History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: August, 1954 Vancouver Medical Association Aug 31, 1954

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 THE
BULLETI
OF
The Vancouver Medical Association
EDITOR
dr. j. h. MacDermot
EDITORIAL BOARD
DR.  E.  F. CHRISTOPHERSON DR.   J.   H.   B.   GRANT
DR.  H.  A.  DesBRISAY Dr.   J.   L.   McMILLAN
Publisher and Advertising Manager
W. E. G. MACDONALD
VOLUME^XXX.
AUGUST, 1954
NUMBER 11
Dr. J. Howard Black
President
OFFICERS 1954-55
Dr. F. S. Hobbs
Vice-President
Dr. D. S. Munroe
Past President
Dr. R. A. Gilchrist
Hon. Treasurer
Dr. G. E. Langley
Hon. Secretary
Additional Members of Executive:
Dr. A. F. Hardyment Dr. Paul Jackson
TRUSTEES
Dr. G. H. Clement Dr. Murray Blair Dr. W. J. Dorrance
Auditor: R.  H. N.   Whiting,  Chartered Accountant
SECTIONS
Eye, Ear, Nose and Throat
Dr. W. Ronald Taylor Chairman Dr. R. S. Grimmett Secretary
Paediatric
Dr. E. S. James Chairman Dr. G. R. Gayman Secretary
Orthopaedic and Traumatic Surgery
Dr. W. H. Fahrni Chairman Dr. J. W. Sparkes Secretary
Neurology and Psychiatry
Dr. T. G. B. Caunt Chairman Dr. J. R. Wilson Secretary
Radiology
Dr. H. H. Brooke Chairman Dr. S. Miller Secretary
STANDING COMMITTEES
Library
Dr. R. J. Cowan, Chairman; Dr. W. F. Bie, Secretary; Dr. D. W. Moffat;
Dr. C. E. G. Gould; Dr. W. C. Gibson; Dr. M. D. Young.
Summer School
Dr. Max Frost, Chairman; Dr. E. A. Jones, Secretary; Dr. S. L. Williams;
Dr. J. A. Elliot ; Dr. Robert Gourlay ; Dr/ G. C. Walsh
Medical Economics
Dr. E. A. Jones, Chairman; Dr. W. Fowler, Dr. F. W. Hurlburt, Dr. R. Langston,
Dr. Robert Stanley, Dr. Charles Battle, Dr. S. Kaplan
Credentials
Dr. J. C. Grimson, Dr. E. O. McCoy, Dr. D.' S. Munroe
V.O.N. Advisory Committee
Dr. D. M. Whitelaw, Dr. R. Whitman, Dr. R. A. Stanley
Representative to the Vancouver Board of Trade (Health Committee) : Dr. F. S. Hobbs
Representative to the Greater Vancouver Health League: Dr. F. S. Hobbs
Published  monthly   at  Vancouver,  Canada.     Authorized   as   second   class  mail,  Post  Office  Department,
Ottawa, Ont.
Page 431
-*___m E53E PROFESSIONAL §
1   PHARMACEUTICAL
SERVICE
Iflacdo
Medical Dental B _fldm$
_^r__   C-itu  eJjellveru and ^rree J^rovincial f^odtaat
Page 432 HOSPITAL CLINICS
VANCOUVER  GENERAL  HOSPITAL
Regular Weekly Fixtures in the Lecture Hall
Monday, 8:00 a.m.—Orthopaedic Clinic.
Monday, 12:15 p.m.—Surgical Clinic.
Tuesday, 8:30 a.m.—Ophthalmology Clinic  (Health Centre for Children)
Tuesday—9:00 a.m.—Obstetrics and Gynaecology Conference.
Wednesday, 9:00 a.m.—Clinicopathological Conference.
Thursday, 9:00 a.m.—Medical Clinic.
12:00 noon—Clinicopathological Conference on Newborns.
Friday, 9:00 a.m.—Paediatric Clinic.
Saturday, 9:00 a.m.—Neurosurgery Clinic.
ST. PAUL'S  HOSPITAL
Regular Weekly Fixtures
2nd Monday of each month—2 p.m Tumour Clinic
Tuesday—9-10 a.m : —Paediatric Conference
Wednesday—9-10 a.m. | Medical Clinic
Wednesday—11-12 a.m Obstetrics and Gynaecology Clinic
Alternate Wednesdays—12 noon Orthopaedic Clinic
Alernate Thursdays—11 a.m.- Pathological Conference (Specimens and Discussion)
Friday—8 a.m. Clinico-Pathological Conference
(Alternating with Surgery)
Alternate Fridays—8 a.m 1 Surgical Conference
Friday—9 a.m Dr. Appleby's Surgery Clinic
Friday—11 a.m.____ Interesting Films Shown in X-ray Department
SHAUGHNESSY  HOSPITAL
Regular Weekly Fixtures
Tuesday, 8:30 a.m.—Dermatology. Monday, 11:00 a.m.—Psychiatry.
Wednesday, 10:45 a.m.—General Medicine.     | Friday, 8:30 a.m.—Chest Conference.
-Wednesday, 12:30 p.m.—Pathology. Friday, 1:15 p.m.—Surgery.
BRITISH  COLUMBIA  CANCER  INSTITUTE
265. Heather Street
Vancouver 9, B.C.
SCHEDULE OF CLINICS—1953
MONDAY—9:00 a.m.-10:00 a.m.—Nose and Throat Clinic.
TUESDAY—9:00 a.m.-10:00 a.m.—Clinical Meeting.
10:30-12:00 noon—Lymphoma Clinic.
THURSDAY—11:00 a.m.-12:00 noon—Gynaecological Clinic.
DAILY—11:45 a.m.-12:45 p.m.—Therapy Conference.
Page 433 In bacterial diarrheas:
bacteriostasis — adsorption
protection
Streptomagma provides all the essentials for securing prompt and complete remission of many bacterial diarrheas. To accomplish these ends
Streptomagma contains:
H Streptomycin... "much more effective against the coliform fecal
flora than the sulfonamides... not readily absorbable... non--
irritating to the mucosa"1
j| Pectin... "various pectins... become bactericidal agents in the
gastrointestinal tract when given together with streptomycin"2
I Kaolin... for "tremendous surface and high adsorptive power"3
II Alumina gel... itself a potent adsorptive, acts as a suspending
agent for the Kaolin and enhances its action; soothes and protects
the irritated intestinal mucosa.
1. Pulaski, E. J. and
Connell, J. F., Jr.:
Bull. U. S. Army
M. Dept. 9565.
2. Wooldridge, W. E.
and Mast, 0. W.:
Am. J. Surg. 78:-
881.
3. Swalm, W. A: M.
Rec 140:26.
Dihydrostreptomycin sulfate and pectin
with kaolin in alumina gel
|^?_r
Thwjiitariirl Trod- Mark
WALKERVILLE, ONTARIO
Page 434 The July Medical Gazette, issued by the B.C. Medical Division of the C.M.A.,
makes very interesting reading—and there are two items in it of especial interest which
we think will bear emphasizing a bit.
The first is the Annual Convention of the B.C. Division, to be held at Penticton,
one of the most beautiful spots in the Okanagan, that most beautiful part of British
Columbia, especially in late September. The medical men of Penticton will be our hosts,
and are doing everything in their power to make this a most enjoyable and memorable
meeting. It is up to us all to show our appreciation of their efforts by being there. The
town is easily reached by a perfect road, and quickly. The meeting will last two days,
of which the first, Friday, Sept. 24th, will be mainly given up to the business affairs of
the profession. The General Assembly sits all day Friday—and any member of the Association, whether a member of the Assembly or not, is welcome to sit in as a visitor.
The officers of the Association for the coming year will be elected.
All this is set forth in the News Letter. But we think it is worthwhile to urge that
everyone who can possibly go, do so, for various reasons—but chiefly that we may each
take our share in the democratic system of medical organization which is now in effect.
Each one of us has a vital interest in the deliberations of this Assembly; our pockets
are affected, as well as our way of life, and our practice of our profession. It is quite
difficult for us to understand why there are still some men who do not belong to the
B.C. Division. This body is recognized as our agent, and what they say, and what they
decide, will affect every one of us for good or ill. Surely it is only common sense that
we should put ourselves in the position of having a voice in these deliberations.
