusting and cleaning, etc., was done by the students, but as advances in nursing techniques developed and responsibilities were added, more and more time of the student
nurses was taken up with lectures, classes and demonstrations. As a result, lay help
began to be employed for duties that did not entail actual nursing. Instead of a day's
work on the wards for practical experience and evening hours for lectures and studies,
the curriculum was changed. Classes and lectures were given during the day and this
necessitated the employing of lay help. Further, these adjustments in curriculum and
the cutting down of hours available for ward work and the demands for experienced
nursing resulted in the employment of graduates for general duty on the wards in increasing numbers. With increased knowledge they were able and were required, to use
and interpret, more and more, the techniques that were developed in the practice of
medicine.
Other special aids were developed and employed and personnel trained for this work
such as in the fields of medical technology, Dietetics and Radiology.    Graduate nurses
Page 125 were given further training in specialties for duties in certain departments such as thej
operating theatre, case rooms, etc.   As these postgraduate courses became more essential
and the demands of Medicine became more critical, the standards of basic training werej
raised.   It was not long before'the Universities were called upon to help in this advanced
training and today we see nurses graduating with degrees of B.A. and B.Sc.
All this is costly and takes the nursing profession further away from actual bedside
nursing. The change in the immediate future therefore is stress on the development of
personnel for bedside nursing, the hour to hour and day to day care of sick and convalescent patients.
When we study the economic situation we can see at once why a change is necessary
and where the change will come. Let us look at it from the nurse's point of view. She
is a highly qualified person with powers of understanding and observation, a knowledge
of basic sciences, and training in special techniques. The educational requirements call
for Junior matriculation, and then three years' specialized training without remuneration. Further training may require, in addition, one or two years in University or post-
graduate work in hospital, again without remuneration. That is, three to five years
more education than the average individual who enters commercial life without special
training. The nurse thinks therefore, when she enters the labour market to sell her
abilities, that she receives inadequate compensation in comparison with other workmen
less well trained. She thinks that many of the duties assigned to her profession can be
done by persons less highly trained, that much of her training and knowledge is wasted.
The solution of these dissatisfactions would appear to be higher wages for the well-
trained nurse, and the employment of less highly trained personnel for the less important duties.
Now let us look at the problem from the hospital point of view. Hospital authorities do not wish to see talent wasted, nor can they afford with the present hospital income, to pay high salaries to competent nurses, for work that less highly trained personnel can do well at a lower wage scale. If circumstances compel them to do this,
then their only recourse is to increase hospital rates to cover this cost, or else pass it on
to taxpayers or endowment reserves, by way of their deficit. Just criticism will then
develop and force a more economic labour set-up.
What do the patients think of this situation? Hospital rates which include nursing
service have been steadily rising and the average patient cannot afford the costs of sickness and all it entails. Indigents and charity patients, most of whom would like to pay
their share cannot do so. The well-to-do are ever mindful of costs and value received,
in spite of their easy ability to pay. But the large middle group feel this burden of
increasing hospital costs the most, and being conscientious are more and more protecting
themselves by various insurance schemes. The premium rates, of course, are based on
costs. Should the Federal Health Insurance Scheme develop it will not take long for
nation-wide cost comparisons to show up the fallacy of employing highly trained personnel to do medium grade work.
It seems inevitable therefore that a change in the nursing service, which has already
started because of labour shortage, will have to come. It is wise to recognize this, plan
for it and be prepared for it. The question therefore arises, how can a complete nursing
service in the broad sense be set up, having in mind the costs as affecting patients and
hospitals, and at the same time keeping control of the necessary nursing standards
required?
To answer this, question by an example, the nursing service to the patient in a broad
sense could be divided into three types or groups that would supply the needs in hospitals
and in homes.
The first group in this suggestion would be a specialized group and includes Supervisors, Instructors, Operating and Case Room Assistants and Public Health Nurses.   It
Page 126 ^is obvious that this group should require higher training in University or post-graduate
work in hospitals.
The second group, now spoken of as the general duty nurse, would be composed of
those who had graduated from qualified nursing schools but without further postgraduate qualifications.    They would give actual bedside nursing care to moderately or
seriously ill patients in hospital or in homes.    It should be pointed out here that the
j training period of this group could be reduced from three years to two years, as exem-
iphfied in the accelerated course developed during the war years in the Vancouver Gen-
ieral Hospital.    This wartime course concentrated all the lectures and classes to almost
a two-year period leaving the final eight months for uninterrupted bedside nursing
duties.    The third year could be an apprenticeship before the diploma is given or the
Registered Nurses' Examinations are written insuring adequate experience.   Some modification of the Registered Nurses' Act and some detail changes in the course would be
necessary.   This group could proceed, if they desire, to University or post-graduate work
to qualify for certification in the first group.
