History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: November, 1938 Vancouver Medical Association Nov 30, 1938

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 The BULLETIN
of the
VANCOUVl#f"
MEDICAL ASSOOSAllON
■Jl&iS
Vol. XV.
NOVEMBER, 1938
No. 2
With Which Is Incorporated
Transactions of the
Victoria Medical Society
and the
Vancouver General Hospital
In This Issue:
LETTER FROM THE B. C. CANCER FOUNDATION
TUMOURS OF THE PITUITARY AND
|PARAPITUITARY REGION       J
SURVEY OF EPILEPTICS BULKETTS
(With Cascara and Bile Salts)
. . FOR . .
Chronic  Habitual
Constipation
BULKETTS POSSESS ENORMOUS BULK
PRODUCING PROPERTIES AND BEING
PROCESSED WITH CASCARA AND
BILE SALTS PRODUCE BULK WITH
MOTILin||
WE WILL BE PLEASED TO PROVIDE
ORIGINAL CONTAINERS FOR TRIAL
ON REQUEST.
Western Wholesale Drug
(1928) Limited
456 BROADWAY WEST
VANCOUVER   -   BRITISH COLUMBIA
(Or at all Vancouver Drug Co. Stores) THE    VANCOUVER   MEDICAL   ASSOCIATION
BULLETIN
Published Monthly under the Auspices of the Vancouver Medical Association
in the interests of the Medical Profession.
Offices:
203 Medical-Dental Building, Georgia Street, Vancouver, B. C.
Editorial Board:
Db. J. H. MacDermot
Dr. M. McC. Baird Dr. D. E. H. Cleveland
All communications to be addressed to the Editor at the above address.
Vol. XV
NOVEMBER, 1938
No. 2
OFFICERS  1938-1939
Dr. G. H. Clement
Past President
Dr. D. F. Busteed
Hon. Secretary
Dr. Lavell H. Leeson Dr. A. M. Agnew
President Vice-President
Dr. W. T. Lockhart
Hon. Treasurer
Additional Members of Executive: Dr. J. P. Bilodeau, Dr. J. W. Arbuckle.
Dr. F. Brodie
Dr. Neil McDougall
TRUSTEES:
Dr. J. A. Gillespie
Historian: Dr. W. D. Keith
Auditors: Messrs. Shaw, Salter & Plommer.
SECTIONS
Clinical Section
Dr. W. W. Simpson Chairman     Dr. F. Turnbull Secretary
Eye, Ear, Nose and Throat
Dr. S. G. Elliott Chairman     Dr. W. M. Paton Secretary
Pediatric Section
Dr. G. A. Lamont Chairman     Dr. J. R. Davies Secretary
Cancer Section
Dr. B. J. Harrison Chairman     Dr. Roy Huggard ..Secretary
STANDING COMMITTEES
Library:
Dr. A. W. Bagnall, Dr. H. A. Rawlings, Dr. D. E. H. Cleveland,
Dr. R. Palmer, Dr. F. J. Buller, Dr. J. R Davies.
Publications:
Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. Murray Baird.
Summer School:
Dr. J. R. Naden, Dr. A. C. Frost, Dr. A. B. Schinbein, Dr. A. Y. McNair,
Dr. T. H. Lennie, Dr. Frank Turnbull.
Credentials:
Dr. A. B. Schinbein, Dr. D. M. Meekison, Dr. F. J. Buller.
V. 0. N. Advisory Board:
Dr. I. Day, Dr. G. A. Lamont, Dr. Keith Burwell.
Metropolitan Health Board Advisory Committee:
Dr. W. T. Ewing, Dr. H. A. Spohn, Dr. F. J. Buller.
Greater Vancouver Health League Representatives:
Dr. W. W. Simpson, Dr. W. N. Paton.
Representative to B. C. Medical Association: Dr. G. H. Clement.
Sickness and Benevolent Fund: The President?—The Trustees. Protection Against Typhoid
Typhoid and Typhoid-Paratyphoid Vaccines
Although not epidemic in Canada, typhoid and paratyphoid infections remain a serious menace—particularly
in rural and unorganized areas. This is borne out by the
fact that during the years 1931-1935 there were reported,
in the Dominion, 12,073 cases and 1,616 deaths due to
these infections.