The doctors of the Okanagan will give us a hearty welcome, and they are organizing a clinical meeting. These men in the interior of B.C. have a great deal to give us:
some of the best work of the profession is done here—and we can all profit by their
knowledge and experience.
The second item is the news about the^progress of Medical Services Incorporated,
which is an extension of prepaid plans of very great significance and promise. It is for
us to do all we can to speed this up, by joining and being prepared to do our share -in
making it go, and making a Success of it. Our cooperation here will be a measure of the
sincerity of our words, As a profession, we have again and again expressed our belief
in prepaid medicine, provided it was run on lines of which we could approve. These
lines are the ones which are being followed by M.S.I., as they have been followed by
M.S.A. and the other prepaid plans of which we have approved. Doubtless, from time
to time, modification in certain details will be found necessary, but the broad principles
of the scheme are the basic principles on which we have insisted, and which we have
approved. ¥e hope sincerely that this scheme will shortly become an actuality. A
tremendous amount of work has been done by those who are the directors of this scheme
and every eventuality has been provided for, as far as this is humanly possible. We
owe them a great debt of gratitude. Of course, we cannot tell just how the public
will react to this new plan, but there is every reason to believe that the initial response
will be quite adequate to make the scheme actuarially sound from the beginning. After
all, M.S.A. began its operations with a great deal of doubt and misgiving on the part of
many medical men, and look at it today—a model for all prepaid plans. Other plans,
too, have had outstanding success, because they meet a definite demand—and satisfy it.
Unfortunately, neither they nor the M.S.A. go far enough—and M.S.I, is the answer.
Page 437 Summer Library Hours
Monday to Friday . ^ 9:00 a.m.
Saturday  9:00 a.m.
to 5:00 p.m.
to 1:00 p.m.
Recent Accessions
Anatomy and Surgery of Hernia, by Leo Zimmerman and Barry J. Anson, 1953.
Carcinoma of the Female Genitalia by H. L. Kottmeir, 1953.
Surgery of Repair as Applied to Hand Injuries by B. K. Rank and A. R. Wakefield,
1953.
Science and Man's Behaviour by Trigant Burrow, 1953.
No Other Gods by Wilder Penfield, 1953.
Acute Pulmonary Edema by Mark D. Altschule, 1954.
The Cutaneous Manifestations of Systematic Disease by John G. Downing, 1954.
Inhalation Therapy and Resuscitation by Meyer Saklad, 1953.
The Obstetrical Forceps by L. V. Dill, 1953.
Water, Electrolyte and Acid-Base Balance by Harry F. Weisberg, 1953.
Modern Trends in Urology by E. W. Riches, 1953.
Diseases of the Liver by Mitchell A. Spellberg, 1954.
Surgical Clinics of North America, June 1954, Surgery in Poor Risks and the Aged.
New and Non-official Remedies, 1954.
Medical Clinics of North America, July 1954, Bronchial and Pulmonary Diseases.
Stress Incontinence in the Female by John C. Ullery, 1953.
%  ■      ;||   :1»1_EVIEW   :|      -^6i-
THE GOLDEN JUBILEE ISSUE OF THE ANTISEPTIC
Medical journalism in India is relatively young and "The Antiseptic", a monthly
Journal of Medicine and Surgery, has celebrated its 50th anniversary this year. The
editors have proudly drawn our attention to their Golden Jubilee Volume, which is
unique in several aspects. This issue contains a half century review in all fields of
medicine, written chiefly by Indian contributors. Nothing new in medicine has been
omitted and what is new, has been well integrated with the old. These reviews amount
to a reference book consisting of 500 pages—six times the size of the ordinary edition.
Contributions were no doubt heartening to the editor, who regretted he was able to use
only approximately one-third of the papers submitted.
Reviews of specialties are of local interest, but readers from other lands will turn
to their experiences in leprosy control and rehabilitation with the new sulphore drugs;
the findings of the Nutrition Research Laboratories originally founded under McCarrison
in 1928 and its effect of improving the health of the people.
The section on Venereal Disease control is written in a very generous and easy style
ending with the work of a World Health Organization. It ranks with the contemporary
articles on the subject.
This special issue is worthy of considerable note—not only from the issue itself, but
for the fact it represents the survival of a Medical Journal through a very stormy passage
in Indian medical history.
HI   E-c
Page 438 Vancouver Medical  Association
OFFICERS— 1954-55
President Dr. J. Howard Black
Vice-President Dr. F. S. Hobbs
Honorary Treasurer „_Dr. R. A. Gilchrist
Honorary Secretary Dr. G. E. Langley.
Editor Dr. J. H. MacDermot
NOTICE
The SECOND PEARSON MEMORIAL LECTURE of the Vancouver Medical
Association will be held in the Tuberculosis Institute Auditorium (10th and Willow)
on TUESDAY, SEPTEMBER 14th, 1954, at 8:00 p.m.
The distinguished British Pathologist, Dr. S. C. Dyke, D.M., F.R.C.P., who is President of the International Society of Clinical Pathology and was Editor of "Recent
Advances in Clinical Pathology" until 1952, will deliver the lecture. His topic will be
"Pernicious Anaemia.3*
SYMPOSIUM
THE VANCOUVER MEDICAL ASSOCIATION IS SPONSORING A "SYMPOSIUM ON GERIATRICS" TO BE HELD ON WEDNESDAY, OCTOBER 20th,
1954, IN THE HOTEL VANCOUVER. ALL MEMBERS OF THE MEDICAL
PROFESSION IN THE PROVINCE ARE CORDIALLY INVITED TO ATTEND.
The following speakers will take part:
EDWIN M. ROBERTSON, M.B., F.R.C.S. iEdinburgh)—Professor of Obstetrics and
Gynaecology, Queen's University, Kingston, Ontario.
"The Menopause—a gynaecological complex"
MORRIS LEIDER, M.D.—Associate Professor of Dermatology, New York University
Post Graduate Medical School.
"Dermatological Problems in the Aged"
J. C. LUKE, M.D.—Assistant Professor of Surgery, McGill University, Montreal.
"The Arteriosclerotic Leg"
M. K. HORWITT, Ph.D.—Director of Biochemical Research Laboratories, Elgin State
Hospital, Elgin, Illinois.   .
"Nutrition in the Elderly"
IAN MACDONALD, M.D.—Chief of Service Medicine, Sunnybrook Veterans Hospital,
Toronto, Ontario. ^p
"Medical Problems in the Aged"
MICHAEL M. DACSO, M.D.—Associate Professor of Physical Medicine and Rehabilitation, New York University School of Medicine.
"The Preventive Value of Rehabilitation"
Page 439 DIAMOX — A NEW DIURETIC*
By DR. JOHN DICK
The treatment of the waterlogged patient is the every day concern of most practising physicians. With the recent introduction of a new and powerful therapeutic
weapon called DIAMOX, it seems appropriate with its general release to review briefly
our present knowledge of this drug and to valuate its place in the treatment of oedema.
For many years the mercurials have stood as the most effective diuretics in the
treatment of massive oedema of cardiac origin. However, they have never been entirely
satisfactory because of their side effects. Many patients actually dread their routine
injections because of the associated nausea and malaise. It is extremely gratifying therefore that we now have in our hands an entirely new drug which achieves its diuretic
effect by blocking enzyme activity in the kidneys themselves rather than by irritating
the renal tubules as do the mercurials.
EVENTS LEADING UP TO THE CLINICAL USE OF DIAMOX
This new drug DIAMOX was developed in the search for powerful inhibitors of
carbonic anhydrase.
The search was initiated by Mann and Keilin1 (1940) who had found that sulfanilamide was a mild inhibitor of the action of carbonic anhydrase.
Davenport and Wilhelmi2 (1941) identified carbonic anhydrase in the kidneys
themselves but it was HOBER3 (1942) who actually suggested that the alkalinization
of the urine produced by sulfanilamide was due to the inactivation of carbonic
anhydrase.