The third group could be composed of personnel with Grade XI standing who have
qualified after a two months' training course, including the requirements of first aid
certificates and Home Nursing certificates, and practical demonstrations of some hospital procedures. This group would care for convalescent or less sick patients. It does
not require three years of special training to give bed baths, take temperatures and perform other simple nursing duties. Many very sick patients are taken care of at home by
family relatives with little or no training. Such a group, called nurse-aides or hospital
attendants could be quickly taught and brought immediately into use. Male attendants
also could be similarly trained for male wards. The Vancouver General Hospital started
such a course as a war necessity, and out of the class of 40 there were 30 that left the
hospital immediately for work in homes—showing the need for this development. If
continued it could eventually permit considerable expansion of the bedside nursing care
for an increasing number of patients.
The great need for this third group is exemplified and proven. As above stated the
high cost of care of patients in hospital is still climbing and sick patients, already burdened, cannot afford it. The shortage of available nurses is very apparent and this plan
would alleviate this situation quickly. Existing nursing schools cannot train any more
nurses than they were doing without lowering their standards. The loss in nursing per-
3onnel in hospitals is continuous and it has been estimated that the average student nurse
stays in hospital ot nurse for only two years after graduation. Although their education and training remains of value for future necessity it is soon lost to the community
for immediate hospital needs. Now the third group of personnel, aides or attendants,
could be replaced more quickly and the male attendants might continue on until superannuation. The expansion of hospital service permitted under this scheme would necessitate the same demand for general duty nurses and special nurses of the first group.
All over Canada there is a desperate need for increased hospital accommodation.
Hundreds of patients would come into hospital tomorrow if there were hospital facilities. At the Vancouver General Hospital alone there are still seventy-five beds in the
newly constructed semi-private pavilion, equipped but never occupied because of lack
of nursing service. Gravely ill patients are being turned away and operations postponed,
and this might thereby seriously endanger the patient's ultimate recovery. Even if more
hospitals could be built there is not the nursing personnel to staff them. Even if army
hutments were to be used temporarily there is not the staff for them. Since it is impossible to increase our supply of trained nurses in our hospitals sufficiently, it seems
obvious that quickly trained lay help would solve this most pressing problem rapidly,
efficiently and economically.
Page  127 HAEMOGLOBIN LEVELS OF CHILDREN IN BRITISH
|p       COLUMBIA     •   ':£ f
By L. B. Pett, Ph.D., M.D.; F. W. Hanley, B.A., M.D.,
and Edith Perkins, R.N.
Nutrition Division, Department of National Health and Welfare, Ottawa, Canada
Relatively few figures are available on haemoglobin values for normal persons in different age, sex, occupational, geographical and other groups in Canada. Such figures as
may be compiled usually suffer from uncertainty as to the accuracy of the estimation,
since many different procedures and much unstandardized, uncalibrated equipment is in
use. Comparison with results in other countries, such as the wartime Haemoglobin Survey in England", is hazardous for the same reason. The present report on nearly 1,500
school children, using one standardized method, which has been brought into comparison
with the extensive survey in England, is, therefore, a step toward a more secure basis
for considering haemoglobin values.
The results presented were obtained during a nutrition survey which has been carried
out in selecting representative areas of British Columbia by a Survey Team from Ottawa,
working with personnel from the Provincial Board of Health, the Metropolitan Vancouver Health Unit, the B. C. Division of the Canadian Red Cross Society, and from i
each area. This survey included dietary, clinical and biochemical studies, on which a
full report is filed with the Provincial Health Officer. Certain of the scientific aspects
are being reported individually, and this is the first such report, since it would appear
to have practical importance to the medical profession in the assessment of anaemia and
in the standardization of methods.
Haemoglobinometry has been well established in clinical medicine for nearly a century. A reduction in the amount of haemoglobin is generally accepted as evidence of
"anaemia." Although low haemoglobin may be the result of loss of blood (haemorrhage)
or destruction of blood, the commonest cause in otherwise 'healthy" people is deficient
production. Deficient haemoglobin production may be absolute or relative to an increased requirement such as occurs during childhood and pregnancy. Direct deficiency
of haemoglobin formation may come from long continued neglect of foods like meat,
whole grain cereals, and certain vegetables, resulting in a lack of iron in the diet, or less
comonly it comes from a neglect of other dietary constituents. A conditioned or secondary deficiency may result from certain physiological and pathological causes. The
first includes poor absorption of haemopoietic principles and changes in plasma volume
such as occasioned by exercise, temperature, posture and pregnancy. Pathological causes
include infection, drugs, and many diseases.
Methods
The more accurate methods of measuring haemoglobin levels, such as oxygen capacity,
are too tedious and complicated for routine clinical use and many alternative methods
have been developed to permit easy routine application to patients. These less accurate
methods have usually involved comparison of colours, in which individuals are notably
different in their accuracy, and have involved different types of "standards," some of
which are not very constant. Much confusion has arisen when comparisons have been
made between results by different methods. The sources of error are emphasized by
the fact that on the North American continent there are still in common use the Tall-
quist paper scale method, the Dare, Newcomer, and at least two different Sahli standards. The recent trend to express all these results in "grams of haemoglobin per 100 cc.
of blood" has lulled many into complacency which should not exist without a careful
check of the instruments used. The recent increase in the use of photo-electric instruments will help to remove the subjective errors in colour comparisons, but even here the
calibration should be checked carefully. In Britain the Haldane-Gowers method, using
carbon monoxide, has held the field for many years.