The preventive values of typhoid vaccine and typhoid-
paratyphoid vaccine have been well established by military and civil experience. In order to ensure that these
values be maximum, it is essential that the vaccines be
prepared in accordance with the findings of recent laboratory studies concerning strains, cultural conditions and
dosage. This essential is observed in production of the
vaccines which are available from the Connaught
Laboratories.
Residents of areas where danger of typhoid exists and
any one planning vacations or travel should have their
attention directed to the protection afforded by vaccination.
Information and prices relating to Typhoid Vaccine and to
Typhoid-Paratyphoid Vaccine will be supplied
gladly upon request.
CONNAUGHT LABORATORIES
UNIVERSITY   OF ^TORONTO
Toronto 5
Canada
Depot for British Columbia
Macdonald's Prescriptions Limited
MEDICAL-DENTAL BUILDING, VANCOUVER, B. C VANCOUVER HEALTH DEPARTMENT
STATISTICS, SEPTEMBER, 1938.
Total Population—estimated  259,987
Japanese Population—estimated  8,685
Chinese Population—estimated  7,808
Hindu Population—estimated .  335
Rate per 1,000
Number Population
Total Deaths    205 9.6
Japanese Deaths        3 4.2
Chinese Deaths ..•_        8 12.5
Deaths—Residents only . .    175 8.2
BIRTH REGISTRATIONS—
Male, 183; Female, 174 .    357 16.7
INFANTILE MORTALITY— Sept., 1938 Sept., 1937
Deaths under one year of age        9 9
Death rate—per 1,000 births      25.2 26.4
Stillbirths (not included in above)        9 9
CASES OF COMMUNICABLE DISEASES REPORTED IX THE CITY
October 1st
August, 1938 September, 1938 to 15th, 1938
Cases  Deaths Cases  Deaths Cases  Deaths
Scarlet Fever    14          0 20          0 3          0
Diphtheria       0           0 2           1 0           0
Chicken Pox      4           0 19           0 15           0
Measles       3           0 10 10
Rubella       0          0 0          0 0          0
Mumps         10 6           0 10
Whooping Cough    44           0 28           0 7           0
Typhoid Fever       10 10 2           0
Undulant Fever      0           0 0           0 0           0
Poliomyelitis        3           1. 10 0           0
Tuberculosis       37           9 36         17 15
Erysipelas         2           0 10 0           0
Ep. Cerebrospinal Meningitis      0           0 0           0 0           0
V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH,
DIVISION OF VENEREAL DISEASE CONTROL.
West North Hospitals and
Vancouver    Richmond    Vancouver    Vancouver  private doctors      Totals
Syphilis        1 0 0 73 45 119
Gonorrhoea        0 0 1 100 39 140
BIOGLAN
THE SCIENTIFIC HORMONE TREATMENT
Descriptive Literature on Request.
A Product of the Bioglan Laboratories, Hertford, England.
Represented by
STANLEY    N.   BAYNE
1432 MEDICAL-DENTAL BUILDING
"Ask the Doctor Who Is Using It"
Phone: SEYMOUR 4239 VANCOUVER, B. C.
Page 25  EDITOR'S PAGE
We have received a number of kind comments about the new Bulletin, and appreciate these greatly. The first number was in some ways not quite what we wanted, but we
shall hope to iron out any lumpy places as we go along.
Victoria contributes this month a paper read by Dr. H. H. Murphy, Director of the
Department of Radiology at the Jubilee Hospital. Those of us who have heard Dr. Murphy
speak will not be surprised to find this a most readable and suggestive paper, written
currente calanto, in an easy style, yet full of valuable matter.
The Bulletin is publishing shortly a Supplement containing the papers read at the
Annual Meeting of the B. C. Medical Association in Victoria. Either jointly with this, or
separately, the papers read at the Vancouver Medical Association Summer School will also
be published.