The first clinical use of this discovery was made by Schwartz4 (1949) who treated-
congestive cardiac failure by sulfanilamide.   He noted increased sodium excretion and
corresponding reduction of oedema with clinical improvement. f^jt
Eventually after study ranging over 4-6 years DIAMOX was made available and
the initial clinical work was done by Berliner5 (1951) and his colleagues in which
with the use of Diamox they elucidated the relation between the acidification of urine
and the excretion of potassium.
CHEMISTRY
The full chemical name of DIAMOX is 2 - acetylamino- 1, 3, 4 thiadrozole - 5
sulphanomide. It is a weak acid slightly soluble in water. It has an unsubstituted
sulfonamide group—a heterocyclic ring relatively new to medicinal chemistry and an
acetylated amino group.
PHARMACOLOGY
Following a single oral dose in man, dog or rat the drug is rapidly absorbed and is
excreted largely unchanged by the kidney in 6 - 12 hours. It is not a renal irritant. No
significant action of Diamox other than its inhibition of carbonic anhydrase has been
found. A single dose of 5 mg/kg. is sufficient to cause pronounced diuresis. Dogs can
survive single intravenous doses 400 times as great. Only when a dog is given 1000
mgm. of Diamox/kg. for three successive days can severe loss of potassium, resulting
in death, be induced. Dogs have received daily oral doses of 100 mgm/kg. for sixteen
months with no clinical or pathological signs of damage.
In long term experiments of this type there is a metabolic acidosis the extent of
which depends on the dose. This acidosis, characterised by low ph and CO2 combining
power has never proved deleterious.
The drug is not cumulative. Red cells contain carbonic anhydrase in huge concentrations, but even as potent an inhibitor as Diamox fails to produce symptomatic
evidence of interference with respiratory exchange of carbon dioxide.
MODE OF ACTION
Before one can begin to understand the action of Diamox it is necessary to understand the action of carbonic anhydrase and the associated movements of potassium and
hydrogen ions in the renal tubules—
—:  . ■*•
* Being the substance of a paper delivered to the Vancouver Heart  Association on April  30th,   1954.
Page 440 Carbonic anhydrase mediates the process of urine acidification by accelerating the
conversion of carbon dioxide and water to carbonic acid in the tubular cells.
The ionization of carbonic acid to form hydrogen ions and bicarbonate ions is
thus indirectly dependent on carbonic anhydrase activity. The hydrogen ions so formed
take the place of the sodium ions of the buffers of the glomerular filtrate chiefly in
DISODIUM PHOSPHATE—(Na2H PO4).
The excretion of sodium acid phosphate (Na H2PO4) in the urine conserves sodium
which returns to the blood.
The carbonic acid formed diffuses back into the blood.   (See Diagram).
The formation of ammonium ion, which also conserves base by buffering nonvolatile strong acids is also dependent on the supply of H ions. When carbonic anhydrase activity is inhibited by Diamox much less H is available for the acidification
process. The sodium ion of the buffers no longer replaced by H is excreted. Filtered
bicarbonate ion, no longer forming carbonic acid in the lumen is also excreted. Therefore
the urine after diamox treatment contains sodium bicarbonate. At the same time, lack
of hydrogen ion decreases the formation and excretion of ammonium ion.
The excretion of the K ion is caused by a different mechanism. Much of the work
in this field has been done by Berliner. He showd that potassium ions compete with
hydrogen ions in the tubules for excretion, hence decrease of hydrogen ion secretion
leads to an increased potassium output.
Much of Berliner's findings can be boiled down to the following:
Administration of K salts leads to—
i.   Alkaline urine
ii. Acidosis of body fluids.
Depletion of potassium associated with—
i.   Acid urine
ii. Increase of blood pH.
Maren6 has worked out the cyclic nature of response and recovery to Diamox.
These studies show that loss of base only occurs in the 6-12 hours after administration.
After that carbonic anhydrase begins to act again.   Bicarbonate, sodium and potassium
are retained and the acidity and secretion of ammonia increase above pre-treatment
levels.
It appears that the retention of base during the recovery phase compensates for
the initial base loss. Therefore when given as recommended no distortion of acid-base
balance ensues.
The interval of 24-48 hours between ^oses is important.
i.   to maintain acid base balance,
ii. to maintain the diuretic effect.
Sufficient time is thereby allowed for regeneration of blood bicarbonate which
occurs during the "recovery" stage.
In summary, therefore the inhibition of carbonic anhydrase by Diamox results in
the renal loss of— lllli
(1) Bicarbonate
(2) Sodium
(3) Potassium
(4) Water
SIDE EFFECTS
Belsky7 reported numbness and tingling in the face or extremities with high doses
of 1 Gm. daily. Symptoms vanished when the dose was brought down to 250 mgm/day.
Some loss of vibration and position sense and equivocal loss of superficial pain in the
lower half of the extremities have been found.
When the drug is stopped all signs go. Disorientation occurs with Diamox in
hepatic cirrhosis occasionally, but this has not been noted in treated cases of congestive
cardiac failure.
Page 441 CLINICAL APPLICATION
Diamox has been used mainly in patients with congestive cardiac failure although
it is hoped to obtain useful results in other conditions such as Hypertension, Nephritis,
Cirrhosis, Emphysema, Epilepsy, Migraine, etc.
In the cases of congestive cardiac failure already treated here in Vancouver it has
been possible to repeat the successful relief of oedema and symptoms which were noted
last year by Belsky.
Several litres of fluid may be lost in the first day with smaller losses thereafter.
After a few days and when the oedema has disappeared, there is no further loss of fluid.
Thereafter, the patients can be maintained oedema-free for an indefinite period of time
on Diamox without need of other diuretics.
Occasionally initial response is slight but it is worth while persevering for seven
days before discontinuing the drug.
Patients in right heart failure with large accumulations of fluid may require paracentesis or mercurial injections in addition to the diamox for successful results. Evidently the drug is not quite capable on its ojwn of relieving such massive oedema. The
average daily ORAL dose is 250 mgm., but this varies from patient to patient. The
I. V. dose is 5 - 10 mgm/kg.
Diamox may be used with mercurials. Since diamox leads to increased excretion of
bicarbonate and mercurials appear to increase excretion of chlorides, mercurials and
diamox have a mutually potentiating action.
On the other hand, ammonium chloride partially or completely blocks the diuretic
effect of diamox.   They should therefore, never be used together.
CONCLUSION
Diamox is a drug which should be extremely helpful in cardiology. It allows continuous control of oedema instead of intermittent control which, has been the only
available method up to the present time. Its low toxicity and ease of administration
makes it a pleasure to use.
Unfortunately the drug is still expensive.
REFERENCES
1. Mann,  T.   and  Keilin,  D.:  Sulphanilamide  as  a  Specific  Inhibitor  of  Carbonic  Anhydrase.'   Nature
146:164   (Aug.  3)   1940.
2. Davenport, H. "W. and Wilhelmi, A. E.: Renal Carbonic Anhydrase.   Proc. Soc. Exper. Biol. & Med.
48:53   (1941).
3. Hober, R.: Effect of Some Sulfonamides on Renal Secretion.   Proc. Soc. Exper. Biol. & Med. 49:87
(1942). |§|1
4. Schwartz,   W". B.:  The Effect  of Sulfanilamide on  Salt  and "Water  Excretion  in  Congestive  Heart
Failure, New England J. Med. 240:173  (Feb. 3), 1949.
5. Berliner, R. W.:   Kennedy, T. J., Jr., and Orloff, J.:   Relationship between Acidification of the Urine
and Potassium Metabolism; Am. J. Med. 11:274  (Sept.)   1951.
6. Maren, T. H., Wadsworth, B.C., and Yale, E. K.:   The Effects of Diamox on Electrolyte Metabolism
(to be published).
7. Belsky, H.: Use of New Oral Diuretic, Diamox, in Congestive Heart Disease.   New England J. Med.
249:140  (July 23), 1953.
LOCUM TENENS
Experienced General Practitioner will be available for Locum Tenens
for three months beginning September.
Write or Phone
Dr. John Playfair
Port Alice, B.C.