Page 128 Two recent studies draw attention to the errors in this field. The Medical Research
Council2 has thoroughly discussed the sources of error, and has estimated the liability
to error in the Haldane-Gowers method, with the evolution of instruments, colour
standards, and method sufficiently standardized to permit their use by different observers
in many parts of England in a widespread survey of haemoglobin levels. The study by
Wiehl3 does not, like the other, stress the errors in standardizing the instrument, but
pays special attention to the photo-electric method, concluding that it gives a high
degree of reproductibility, and that it is suitable for survey and other work.
The work reported here was done on a battery-operated, photo-electric colorimeter
(Cenco-Sheard-Sanford) using a sodium carbonate solution as recommended. The instrument was calibrated by oxygen capacity. A comparison was made with the Haldane-
Gowers method, using pipettes, dilution tubes and colour standards certified by the
National Physical Laboratory in England. A reading of 100 on the Haldane scale was
found (on the average) equal to 14.7 grams haemoglobin per 100 cc. of blood as ascertained by our instrument with a probable error of the mean of -f-0.08. This signifies
that any similar series of comparisons has an even chance of averaging within 14.62 and
14.78 grams. This finding should not be construed as a calibration in grams of the
Haldane procedure since this complex question has not yet received an answer by the
Committee in Britain, but is useful in comparing our results with theirs.
Results
The sample consisted of 1,483 children aged 5 to 14 inclusive, the sexes being almost
exactly equal. Most of the children were in the ages 6, 7, 8, 9 and 10, in almost equal
numbers, and a small number made up the age group 11 to 14 inclusive.
Thees children were found in five areas chosen to be representative of the province
of British Columbia, and from both rural and urban schools in these areas (see Table 1).
In many cases, whole classes were taken so as to avoid a bias in selection, while in Vancouver careful control by the school statistician was used to represent the various socioeconomic groups. There are about 56,000 children in this age group in British Columbia. The sample used in this survey, controlled as outlined, may be considered as representative of this group.
Table 1—Haemoglobin Values of Children Ages 6 to 14 in Different Schools
in British Columbia
(The average is not weighted for the number in each age group since no correlation with age was found.)
Area No. of
School Pupils
Vancouver Model     74
Edith Cavell   120
Cecil Rhodes  61
Simon Fraser  _ 109
General Wolfe   112
Whole Area  476
Nanaimo- a . South Ward
South Wellington
Brechin        232
Harewood
Fraser Valley Abbotsford Elem.
North Poplar       346
Matsqui Superior
Prince George King George Elem.
Thompson       223
Giscome
Vernon Elementary        206
Whole Province - j _ -  1,48 3
Chinese Strathcona  ^ 154
Sikhs Mayo          3 3
Average Hgb
M
in. and Max.
Gm. per 100
cc.
Gm. per 100 cc.
13.4
11.9-15.2
13.2
11.2-15.2
12.9
11.6-15.2
12.9
10.9-14.7
12.8
11.6-14.7
13.0
10.9-15.2
13.0
10.6-15.2
12.5
10.0-15.7
12.5
10.0-14.7
13.0
11.2-14.7
12.8
10.0-15.7
12.8
9.7-14.7
12.4
8.9-14.3
Page  129 No correlation was found between haemoglobin level and sex or age in the group
6 to 10, but the group 11 to 14 shows a shift toward higher values. These results are
in accord with many other observations in this field. It is therefore justifiable to average
the results as a whole, and Table 1 shows by areas, and in Vancouver by schools, the
number of pupils examined, the average haemoglobin level, and the range of values.
For British Columbia as a whole the average found was 12.8 grams haemoglobin per
100 cc. blood by the method used, in a range from 10.0 to 15.7 grams. A recent survey1
in New Zealand on 500 children in the same age group reported 12.5 grams average in a
range from 10.5 to 15.4 grams. While it cannot be assumed that the calibration is the
same, yet the values tend to confirm each other. By the Haldane method, the Medical
Research Council in Britain reports children aged 6 to 10 as having an average haemoglobin of 91.8 Haldane Units, and less than 5 per cent had levels below 80 Haldane;
these latter were considered too low. These values correspond on our instrument to
13.5 grams and 11.8 grams respectively.
The minimum, maximum and average figures are useful but do not in themselves
help to answer the question "How many had too low a haemoglobin, suggestive of
anaemia?" It is necessary to have the complete distribution curve, as given in Table 2
and Chart 1.
Table 2—Distribution of Haemoglobin Levels by Ages for the Whole of British
Columbia, and for Greater Vancouver
(See Chart 1.)
BRITISH COLUMBIA VANCOUVER ONLY
Ages 5-10 Ages 11 - 14 Ages 5-10 Ages 11-14
Hb Group                                                          *ac- inc.                                  inc. inc.
per 100 cc.                                                   % of total % of total % of total % of total
(1,054) (197)                               (413) (60)
10.0   - : 0.2 0 — —
10.3 _ 0.1                             0.5 — —
10.6 1  l.o                             1.0 — —
10.9  0.6                              0.5 0.2 —
11.2  2.7                               2.0 0.7 —
11.6  4.3                              2.5 4.1 —
11.9  9.8                            9.6 7.5                             8.3
12.2  11.3                              8.1 10.2 10.0
12.6  18.4 15.2 18.4 10.0
13.0 j  16.8 16.2 18.9 21.7
13.4  17.1 17.8 17.4 15.0
13.8  8.4 10.7 9.7 13.3
14.3  6.4 11.7 8.2 13.3
14.7  2.5                              4.1 3.4                              8.3
15.2 __  0.6                 .           0 1.2 —
Table 2 and Chart 1 show the numbers at each level of haemoglobin, expressed as a
percentage of the total. Thus it may be seen that the results follow the normal distribution curve, common to all biological material, in which most individuals are near the
average but that some have very high and others very low values.
When Is Haemoglobin "Low"?
The value of 12.8 grams haemoglobin per 100 cc. blood may be taken as the normal
average for children age 6-10 in British Columbia. Any haemoglobin estimation might
be compared with this average (especially if the method had been calibrated against the
instruments used in this survey) with the statement that "This child's haemoglobin-is
below the average for the province." But not all such haemoglobin values would be
too low, or show anaemic individuals.
At what level then is haemoglobin too low? This question has often been arbitrarily
answered in terms of percentages, with great confusion resulting from different stand-
Page 130 Chart I
18-4
16-6
17-1
1*5
3-8
6-4
©•4
45
2-7
Z-5
Q2     01
^O      q-6
0-6
ards. In British Columbia school children at an 80 per cent level of our average would
be about 10.2 grams, on which basis only three cases of anaemia would be reported in this
survey. On the other hand, it might be argued from an inspection of Chart 1, that all
cases below 11.9 do not seem to fit the bell-shaped part of the curve and might be
suspected of anaemia. This would amount to 8.9 per cent or 93 children. A more
statistical approach would be to calculate the Standard Deviation of the mean or average, and measure one deviation below the mean as the dividing line. This procedure has
much to recommend it, since it may be uniformly applied to all kinds of measurements.
Unfortunately, however, for survey results, the distance so measured includes by definition 66 2/3 per cent of all the individuals, and one would always have about 17 per
cent of the population classified as anaemic, no matter what you did about it! For the
moment it seems more reasonable to select a point by inspection, and to make therapeutic
trials of as many as possible of the children below this figure, which in this case is taken
as 11.9 grams.
The Medical Research Council Report refers at several points to the existence of
anaemia, but carefully avoids a direct statement of the point at which they consider an
individual to have too low a Haldane value. The only stated conclusion reads: "Although severe grades of anaemia have rarely been met in this survey, it should be pointed
out that in about 7J4 per cent of men and women the haemoglobin levels were below
90 and 80 respectively, which suggests that the efficiency and well-being of these individuals might suffer." On our photelometer and calibrated pipettes this would mean
below 13.3 grams for men, and 11.8 grams for women. British children with haemoglobin levels less than 80 Haldane (or about 11.8 grams on our instrument) were considered to be too low, and this corresponds closely to the figure of 11.9 grams tentatively suggested for the present survey.
Summary and Conclusions
1. In a survey of nearly 1,500 children aged 6-14 in different parts of British Columbia an average haemoglobin level of 12.8 grams per 100 cc. blood has been found by
a photo-electric technique. It is suggested that this figure may be used as a normal
average for ages 6 to 10 inclusive, in British Columbia.
Page  131 2. The average noted compares favourably with an average of 12.5 grams for New
Zealand school children, and of 13.5 grams estimated from data by the Medical Research
Council in Great Britain for British children in 1943.
3. The question is discussed of when haemoglobin values are too low, and the use of
distribution curves for this purpose has been pointed out; the figure of 11.9* grams has
been taken as the point beneath which individuals in this survey will be recommended for
iron therapy. This would show about 9 per cent anaemic among the children studied,
which cannot be regarded with complacency, especially in childhood.
4. The errors in instruments, and the dangers of comparing results unless instruments have been checked together has been discussed. The Nutrition Division is prepared to assist practitioners and others doing haemoglobin estimations by comparing
instruments with those used in this survey, and with certified Haldane-Gowers standards from Britain.
REFERENCES
1. Hayes, L., Haemoglobin Levels of a Group of School Children in Dunedin. New Zealand Medical
Journal, vol. 44, p. 165, August, 1945.
2. Medical Research Council, Special Report Series No. 252, 1945. Haemoglobin Levels in Great
Britain in 1943.
3. Wiehl, Dorothy. Accuracy of Hemoglobin Determinations on Finger-tip Blood. Milbank Memorial Fund Quarterly, vol. 24, p. 5, January, 1946.
The Committee on Medica
• of British Columbia
E
conomics
JOINT COMMITTEE OF
Committee on Economics of the Council of the College of Physicians and Surgeons of
British Columbia and the British Columbia Medical Association
Canadian Medical Association (British Columbia Division)
In this issue your Committee had hoped to be able to announce that the "Family
Doctor Scheme" of the Department of Veterans Affairs was finalized and in operation.