Page 442 SURGERY IN OBLITERATIVE ARTERIOSCLEROTIC
DISEASE-*
By DR. J. E. MUSGROVE
The earliest symptom of obliterative arteriosclerotic disease of the lower extremities is usually pain in the calf of the leg brought on by exercise and relieved by
rest. The term, intermittent claudication, was coined by Bouley1, a French Veterinarian
surgeon, in 1831 and Benjamin Brodie1 described a similar syndrome in man in 1846.
The lameness is due to the insufficiency of a reduced arterial supply for the added
demands of muscle exercise.
PATHOLOGY
Arteriosclerosis is a term which includes two pathological entities, the first being
atherosclerosis and the second, medial sclerosis of Monckeberg.
The basic lesion in atherosclerosis is the deposition of lipoid material in the tunica
intima of the artery. This material may go on to calcification and/or ulceration into the
vessel Jumen, with subsequent thrombosis. The atheromatous depositions are patchy
and therefore the subsequent calfications and thromboses are also laid down in scattered
plaques. It must be emphasized that the thrombosis may cause incomplete, as well as
complete occlusion of the vessel lumen. The tunica media, or muscular coat of the
artery, is left more or less intact, a very important point as far as surgery is concerned.
In 1903, Monckeberg2 described a lesion occurring in medium-sized arteries, in
which the tunica media undergoes diffuse degeneration with subsequent calcification,
producing the so-called "pipe-stem" arteries. This disease does not implicate the arterial
intima, is not related to atherosclerosis and plays no part in compromising the vessel
lumen3.
DIAGNOSIS
The accurate assessment of obliterative vascular disease of the lower extremities is
arrived at by an integration of the history, physical examination, special laboratory
procedures and radiographic investigation.
HISTORY
As previously mentioned, the patient usually complains primarily of intermittent
claudication. As the vascular obstruction increases, the exercise tolerance decreases
while the duration and degree of pain increases. With further progression of the vascular
insufficiency, the blood supply becomes insufficient to maintain the metabolism of the
limb at rest and rest pain ensues. In an attempt to gain relief, the patient usually hangs
the leg over the bedside, which in turn causes dependent edema. The final stage is
gangrene, which usually commences on one or more of the toes.
This is the common history of progressive vascular occlusion that we all know only
too well. However, there is. another type of vascular insufficiency, admittedly much
less common, which is seldom recognized, namely, stenosis or occlusion of the terminal
aorta and/or iliac vessels. In this localized form of obstruction, the patient complains
of low backache, fatigue in the gluteal and thigh muscles, and is often referred to an
orthopedist. In the male there is an additional symptom, which along with the above
mentioned symptoms, is pathognomonic of this condition, namely, the inability to
attain or maintain penile erection. This is the result of bilateral impairment of blood
flow through the internal iliac arteries. Lerriche described this condition in 1923 and
it is now commonly referred to as the Lerriche Syndrome.
The symptoms commonly noted in segmental obstruction of the arterial tree of
the lower limbs are shown in Figure 1.
EXAMINATION
Color changes of the feet should be noted while at rest in the horizontal position,
with elevation and with the feet hanging over the bedside. Abnormal pallor on elevation and rubor on dependency, with delay in return of color is characteristic of occlusive arterial disease.
**Abridgement of paper delivered at St. Paul's Hospital, January 19, 1954.
Page 443 Temperature changes can be determined fairly accurately by running the dorsum
of the fingers down the extermities.
Trophic changes, edema, ulceration, gangrene and infection are carefully recorded.
Impaired arterial pulsation is the most important physical finding.   The degree of
pulsation should be graded 0 to 4 and the individual vessels recorded as follows:
Aorta 0-4
Right Left
Femoral    0-4 0-4
Popliteal      0-4 0-4
Post. Tibial   0-4 0-4
Dorsalis  Pedis   _ 0-4 0-4
The final step in the clinical examination is auscultation over the common femoral
arteries. If there is a partial occlusion, or stenosis of the arterial tree above this level
a systolic murmur will be evident.
SPECIAL LABORATORY PROCEDURE
Urinalysis and blood sugar studies should be carried out routinely, for approximately one-third of the patients with obliterative vascular disease will have diabetes
mellitus.
Skin temperature studies and oscillometric readings are not necessary in the appraisal
of vascular insufficiency.
RADIOGRAPHIC INVESTIGATION
In the final assessment of the degree of vascular impairment in the lower extremities,
particularly when surgery is contemplated, the roentgenographic investigation is extremely important.
X-rays taken with soft tissue technique will depict the degree and sites of arterial
calcification and will differentiate between the patchy calcification of atherosclerosis and
the "pipe-stem" calcification of Monckeberg. However, these findings are of relatively
minor importance compared to arteriography, which outlines the lumen of the vascular
tree.
TECHNIQUE OF ARTERIOGRAPHY
Two long needles are inserted into the upper abdominal aorta through the left
costovertebral angle, the patient lying in the face-down position on the X-ray table.
60 cc. of 70% Urokon are injected into the aorta and then three sets of X-rays are
taken by rapidly changing the cassettes.
By studying this series of roentgenograms the exact site and degree of vascular
obstruction can be determined.
TREATMENT
The treatment of obliterative arteriosclerotic disease tends to proceed through four
phases:
Phase   1—Medical Regime
2—Sympa thee tomy
3—Medical Regime (continued)
4—Amputation.
The medical regime will not be discussed.
Lumbar sympathectomy has been the main surgical effort in this disease for the
past twenty years. In approximately 50% of the cases this operation has been beneficial.
In an effort to improve these results and prevent subsequent amputation Dos Santos, of
Lisbon, in 1946 first performed the operation now known as Thromboendarterectomy.
Lerriche and his Associates in Paris also pioneered this operation in Europe. Wylie, of
San Francisco, first performed this operation in 1950 and it has been his work which
has stimulated the surgeons on this continent. 4 5 6
TECHNIQUE OF THROMBOENDARTECTOMY
As the name implies, the obstructing thrombus, along with the intima of the
artery are removed. The involved artery is segregated from the circulation by appropriate vascular clamps, a longitudinal incision made through the vessel wall and a plane
Page 444 of cleavage is quite readily formed between the intima and media of the vessel wall.
By blunt dissection the intima, atherosclerotic plaques and thrombus are stripped from
the artery and the artery reconstituted by suturing the media and adventitia with a
running 5-0 vascular silk stitch. Just prior to applying the vascular clamps the patient
is heparinized, but no anticoagulant is used post-operatively. "Whenever feasible, a
lumbar sympathectomy is also carried out at the time of the Thromboendarterectomy.
PROGNOSIS FOLLOWING THROMBOENDARTERECTOMY
When carried out for obstruction of the terminal aorta and its major branches,
the results of this operation have been encouraging to date.   In a series of fifty cases,
Wylie has had only one post-operative thrombosis at the operative site.
J  «, J   ^ J   L
r
m
/a\
J <-
A /(\\ i
j'<_
IA
&
-VA
//*
/aV
7a\
Fig. 2. The extent of thromboendarterectomy carried out in five cases.
CASE REPORTS
Figure 2 depicts the extent of thromboendarterectomy carried out in five cases
since June, 1953.
1. Mr. /. P., age 60. This man had increasing intermittent claudication of the left calf
for one year.
16 May, 1953. Arteriogram showed a stenosis of the lower aorta and left iliac
vessels.
22 May, 1953. Left lumbar sympathectomy. Twenty-four hours post-operatively,
he developed severe pain in the left leg, which became cool from the knee down.
This was the so-called "Paradoxical Reaction" to sympathectomy, which is in
reality, a thrombosis developing in the athersclerotic vessel. His limb remaineal
barely viable and on—
5 June, 1953, an extensive thromboendarterectomy was carried out, as shown in
Figure 2. Recent thrombus was found completely occluding the left iliac arteries.
He made a good post-operative recovery and for several months was free of
claudication. In December, 1953, slight claudication returned in the left calf
but he still gets around quite well.
2. Mrs. W. L., aged 60.   This woman had suffered from calf pains bilaterally, worse
in the left, for six years.
4 July, 1953. Arteriogram showed stenosis of the left external iliac and common
femoral arteries, with segmental obstruction of both superficial femoral arteries.