Previous information was that the scheme was definitely approved at Ottawa, and was
delayed only for the necessary printing and delivery of the new regulations to every
doctor in Canada.
It is learned now on the eve of going to press that the necessary Order-in-Council
required to render the scheme operative is delayed pending further consideration by the
Treasury Department. This delay will also affect the new arrangements with the
Dependents' Board of Trustees. It is hoped that the present delay will not be unduly
prolonged, and as further information is available it will be published.
In the meantime, the Medical Advisory Committees as outlined in this section of the
January Bulletin have been set up, and will be ready to function when and as called
upon.
*i. +*L *t +tm
+? »*" *c •*•.
Members of the Profession in this Province are no doubt following with interest the
present trend of affairs in Saskatchewan as outlined in the daily press. It is hoped that
when the situation there becomes more definite, we may be able to present representative
outlines and opinions of the situation from some of our colleagues in that Province.
Page 132 |1| THE VIBRATION SYNDROME I    fl
By W. N. Kemp, M.D.
*Being a synopsis of a talk on this subject delivered to the members of the Industrial First Aid Association at Vancouver on February 7, 1946,
The above title is an all-inclusive term for what was formerly called "Riveter's
Arm" or, in Eastern circles, "Pneumatic Hammer Disease." The term "vibration syndrome" has been selected because the symptoms of pneumatic hammer disease are not
confined to the use of the pneumatic hammer: they have been noted in typists, piano
ployers and shoemakers and others subject to percussion.
Compressed air was used in the mines of France as long ago as 1839 but it was not
until 1883 that pneumatic tools were first put to practical use in American industry.
The first report of symptoms in the hands following use of pneumatic tools was made
by Loriga in Italy about 1908; he reported reduced sensibility and increased stiffness of
the fingers associated with numbness and ischaemia of the terminal phalanges.
The present report deals with 150 cases of the syndrome treated at the Rehabilitation
Department of the "W.C.B." during the latter part of the war while ships and Flying
Fortresses were being built in Vancouver. In the shipbuilding industry only men were
employed in the use of the pneumatic tool—commonly known as an "airgun" or simply
a "gun"—while in the airplane industry (Boeing's) only women were used as riveters
and "holders-on."
In the shipbuilding industry the steel plates were guided into place by the "plate
hangers." Then it was the job of the "bolter-up" to temporarily attach the edges of the
plates to each other by inserting a cold bolt in every other hole and using a pneumatic
impact wrench to tighten the nuts. This latter tool weighs about 30 pounds and delivers
between 1200 and 1300 strokes per minute at 90 pounds air pressure. If a bolt did not
fit properly it was the job of the reamer to rebore the holes, using a pneumatic tool
weighing 28 pounds, driving a bit which revolved 86 times per minute at 100 pounds
pressure. This tool was operated by one or two men who held onto a cross bar at the
butt end of the gun. The arm and shoulder muscles of the reamers were subjected to a
jerky type of vibration as the bit bored into the metal plates.
Everything was now ready for the riveter who, by means of a pneumatic gun weighing 22 to 25 pounds and delivering 1300 blows per minute, mushroomed the head of
the rivet. Opposing him on the other side of the plate was the "holder-on" (or
("bucker-up") who used a similar air gun.
After this team had completed riveting the hot rivets the "caulker" came upon the
scene and closed the seam between the plates by a chiselling process, using a gun weighing
12 pounds and delivering 2000 blows per minute.
As would be expected from a knowledge of the duties of the various specialists described above the incidence of the "vibration syndrome" (to be described later) was
greatest in riveters (40 per cent), "holders-on" (25 per cent), and caulkers (22 per
cent). Reamers and "bolters-up" escaped with a comparatively light incidence of 9 and
4 per cent respectively.
The ages of the workers involved varied from 20 to 50 years, the majority being
between 25 and 35 years of age. There was no relationship established between body
weight and susceptibility to symptoms.
There was, however, a definite relationship to (1) experience and (2) overwork.
Ninety per cent of the workmen seen by Dr. Carl McKinnon or myself at the "Clinic"
had not had any experience with pneumatic tools prior to 1941. In the vast majority
of cases the occurrence of symptoms was attributable to inexperience and excessive work
on a piece work basis.
At Boeing's all of the rivetting was done by women. Their job was to flatten the
cold rivets holding the duraluminum plates of the airplane together. For this purpose
a gun weighing only five pounds and striking 1800 blows per minute was used.   It was
Page  13 3 noticed that when "Super Fortresses" with their heavier plates and rivets were being
built the incidence of symptoms was trebled.
As.was the case with the shipyard workers, the women working in aircraft production were inexperienced in the use of pneumatic tools prior to 1942. Furthermore it
was noted on a personal tour of the plant in 1945 that in many instances the riveters
would be working "overhead" with their arms extended upwards in an unsupported
position. Some of those working "on the level" would have their sleeves rolled up above
the elbows; this, together with acute flexion of the elbow joint, could not but interfere
with the blood supply of the forearm and hand. "Holders-on" also followed this practice. In the case of the latter an additional predisposing factor was the remarkably
small blocks of light metal that they used to oppose the shocks of the riveter's gun.
Predisposing Factors: We have mentioned several factors whcih might well be regarded as predisposing to the onset of symptoms following the use, or abuse, of a pneumatic "gun".    They are:
1. Inexperience and lack of skill in taking proper stance and arm position while at work.
2. Excessive overtime work induced by the certainty of financial reward while on a
piecework basis.
3. Awkward postures sometimes necessary as when working on the bottom of the ship
(where workman unable to support his gun elbow with his knee); other overhead
work where the arms must be extended upwards.
4. Cold weather.
Symptoms: The onset was usually gradual, often commencing several months before
the time when the workman was forced to seek medical aid. In right-handed workers
symptoms usually began in the right hand. At first there was numbness and tingling
of the little, ring and middle fingers in riveters and of the thumb and index fingers in
caulkers. The workman complained of burning in the palm of the hand and of swelling
of the thenar and hypothenar eminences. His grip would become so weak that he could
not grasp the tool. In many instances there would be blanching of the fingers, especially
in cold weather. Symptoms were often worse in the early morning. Indeed, not infrequently, the hands were so stiff and numb that the workman could not grasp his gun
properly until he had "fired a few bursts" into the steel plate. This served to "warm
up.
All workmen have found that their symptoms were more severe when working overhead for long periods in a position in 'which they could not support their "gun arm"
against their bodies or thighs in the usual way.
Symptoms should not be allowed to progress beyond this stage. The workman
should be taken off the gun entirely.
During the recent war when victory depended on ships and still more ships and
when we did not know so much about the Vibration Syndrome as we now do, workmen
were encouraged to disregard these early symptoms and to persevere with the job in
hand. In many cases, therefore, symptoms advanced until the forearm and the arm
itself and even the muscles of the shoulder girdle became involved. These latter groups
of muscles were the site of painful cramp-like attacks—often worse during the night.
It will be readily apparent that the effect of this nocturnal pain and insomnia was devastating to the workman's morale and indeed, was a severe strain upon the nerves of "his
better half," in the case of married men.
Fortunately, even at this late stage the prognosis is good. After about 6 to 8 weeks'
treatment at "The Clinic" the patient was ready to return to work—but not to work
with a pneumatic gun!
Discussion: It is very unlikely that pneumatic tools will be used again in this vicinity
with the same intensity that characterized the 1942-45 "rush" to build ships and aircraft. However, I think that this talk may serve a useful purpose. As I have stressed
the right treatment for vibration syndrome is prevention.
If a man comes to you complaining of these symptoms you should recognize it for
Page 134 what it is—an early case of vibration syndrome.   Many men are naturally loath to give
up the increased pay that goes with rivetting or caulking and will not change their
work until their symptoms  are really desperate.    Much can be done to help these
| workers.
I have stressed the part that gravity plays in inducing symptoms. Perhaps he is
doing too much "overhead" or "bottom" work with his arms extended. Perhaps there
'is some error in his stance and posture even when he is working on the level. We
found in the 150 cases reviewed at The Clinic that vibration syndrome rarely occurred
in experienced men. It follows therefore that if a man develops symptoms using the
pneumatic tool he is either working too hard or is not well trained in the expert use of
his gun. In either case, "tuum est," as they have it at the University of British Columbia: "It is up to you."
IMPORTANT
CM. A. MEMBERSHIP
Physicians are reminded that membership in the C. M .A. is essential
for those attending the Annual Meeting of the Association in Banff.
WARNING
VACCINATION MAY CAUSE FALSE POSITIVE TESTS
|     I     J     FOR SYPHILIS
We are requested by the Division of Venereal Disease Control to call
attention to the following:
Ten to twenty-five percent of persons with vaccinia or vaccinoid
reactions show false positive serological tests for syphilis. These usually
appear about twelve days after vaccination and persist from several weeks
to several months.
Because of recent mass vaccinations in British Columbia physicians
should be specially alert for this phenomena.
Whenever a positive serological test is obtained on a recently vaccinated individual the above contingency should be kept in mind, and
repeated blood tests taken on the patient for a period of three to six
months. If results are conflicting or inconclusive for syphilis, treatment
should not be commenced except upon the opinion of an expert.
For further information regarding false positive serological tests for
syphilis please write to the Division of Venereal Disease Control, 2700
Laurel Street, Vancouver, B. C.
Page  135 DOMINION INCOME TAX RETURNS BY MEMBERS   §
OF THE MEDICAL PROFESSION
As a matter of guidance to the medical profession and to bring about a greater
uniformity in the data to be furnished to the Income Tax Division of the Department of
National Revenue in the annual Income Tax Returns to be filed, the following matters
are set out:
Income
1. There should be maintained by the doctor an accurate record of income received,
both as fees from his profession and by way of investment income. The record should
be clear and capable of being readily checked against the return filed. It may be maintained on cards or in books kept for the purpose.