17 July, 1953. Thromboendarterectomy as shown in Figure 2. This patient has had
a good result from this operation and is now back at work as a cook.
Page 445 3. Mrs. H. N., aged 63. This patient has a long story of vascular insufficiency dating
back fifteen years.
1950. Ulcer on left heel.
1951. Bilateral lumbar sympathectomy.
May, 1952.  Right mid-thigh amputation.
March, 1953.   Ulcer over left "bunion" area.
29 July, 1953.  Arteriogram showed stenosis of the left iliac vessels (Fig. 3) with
complete occlusion of the superficial femoral artery.
5 August, 1953.- Thromboendarterectomy as depicted in Figure 2.  The ulcer healed
up in 2 months and this woman is now pain free and getting around very well
on crutches.
4. Mrs. A. W.y aged 63. This woman had been a diabetic for ten years and ha,d suffered
with intermittent claudication bilaterally for three years.
June, 1953.  Left thigh amputation.
July, 1953.  Began having rest pain in right foot.
10 November, 1953. Arteriogram showed questionable obstruction of the right
common iliac artery.
18 November, 19593. Right lumbar sympathectomy and thromboendarterectomy
of the right common iliac artery. The arterial lumen was still quite patent, thus
the vascular exploration was of no benefit.
17 December, 1953.  Amputation through right thigh.
5. Mr. A. N., aged 69. This man had been a known hypertensive for many years but
he was still very active mentally and physically. He complained of severe, increasing, intermittent claudication of the left calf for three months.
31 December, 1953. Arteriogram showed stenosis of left iliac arteries and occlusion
of the left superficial femoral artery.
9 January, 1953.   Thromboendarectomy and left lumbar sympathectomy (Figures
.2, 4, 5, 6).   The left leg and foot are now warm but since the tenth postoperative day, he has'complained of pain in the left sacro-iliac region coming
on at night.   The pain has no relation to exercise and is thought to have an
orthopedic basis. Wr*%
SUMA_ARY AND CONCLUSIONS
The pathology, diagnosis and surgical treatment of artersclerotic obliterative vascular disease have been discussed. A patient suffering from this disease should not be
submitted to lumbar sympathectomy without previously having had arteriography. If
the latter shows considerable stenosis or occlusion of the terminal aorta or its major
branches, a thromboendarterectomy plus a sympathectomy should be considered. The
prognosis following this new surgical approach is discussed and five case reports
presented.
BIBLIOGRAPHY
1. Boyd, A. M.; Ratcliflfe, A. Hall; Jepson, R. P., and James, G. W. H.: Intermittent Claudication.
Journal of Bone and Joint Surgery  (British Number)   31:  325-355, August, 1949.
2. Monckeberg, J. G.: Ueber die Reine Mediaverkalkung der Extremitatenarterien und ihr Verhalten
zur Arteriosklerose, Virchows Arch f. path. Anat.  171:  141, 1903.
J.A.M.A. 151.
3. Silbert, Samuel, Lippmann, H. J., and Gordon, Elias: Monckeberg's Arteriosclerosis. 1176-1179,
April 4,  1953.
4. Wylie, E. J.; Kerr, Edwin; and Davres, Orland: Experimental and Clinical Experiences with the Use
of Fascia Lata Applied as a Graft about Major Arteries after Thrombo-End-Arterectomy and
Aneurysmorrhaphy.   Surg.; Gyn.; and Obst. 93: 257-272, 1951.
5. Wylie, E. J.:   Thromboendarterectomy for Arteriosclerotic Thrombosis of Major Arteries.   Surgery;
|||p2: 275-292, 1952.
6. Wylie, E. J. and McGuinness, J. S.: The Recognition and Treatment of Arteriosclerotic Stenosis of
Major Arteries.   Surg.; Gyn.; and Obst. 97: 425, 433, 1953.
Page 446 CANADIAN   MEDICAL   ASSOCIATION
BRITISH   COLUMBIA   DIVISION
1807 West 10th Ave., Vancouver, B.C.      Dr. G. Gordon Ferguson, Exec. Secy
OFFICERS 1953-1954
President—Dr. R. G. Large j< Prince Rupert
President-Elect—Dr. F. A. Turnbull : ^L Vancouver
Immediate Past President—Dr. J. A. Ganshorn Vancouver
Chairman of General Assembly—Dr. G. C. Johnston p£= Vancouver
Hon. Secretary-Treasurer—Dr. J. A. Sinclair | New Westminster
PRINCIPAL DELEGATES TO THE  BOARD OF  DIRECTORS
Victoria
Dr. J. F. Tysoe
Dr. E. W. Boak
Nanaimo
Dr. C. C. Browne
Prince Rupert and Cariboo
Dr. J. G. MacArthur
New Westminster
Dr. J. F. Sparling
Dr. D. G. B. Mathias
Kootenay
Dr. S. C. Robinson
Yale
Dr. A. S. Underhill
Vancouver
Dr. Ross Robertson
Dr. R. A. Gilchrist
Dr. J. Ross Davidson
Dr. R. A. Palmer
Dr. A. W. Bagnall
Dr. P. O. Lehmann
Dr. Roger Wilson
Constitution and By-laws,
Finance	
Legislation-
Medical Economics-
Medical Education-
Nominations-
Programme & Arrangements-
Public Health	
Chairmen of Standing Committees
 Dr. Carson Graham, North Vancouver
 I Dr. J. A.  Sinclair,  New Westminster
 Dr. J. C. Thomas, Vancouver
 Dr. P. O. Lehmann, Vancouver
 Dr. Charles G. Campbell, Vancouver
 Dr. R. G. Large, Prince Rupert
 Dr. Myles Plecash,  Penticton
 i Dr. J. Mather, Vancouver
Archives	
Arthritis and Rheumatism-
Cancer	
Civil Defence	
Ethics	
Hospitals-
Industrial Medicine-
Maternal Welfare—
Membership	
Nutrition	
Pharmacy-
Public Relations-
Chairmen of Special Committees
 Dr. J.  H. MacDermot, Vancouver
 Dr. F. W. B. Hurlburt, Vancouver
• j Dr.  Roger Wilson, Vancouver
 Dr. John Sturdy, Vancouver
 Dr. Murray Baird, Vancouver
 , Dr. F. A. Turnbull, Vancouver
 Dr. W. S.  Huckvale, Trail
 . Dr. A. M. Agnew, Vancouver
 ! Dr. L. Fratkin, Vancouver
 Dr. J. F. McCreary, Vancouver
 _.Dr. B. T. Shallard, Vancouver
 Dr. A. W. Bagnall, Vancouver
^
MEMBERSHIP—B.C. DIVISION
While any report of membership or physician population is accurate only for the
moment it is compiled, the following facts are, nevertheless, worth noting. Always
some member is retiring, going away for P.G., or back to hospital, or moving, so
voriation must always be expected.
Membership—July 1954
Ordinary Members   1,174
Post Graduate Members  .^^^s^-__ 15
Retired Members 	
Senior Life Members   8
Honorary Members   0
1,204
"We are now the second largest Division in the Canadian Medical Association. The
College News Letter No. 9 (May 19954) lists the number of doctors registered,
resident and practising in B.C., at 1,493.
Page 447 The Board of Directors are heartened at the very excellent voluntary response to
membership in the Association. They feel, however, that their task is not complete
until all doctors join. In the apparent discrepancy of 289, it is realized that there are
some in the twilight of their practice who have not seen fit to register with the College
as "retired", and there are some at the other end of life who have registered but remain
as resident in a hospital.
Professional life cannot be achieved in isolation. We hope that soon every active
doctor, employed or self-employed, will welcome this voluntary expression of professional obligation.
PENTICTON, SEPTEMBER 24 AND 25, 1954
All members have been previously advised that in the year in which a Division acts
as host to the Canadian Medical Association that Division holds only a business meeting.
The reasons behind this are that the Canadian Medical Association puts on a superb
Scientific Programme and the efforts of the Commercial Exhibitors are concentrated into
one excellent medical week. In British Columbia we have seen a superb Canadian
Medical Association meeting that will be a source of pleasure and pride with us for
some time. Our acknowledgement must first go to Dr. G. F. Strong, President of the
C.M.A., and his committee for their excellent work, and to our own members who
supported it so well. The number of doctors registered exceeded 1,700. The Convention in Toronto in 1948 is the only remembered one which was larger.