Expenses
2. Under the heading of expenses the following accounts should be maintained and
records kept available for checking purposes in support of charges made:
(a) Medical, surgical and like supplies;
(b) Office help, nurse, maid and bookkeeper; laundry and malpractice insurance
premiums.    (It is to be noted that the Income War Tax Act does not allow 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 the Inspector of Income Tax.
(e) Rentals paid;
The name and address of the owner (preferably) or agent of the rented
premises should be furnished (See (j));
(f) Postage and stationery;
(g) Depreciation on medical equipment;
The following rates will be allowed provided the total depreciation already
charged off has not already extinguished the asset value:
Instruments—Instruments costing $50 or under may be taken as an expense
and charged off in the year of purchase.
Instruments costing over $50 are not to be charged off as an expense in the
year of purchase but are to be capitalized and charged off rateably over the
estimated life of the instrument at depreciation rates of 15 per cent to 25 per
cent, as may be determined between the practitioner and the Division according
to the character of the instrument, but whatever rate is determined upon will
be consistently adhered to;
Office furniture and fixtures—10 per cent per annum.
Library—The cost of new books will be allowed as a charge.
(h)  Depreciation on motor cars on cost:
Twenty per cent 1st year;
Twenty per cent 2nd year;
Twenty per cent 3rd year;
Twenty per cent 4th year;
Twenty per cent 5 th year*
Page  13*" The allowance is restricted to the car used in professional practice and does
not apply to cars for personal use.
For 1940 and subsequent years the maximum cost of motor car on which
depreciation will be silo wed is $1,800.
(i)  Automobile expense;  (one car)
This account will include cost of licence, oil, grease, insurance, washing,
garage charges and repairs;
Alternative to (h)  and  (i)  for 1940 and subsequent years—
In lieu of all the foregoing expenses, including depreciation, there may be allowed
a charge of 4l/2c a mile for mileage covered in the performance of professional
duties. Where the car is not used solely for the purpose of earning income the maximum mileage which will be admitted as pertaining to the earning of income will be
75 per cent of the total mileage for the year under consideration.
For 1940 and subsequent years where a chauffeur is employed, partly for business purposes and partly for private purposes, only such proportion of the remuneration of the chauffeur shall be allowed as pertains to the earning of income.
(j)   Proportional expenses of doctors practising from their residence—
(a) owned by the doctor;
Where a doctor practises from a house which he owns and as well
resides, a proportionate allowance of house expenses will be given for the
study, laboratory, office and waiting room space, on the basis that this space
bears to the total space of the residence. The charges cover taxes, light,
heat, insurance, repairs, depreciation and interest on mortgage (name and
address of mortgagee to be stated);
(b) rented by the doctor;
The rent  only will  be  apportioned  inasmuch  as  the  owner  of  the
premises takes care of all other expenses.
The above allowances will not exceed one-third of the total house expenses
or rental unless it can be shown that a greater allowance should be made for
professional purposes.
(k) Sundry expenses (not otherwise classified) — The expenses charged to this
account should be capable of analysis and supported by records.
Claims for donations paid to charitable organizations will be allowed up to
10 per cent of the net income upon submission of receipts to the Inspector of
Income Tax.    This is provided for in the Act.
The annual dues paid to governing bodies under which authority to practice
is issued and membership association fees not exceeding $100, to be recorded
on the return, will be admitted as a charge. The cost of attending postgraduate courses or medical conventions will not be allowed.
(1)   Carrying charges;
The charges for interest paid on money borrowed against securities pledged
as collateral may only be charged against the income from investments and not
against professional income.
(m) Business tax will be allowed as an expense, but Dominion, Provincial or Municipal income tax will not be allowed.
Professional Men Under Salary Contract
3. It has been held by the Courts that a salary is "net" for Income Tax purposes.
The salary of a Doctor is therefore taxable in full without allowance for automobile
expenses, annual medical dues, and other like expenses. If *the contract with his employer
provides that such expenses are payable by the employer, they will be allowed as an
expense to the employer in addition to the salary paid to the assistant.
Page  137 The profession in British Columbia suffered the loss of two pioneer members in the
passing of Dr. W. A. Richardson, O.B.E., of Campbell River on March 15th, who had
practised in the Province since 1888, and Dr. James A. Gillespie of Vancouver, who!
died on April 10th.    Dr. Gillespie came to Vancouver in 1902.
*
We regret to record the passing of Dr. Victor Franklin of Port Simpson.
*
The profession extends sympathy to Dr. R. McCaffrey of Chilliwack in the passing
of his wife.
i        k-        *:-        *
Sympathy is extended to Dr. G. R. Barrett of Nelson in the loss of- his father,
W. G. Barrett of Vancouver, formerly of Winnipeg.
*       z~      *      *
Dr. and Mrs. T. R. Harmon of Vancouver are receiving  congratulations on the
birth of two sons on March 17th.
s£ *?■ s£ sfr
Dr. D. S. Munroe has resumed practice in Vancouver, following his discharge from
the Air Force with the rank of Squadron Leader.