For this year, then, the B.C. Division will have a less intensive meeting than usual.
The meeting is to be held in Penticton in the Prince Charles Hotel and will take the
form of the General Assembly meeting on Friday, September 24, and a full day on
Saturday, the 25 th, for all members. This full day will include the Annual General
Meetings of the Association and the College in the forenoon, a scientific programme put
on by the Okanagan Clinical Society in the afternoon, and a monster Barbecue and
Dance in the evening. Details of this have been forwarded in the Gazette No. 3 and
you will also receive a programme in the mail. It is hoped that as many members as
possible can accept the invitation of the Penticton doctors to be with them for that
week-end.   It is an opportunity that should not be missed.
The housing in Penicton is adequate and arrangements are made with hotels and
motels for your accommodation. If you will please direct your requests for housing to
Dr. H. B. McGregor, 125 Nanaimo Ave. West, Penticton, letting him know whether
you wish to have a hotel or motel; when you expect to arrive and how many you wish
to be accommodated. He will make certain that a place is found that has been inspected
by himself beforehand.
On the social side there is to be a mixed Dinner on Friday evening and a Barbecue
and Dance on the Saturday evening. When communicating with the Penticton doctors
about your housing, it would be very much appreciated if you would also indicate
which functions you propose to attend. This is important for the Penticton doctors so
that their planning might be adequate.
SUMMARY
Thursday, Sept. 23—4th Meeting Board of Directors 1953-54.
Friday,    Sept.    24—The General Assembly 9:00 a.m. to 5:00 p.m.
—Dinner for Members and Wives 7:00 p.m., Glengarry Room, Prince
Charles Hotel.
Saturday, Sept. 25—9:30 a.m.   The Glengarry Room, The Annual General Meeting,
Canadian Medical Association—B.C. Division.
—11:00 a.m.   The Annual General Meeting, College of Physicians
and Surgeons of B.C.
—Noon,    12:30.     1st   meeting   New   Board   of   Directors,   "The
Sicamous"—Luncheon.
—Afternoon—Okanagan Clinical Society—Glengarry Room.
—Evening—Barbecue and Dance "The Sicamous".
Page 448 ELECTIONS, C.M.A.—B.C. DIVISION, JULY 29,  1954
The Returning Officer for this election was Dr. Gordon O. Matthews, Vancouver,
and he appointed as his scrutineers Dr. E. Day, Dr. Clarence Moffatt and Dr. Keith
McLean.  The ballots were counted on the evening of Thursday, 29th July.
Those who won top preference are the Principal Delegates for their district and
will function on the Board of Directors. Those next in order of preference are the
Vice Delegates and will represent the district on the Geenral Assembly in addition to
the Principal Delegates.
The members elected to the Nominating Committee represent their district on
that committee and also represent the district on the General Assembly.
All members elected are your representatives and may be approached directly any
time during the year for information or discussion on professional affairs.
Duties commence following the Annual Meeting on September 25, and the General
Assembly referred to above is for 1955. Principal Delegates serve for two years and
the others for one year.
The following list shows the Principal Delegates, Vice Delegates and Nominating
Committee for the year 1954-55.
District    Principal Delegates
No. 1        Tysoe, John—completing 2nd year
Bonnell, Fred H.—elected for 2 years
No. 2        Helem, George B.—elected for 2 years
No. 3 Bagnall, A. W.—completing 2nd year
Lehmann, P. O.—completing 2nd year
Wilson, Roger—completing 2nd year
Stanley, R. A.—elected for 2 years
Sutherland, W. H.—elected for 2 years
Poole, John C.—elected for 2 years
Blair, N. J.—elected for 2 years
No. 4        MacArthur, John G.—completing 2nd year
No. 5 Sparling,   J.   F.—completing  2nd  year
McLean, Palmer M.—elected for 2 years
No. 6        Campbell-Brown, H. I.—elected for 2 yrs.
No. 7        Robinson, S. C.—completing 2nd year
Vice Delegates
Hewitt, Donald A.
Ransford, Peter M.
Lunam, James B.
McCoy, Edwin C.
Jackson, Paul P.
Elliot, G. R. F.
Coltart, J. L.
Bridge, Tom
Hall, Morton E.
Farish,  James  R.
Greene, L. M.
Watson, Harry N.
Wellwood, J. P.
Murray, J. V.
Nominating Committee
Elkington, E. H. W.
Conn, Robert S.
Brown, Charles Y.
Jamieson, C. A.
Depew, John
Black, John Howard
Dorrance, Wallace J.
Hurlburt, F. W. B.
Gourlay, Robert H.
Watson, Gerald L.
Kergin, W.  S.
Ireland, J.  R.
Sinclair, J. A.
McMurtry, T. S. G.
Beauchamp, A. J.
FOR RENT
Available October
1st,
Doctors' Offices
in business centre of densely
populated
Vancouver
city area.   Will
adjust
space to
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tenant.
Phone HAstings
6533
Page 449 THE COLLEGE OF GENERAL PRACTICE OF CANADA
At a luncheon in the Palomar Supper Club of Vancouver, B.C., on Thursday, June
17th, Dr. G. F. Strong, the President of the Canadian Medical Association, installed
Dr. Murray Stalker of Ormstown, Que., as the first President of the College of General
Practice of Canada. That is serious business, as the starting of a new medical group in
organized medicine is not undertaken lightly. Dr. Stalker accepted the honour with
a very thoughtful address, which will appear in an early issue of the Canadian Medical
Association Journal.
Dr. W. B. Hildebrand of Menasha, Wisconsin, President of the American Academy
of General Practice, brought greetings and a stimulating message from this sister
organization. He declared that it was inevitable that the family physician have an
organized, academic body through which his voice Can be heard; and, he continued, "the
College of General Practice and the American Academy of General Practice are giving
and will give general medicine in your country and in mine, a better sense of direction."
Dr. Hildebrand stated that such a movement as the College of General Practice
must be accepted in full measure by all other organized medical groups, and that we
were indeed fortunate to have the whole-hearted support of organized Canadian Medicine. In addition, he believed that the College must continue to be nurtured and
actively supported by the parent body, because the problems of the family doctor,
as an integral part of our society, are not only the problems of the individual physicians
but of the whole profession.
Dr. Wm. Pickles, the President of the College of General Practitioners of the
United Kingdom, sent a cordial and sincere message of congratulations and good
wishes. He had the happy thought of conveying this on a Die tablet which brought his
voice to us over the loud speaker system of the banquet hall.
Dr. T. C. Routley followed with a very interesting presentation to our President.
About a year ago, when Consultant General to the World Medical Association, he
asked Dr. A. Mantellos of Greece if he could obtain for him a piece of wood from the
Island of Cos, the birthplace of Hippocrates. From this wood Dr. Routley hoped to
have a gavel made. He heard nothing further of the matter until this spring when
he received a gavel, entwined with a serpent, the whole beautifully carved from one
piece of wood taken from a Plane tree believed to be 3,000 years old. This was prepared
by the Hipprocratic Medical Society of the Island of Cos, the oldest medical association
in the world and dating back to 400 B.C. Accompanying it was a scroll signed by the
officers of that society.  This, indeed, is a unique gift to the College of General Practice.
When the College added up the score of the inauguration ceremonies, along with
the results of its other initial meetings in Vancouver in June, it felt it had reasonable
grounds for encouragement and optimism. The early support given it has been much
greater than expected.
On June 30th there had been received some 400 applications for membership.
There were 135 donations to the Foundation Fund. The receipts from donations and
dues were $21,500.00. It is planned to inform the membership of the College by newsletter every 2 or 3 months of its activities and progress.
The College is founded on the belief that it will do several things; that it will
prove to ourselves and those for whom we work, that we respect general practice as it
deserves, and take pride in it. Also, it will show that we appreciate our duty to maintain and improve our stondards, and to make ourselves ever better rand more useful
general practitioners.
The ultimate success of the new organization is dependent entirely upon the support given by the general physicians of this country. It must rely upon the wisdom and
good judgment of these individual physicians everywhere. It pleads for their interest
and assistance. Information, about the College may be obtained from its office at 176
St. George Street, Toronto, Ont., or from its provincial representatives.
W. V. JOHNSTON, Exec. Director.
June 30, 1954.
Page 450 PUBLIC HEALTH AND MENTAL HEALTH NEWS
G. F. AMYOT, M.D., D.P.H.,
Deputy Minister of Health, Province of British Columbia
A. M. GEE, M.D.,
Director, Mental Health Services, Province of British Columbia
FLUORIDATION —A PUBLIC HEALTH NEED
Anyone attending a clinic where young children are being examined cannot help
but notice the amount of untreated dental caries exhibited by the youngsters. Time
after time, in answer to the examiner's question, "Have you been to a dentist before?"
the child answers "No".
During one series of examinations made by dentists with the Provincial Health
Branch, 8 out of every 10 Grade I children reported that they had never been to a
dentist. Yet by the age of three, these children already must have had an average of
three tooth surfaces requiring restoration; by the age of six the toll will be seven tooth
surfaces, representing two hours work by the dentist, and by the age of seven the score
will be eight or nine tooth surfaces needing repair.
The problem of providing dental care for adults is bad enough. When the problem of adequate dental care for children is also considered, a solution taxes the imagination. Many dentists, busy treating adults, often feel that their efforts are akin to "bailing the boat while neglecting the leak". In other words, dental caries is accumulating
faster than it can be treated.
What are the causes of this situation? First and foremost, there are simply not
enough dentists in proportion to the Province's rapidly expanding population. Secondly,
the demand for dental services in the metropolitan areas has led to a greater concentration of dentists there than in other areas of the province, with the result that people
in these other areas do not always have adequate facilities for dental treatment.
There are other causes too, such as lack of concern on the part of the public
for proper diet and oral hygiene, delay in seeking dental treatment, and so forth, but
the fundamental problem is the shortage of dentists and the backlog of untreated dental
caries.
This backlog of untreated dental caries is stupendous. It has been estimated that
dental care for all school children alone would cost in the neighborhood of $9,000,000
in the first year of such a programme, and would require about 545 dentists working
full-time. Since the total number of dentists in British Columbia is less than 600 one
can see the magnitude of the problem of untreated dental caries among school children,
to say nothing about the problem in the adult population. Translated into more personal terms, this means unnecessary pain, discomfort, loss of teeth, loss of ability to chew
food properly and, especially among youths, embarrassment due to decayed, missing or
irregular teeth.
Part of the answer, of course, is to increase the facilities for the dental care of
school and pre-school children. This is the method used by school boards in the larger
cities, and by the Health Branch through the local health unit dental services and
through its support of community dental programmes whereby a local sponsoring group
and a dentist in private practice make arrangements for the treatment of the younger
children. Projects of this nature have been expanding rapidly in the last year or two.
Dental care of children, it is felt, is the best way of preventing the toll exacted in later
years by untreated dental caries. WjM
However, the fact remains that one effective means of reducing the general incidence of dental caries—fluoridation of community water supplies—is not yet being used
in British Columbia, although this method has been shown to be very effective. Across
Canada, some 19 communities have decided to install fluoridation equipment, voted in
favor of it, have approved it in principle or are actively considering the measure. In
Ontario and Saskatchewan eight cities (Brantford, Fort Erie, Thorold, Sudbury, Chalk
Page 451 River, Oshawa, Moose Jaw and Assiniboia) are adding fluorides to their water supplies.
In Brantford, Ontario, fluoridation has been in effect since 1945.
Fluoridation appears to be the most practical method of reducing by amounts up
to 65 per cent the dental caries which will otherwise inevitably appear among our
younger children, and offers some positive hope that the overall problem of dental caries
will be overcome.
Without fluoridation it is difficult to see how this can be accomplished.
PHYSICIAN'S REFERENCE MANUAL REVISED
This month the Health Branch, Department of Health and Welfare, and the Mental
Health Services, Department of the Provincial Secretary, released a revised edition of the
Physician's Reference Manual on Mental Health and Public Health Services.
This manual which was issued in 1952 at the request of the College of Physicians
and Surgeons is a ready reference guide which lists briefly some of the mental health
and public health services available to physicians in this Province.
In this new edition the section dealing with cancer services has been considerably
expanded, and additional information with respect to poliomyelitis has been provided.
As in the 1952 edition, the manual outlines the procedures of the doctor in his
dealings with communicable diseases, births, deaths, cancer, mental institutions, etc.,
as required by various acts and regulations of the province.
Excellent office accommodation available for 3 or 4 doctors in building
being completely rebuilt to suit tenants. Close to new complete
housing project near 33rd Ave. on Main St. Leases available. Tenancy
approx. Oct. 1. Complete details from Rental Agents.
WEST & HEGLER
4294 Dunbar St.
CH. 3128
PHILIP PINKUS
CHARTERED ACCOUNTANT
1901 Barclay
Suite 107
TAtlow 7970
WANTED
General Practitioner
For Pender Harbour in association with St. Mary's Hospital operating as an acute
general seventeen-bed hospital under B.C.H.I.S. by a community hospital committee.
Thoroughly remunerative practise; * first clan residence available adjoining hospital;
doctor's office and consulting room in hospital. Apply E. S. Johnstone, Chairman
Hospital Committee, Pender Harbour, B.C. Telephone Pender Harbour 9C2 giving
full particulars of medical qualifications and experience, marital status and references.
Page 452 ON DOCTOR-PATIENT RELATIONSHIP
By DR. H. BAKER
It is generally felt in medical circles that the doctor-patient relationship is weak.
Many associations are taking this as a challenge. Some have evolved very commendable
means of improving this relationship in their communities.
Two instances come to mind. Methods have been established in some centres
■whereby people who need medical attention, in an emergency, can get help more readily
than in the past. Another good idea is the establishment of grievance committees where
differences between doctor and patient may be aired and cleared. A good place for the
establishment and maintenance of good doctor-patient relationship is in the free outpatient clinic. Many of the people who attend these are looking for a little kindness
and understanding in addition to medical care. The doctor can give this very easily.
Many doctors do so graciously. This type of work is good and removes sore places
where misunderstanding may arise between doctor and patient. There are other ways
that may evolve by which goodwill may be fostered between doctor and patient.
What does doctor-patient relationship mean? Does it mean the same thing to everybody? Actually there are two meanings in the phrase. There is first the relationship
between doctor and patient as individuals. The sick individual comes to the doctor
for help. It is the ancient relationship of sick man and healer. This is the only time
that this relationship is established. The patient only comes when he is in trouble.
It brings into play a most primitive group of reactions. The personal relationship
between doctor and patient is therefore on a very primitive level, emotionally. It is
not without reason that once priest and healer were combined in one man. Some of
these primitive feelings that come to the surface when a man is ill are his deepest
feelings about his place in the universe. They are his feelings about life and death.
A man, no matter how arrogant, senses his smallness in the universe and has a guilty
feeling about his illness. There is always the feeling that this illness is a punishment
for some wrong done. The worse the illness, the stronger this feeling is. The man
looks to some higher power for help and forgiveness. At this time the doctor is that
power on earth. Help from a Greater Power is called upon, but the doctor is the
visible answer. As well as the visible helpful power the doctor is also the representative
of the punishing power, the father figure. A patient truly has the basis for very
mixed emotions in relation to his doctor when he is ill.
Till recently the doctor retained some of the quality of his predecessor, the priest-
healer individual. With the development of the specialist type of practice the cleavage
between priest and healer become more marked. With this division the priest in many
ways retained the more pleasant duties. The priest sees his people during the more
pleasant times. He is the one who consecrates marriage and later gives the child his
name. He blesses and forgives. Even when there is death he helps relieve the unhappi-
ness and the tension by his calm presence. When the sick man is cured the priest often,
rightly, receives the praise in the name of the Lord. Moreover the priest does not
charge for his duties.   He has always practiced socialized healing.