We learn that Dr. H. A. Bowker, who served with the R.A.M.C. in India for a
number of years, is returning to Ladysmith shortly.
*£■ 55* »5" sfr
Major B. T. Dunham, R.C.A.M.C, formerly of Nelson, has returned to civilian life
and is practising at Lytton.
gjj       I       *       #
Llight-Lieut. R. N. Dick has received his discharge from the Air Force and has
returned to Chemainus to practise.
*t **.
Flight-Lieut. N. H. Jones, who transferred from the Army to the Air Force overseas, has received his discharge, and has returned to practice at Port Alberni.
Major R. E. McKechnie, R.C.A.M.C., who recently returned from overseas,, has
now received his discharge, and has rseumed practice in Vancouver.
Surgeon-Lieutenant E. C. McCoy, who served with the Naval Medical Services, has
resumed practice in Vancouver.
Major J.  Margulius,  R.C.A.M.C,  has  returned  to  New  Westminster  following
service overseas.
*       *       <-       4
Capt. E. Therrien has received his discharge from the army and is now practising in
North Vancouver.
•^ »^. *>L *JL
•IT *ir *r *^
Capt. G. H. McKee, following his discharge from the R.C.A.M.C, is associated
with Dr. W. B. McKee in Burnaby.
A *'. *£ *t
*** *c *c *c
Capt. K. P. Groves has returned to civilian life and to practice in Vancouver.
3^ 5^ 55* 35*
Capt. C H. Beevor-Potts has resumed practice at Duncan, following his discharge
from the R.C.A.M.C.
Page 138 Capt. E. K. Pinkerton, who returned to Vancouver recently from overseas,  has
received his discharge, and is resuming practice in that city.
Capt. A. Herstein is now out of the Army, and commencing practice in Vancouver.
Major F. O. R. Garner has received his discharge from the R.CA.M.C and is now
ssociated with the Division of Tuberculosis Control in Victoria.
Recent visitors to the office were Doctors W. E. Henderson of Chilliwack, L. M.
Greene of Smithers, and W. H. White of Penticton.
Dr. S. C MacEwen, Director of Medical Services of the M-S-A, and Dr. M. R.
Caverhill, Executive Secretary of the College of Physicians and Surgeons, travelled to
Victoria for the meeting of the Victoria Medical Society on April 1st, and while on
the Island visited Nanaimo, Port Alberni and Comox where meetings were arranged.
Discussion at these meetings centred mainly on the M-S-A, and general satisfaction was
expressed by all the doctors in the operation of this Association.
»••••**••••«
UltFS
CASES OF VENEREAL DISEASE INFECTIONS REPORTED
BY THE PROVINCIAL HEALTH DEPARTMENTS TO THE
11 DOMINION BUREAU OF STATISTICS DURING
THE YEAR 1945 §
Ratio
Gonorrhoea Syphilis       Gonorrhoea/Syphilis
Prince Edward Island  42 34 1.2
Nova Scotia   1,176 664 1.7
New Brunswick  1,079 413 2.6
Quebec   5,106 6,037 0.8
Ontario    * J  8,224 4,930 1.6
Manitoba   __.  2,336 622 3.7
Saskatchewan   1,685 410 4.1
Alberta   1,881 599 3.1
British Columbia  I  3,708 1,569 2.3
Canada   25,237 15,278 1.6
During 1945, 25,237 cases of gonorrhoea and 15,278 cases of syphilis were reported
by provincial health departments to the Dominion Bureau of Statistics. This compares
with 21,033 cases of gonorrhoea and 15,911 cases of syphilis reported in 1944. The
ratio of gonorrhoea to total syphilis was 1.6 to 1 compared with a ratio of 1.3 to 1
for 1944.
Page  139 :: Income Tax
Special
ice for Doctors
Records Checked — Books Maintained
ROY  E. BEACOCK
16, 675 Davie Street, Vancouver
MA. 7729
Colonic and
Physiotherapy Centre
Up-to-date  Scientific  Treatments
COLONIC IRRIGATIONS, SHORTWAVE
DIATHERMY, SINNEWAVE GALVIN-
ISM, IONIZATION, ULTRA VIOLET
RAY,  STEAM   BATHS AND  SHOWERS
Medical and Swedish Massage
Physical Culture Exercises
STAFF OF GRADUATE NURSES
Superintendent:
E. M. LEONARD, R.N.
Post Graduate Mayo Bros.
1119 Vancouver Block
MArine 3723      Vancouver, B.C.
IF ARTHRITIS and ECZEMA
ARE ALLERGIC
ETIOLOGICALLY
effective treatment suggests tke use of
agents to correct mineral deficiency,
increase cellular activity, and secure
adequate elimination  of toxic waste.
r
orally given, supplies calcium, sulphur,
iodine, and lysidln bitartrate — an
effective solvent. Amelioration of
symptoms and general functional improvement   may  be  expected.
LYXANTHINE ASTIER -<
Write for Information.
L-ls
J
Canadian Distributors
ROUGIER FRERES
350  Le Moyne   Street,   Montreal

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