The healer has become worldly and practises a form of service that is not metaphysical. Yet the doctor's relationship with the sick man is on just as primitive a level
as the relationship between man and priest. Moreover to the doctor has fallen the lot
of attending the man when he is at his worst and when his troubles are at their worst.
There is truly no phase of the doctor's work that is really pleasant. Even childbirth
carries a threat with it. The convalescent patient may be more difficult to get along
with than the very sick one.  In addition to all this the doctor charges for his services.
This is the doctor-patient relationship of the consulting room and the sick room.
It is as strong as it ever was. It will remain so as long as there are sick people and
doctors to heal them.  It needs no bolstering other than good, kind service rendered.
The second doctor-patient relationship is the relationship between doctors as a
group and the public made up of many other groups. The relationship has evolved as
a result of the many changes in our civilization.
Page 453 In the primary individual relationship, the patient's health is the main factor. In
the group relationship economics is the first matter of concern. Which of these are
we as doctors trying to foster? At this time when medicine tends to be so scientific
and so very cold we must go back to the beginnings to find our place in the scheme
of things. The individual relationship of trust, faith and hope between sick man and
healer is not influenced by what happens in the group relationship whatsoever. In fact
in this age of publicity the personal relationship may be harmed by the attempts to
foster the group relationship which is really of little importance. Actually what we
may be calling a weak doctor-patient relationship on the group level is not this at all.
When the healer stepped into his present worldly phase he set in motion a chain of
events which are inevitable. He, as a member of a group, must learn to fit in with
the other groups that go to make up society. This is largely an economic matter. The
other lay groups read about the doctors' various activities in the newspapers and are
naturally interested. They read about the doctors' day-to-day activities as reported
from conventions, laboratories and clinics. It is simplified so that they can understand
it. They read about doctors' activities in relation to the establishment of various types
of prepaid plans and socialized medicine. They see the doctor as a group in the same
light as they see other workers in a group. They judge its values much as they judge
the values of the activities of any other group of workers.
We as doctors may foster this latter relationship, if we so wish. What its value
may be is at this time unpredictable. It can do no good to the primary doctor-patient
relationship which is what doctors are for. The primary relationship upon which the'
doctors' work is based can continue to thrive in only one way. In the quiet and
sanctity of the consulting room the doctor-patient relationship is unchanged. It is as
it was in the dim past. The sick man has come to the healer for help. The healer o£
the present has potentially more to give to the sick man than he had to give in the
past. Moreover he can do it more quickly. The present-day healer can do more. The
dedicated sensitive healer can more readily put the sick man's mind at east. He has
the knowledge whereby he can often explain to the sick man the why and the how
of his illness. This can be more important than the medicine prescribed. Often enough
the prescription will not help unless there is a kindly understandable explanation given
with the medicine. This is forgotten too often by the healer in the present day
mechanical world. It is in the consulting room that one can tell a patient about hi$
illness, not from the public speaking platform. This bridging of gap between healer
and sick man earns for the doctor not only respect but thanks that is like unto love.
No man can ask for more.
The "lay" public enjoy hearing about methods and things in general that a doctor
uses in his everyday work. They enjoy hearing about his experience. When a doctor
speaks about his work he speaks about life itself. This is fascinating to everyone. It
is all very enjoyable and stimulating. But does not change by the smallest amount
what people really think of doctors as a group.
Are medical meetings for the lay public of any real value? In the light of what
has been said above they cannot foster any true doctor-patient relationship. They
can be of little or no value to explain to the individual about his personal illness.
Certainly they are of no cultural value. The lay person who may wish general information about the various body functions can get it readily in the public library.
The individual may feel that his doctor is very special and merits special consideration. A group of similarly minded people may, however, feel very differently about
a group of such doctors. The feelings that the individual has about his own doctor are
only very slightly reflected in the more complex group relationship. The emotions and
behaviours of a group vary greatly from the behaviour and emotions of the individuals
who make up the group. A group has different attributes and aims than the individuals
who make up the group. Thjat is to say, a group is a new organism with emergent
qualities and it is interested in its own welfare. In this group relationship doctors
cannot expect any special consideration. As a minority they must continually conform
and be moulded by the laws that govern the relationship of all groups.   It is obvious
Page 454 that the group phase of doctor-patient relationship is not any special relationship. It
is no different than the relationship that exists between any number of other groups.
It makes one wonder what value there can be in medical meetings for laymen. They
cannot result in any unusual group relationship. There is no value in them for laymen.
There is no value in them for doctors.
The doctor as an individual, however, with his unique training and position does
have a special place in society. It is this place which he must jealously guard. He must
strive to maintain it. He has done so in the past by giving kind, honest, courteous,
understanding service, often under difficult conditions. He will continue to do so
in the future. The doctor-patient relationship resulting from this needs no public
discussion to strengthen it. Its inherent strength is in the never ending stream of
service that doctors give their patients day and night.
Dr. T. B. Costello has begun a private practice in obstetrics in Vancouver.
Dr. Jack Ross is now associated with Dr. E. A. Trites in Vancouver.
Dr. J. W. McCall is now practising at Watson Lake.
Dr. W. Doughty is now practising in Cowichan, B.C.
Dr. J. F. Beesley is now in the Irving Clinic at Kamloops.
Dr. Donald North is now practising in Trail.
Dr. C. M. Hamilton is practising in Fernie.
Dr. Norman Alsbery is now practising with Dr. A. M. Barrera in Kaslo.
Dr. W. C. Whittaker is now in obstetrics at the Toronto General Hospital.
Capt. W. E. Warwick, R.C.A.M.C, will be going to Germany this Fall.
Dr. B. D. Prusterman is now at the Mount Sinai Hospital in New York.
Dr. R. H. F. McNaughton is taking postgraduate work in obstetrics at San Diego.
Dr. P. H. Melville has temporarily retired from practice because of illness.
Dr. J. S. McAuley is now resident in medicine at the Ottawa Civic Hospital.
Dr. David Garrow is practising this summer at Squamish.
Dr. J. M. Shaw is now in general practice in Vancouver.
Dr. Gordon Stranks is now in general practice on his own in North Vancouver.
Dr. A. W. Trieloff is now practising in Nanaimo, B.C.
Dr. D. C. Ulrich is now studying anaesthesia at the Henry Ford Hospital in Detroit.
Dr. P. /. Woollacott is now practising in Wells.
Dr. R. D. Ellis is now practising in Vancouver.
Dr. C. B. Henderson is now practising in Kelowna.
Dr. Gordon J. Fyfe is nowxin Tofino.
BIRTHS
To Dr. and Mrs. George Walsh of Vancouver, a son.
To Dr. and Mrs. W. E. Shepherd of Vancouver, a son.
To Dr. and Mrs. A. A. Fraser of West Vancouver, a son.
To Dr. and Mrs. W. Pedlow of Vancouver, a daughter.
T© Dr. and Mrs. F. Stanley of Duncan, a son.
To Dr. and Mrs. E. J. Wilford of Chilliwack, a son.
Page 455 "FERROGEN"
COMPOUND
Tablet No. 450 "<§toa_"
Each sugar-coated tablet contains:.
Ferrous sulphate B.P.... 325 mg. (5 gr.)
*Bone flour (edible) 325 mg. (5 gr.)
Vitamin D      500 I.U.
Vitamin A acetate    1500 I.U.
Vitamin Bi  1 mg.
Riboflavin  1 mg.
Niacinamide  5 mg.
Vitamin C        30 mg.
Sodium iodide .. .0.2 mg. (1/325 gr.)
*Average content: calcium 110 mg., •
phosphorus 50 mg., fluorine 0.4 mg.,
and other trace elements.
Packaged in bottles of 100 tablets.
m
m*
eno*-:
IRON
CALCIUM
IODINE
AND
VITAMIN
TABLET
DOSAGE: In order to establish
tolerance  to   iron, full   dosage
should   be arrived  at gradually.
One tablet daily after the main
meal   for several   days,  increase
to  two   tablets   daily,   one   after
breakfast and after lunch for several days  and, finally,  one tablet
three   times   daily   after   meals.
ef__t_&-to_t„&>.
MONTREAL
CANADA
Page 456

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