In another column we reproduce an editorial from a recent number of Collier's Magazine, entitled "R/ Hands Off." There is considerable food for thought in this, and it
seems to us to state fairly and dispassionately what the man in the street is thinking, and
may we add, is justified in thinking. While as a profession it is our right, nay more, our
duty, to maintain a high standard of medical care, and resist any action calculated to
impair or lower this, we must at the same time remember that we are facing conditions, not
merely theories, and that in one way or another, sooner or later, and at the cost of a reasonable sacrifice on our part, a solution is going to be found, and must be found. The sacrifices we must make will be reasonable, only if we make them; if they are forced on us, we
may not fare so well; and we are sure we speak for the best minds in our profession in this
matter when we say that now, as always, we are quite willing and ready to make reasonable
and fair concessions, in order to secure the greatest good for the greatest number.
An important step was taken by the organised medical profession of British Columbia
when, at its Annual Meeting in Victoria, changes in the Constitution and By-laws of the
B. C. Medical Association were made, whereby this body became "The British Columbia
Medical Association (Canadian Medical Association, British Columbia Division)."
This made us into a division or branch of the national body, and is a definite move in the
direction of national unity. This step has already been taken by most of the ten Provinces,
and it is hoped that the remaining Provinces will, soon join the majority.
We congratulate those who have worked hard and long for this consummation, which
has crowned the efforts of many years. Perhaps Dr. J. S. McEachern of Alberta, that most
staunch and loyal member of our profession, is the outstanding figure in this; in our own
Province Dr. H. H. Milburn stands out perhaps as the man who has done most of the actual
work for some time, though, of course, as he himself~would be the first to admit, he has
had many loyal helpers.
NEWS AND NOTES
Dr. J. W. Arbuckle has left for Montreal, where he will meet Mrs. Arbuckle.  He will
probably be away for a month, going south before he returns.
Dr. Schinbein has left for New York, where he will attend the meeting of the American
College of Surgeons.
We offer our congratulations to Dr. and Mrs. W. E. Harrison on the birth of a daughter,
on September 27th.
Dr. J. Whitbread and Dr. A. R. Anthony were elected to membership in the Vancouver
Medical Association at the meeting held on October 2nd.
Dr. Agnew has left with Mrs. Agnew for a month"s well-earned vacation in the South.
Dr. and Mrs. Fred Sparling of Haney are being congratulated on the birth of a daughter
last month.
Page 26 Dr. A. Maxwell Evans has recently arrived in Vancouver to take charge of the Cancer
Clinic which will open here on November 5 th. Dr. Evans was born in Vancouver and
took his pre-medical course at the University of British Columbia. He graduated from
McGill and later won a diploma in medical radiology and electrology from Cambridge
University. He has lately come from England, where he was surgical registrar at Mt.
Vernon Hospital for Cancer at Middlesex; resident medical officer at the Radium Institute,
London, and assistant radiologist at Addenbrooke's Hospital, Cambridge.
Dr. J. A. MacMillan and Dr. Frank Hebb, Vancouver physicians, will be part-time
medical officers of the clinic.
Dr. E. J. Ryan, Superintendent of the Provincial Mental Hospital, Essondale, is doing
post-graduate study in New York.
Dr. Alfred Warren, of the staff of the Provincial Mental Hospital, has left for London,
where he will do post-graduate work.
Dr. L. R. Williams of New Westminster has left for London to do post-graduate work.
Dr. and Mrs. Bruce Cannon of New Westminster returned in August from a trip on
the Continent, where Dr. Cannon was engaged in post-graduate study. During his absence
his practice was attended by Dr. L. R. Williams.
Dr. and Mrs. N. B. Hall of Campbell River will be in the East for two months, where
Dr. Hall will be engaged in post-graduate study in Chicago and New York. Dr. Hall will
stop off at the Mayo Clinic on the way back.
Dr. F. H. Stringer of Rock Bay will carry on the practice for Dr. Hall during the
latter's absence.
A A A A
Dr. R. B. Shaw of Nelson has returned from Montreal, where he was doing postgraduate work.
Dr. E. S. Hoare of Trail has returned from a vacation in Edmonton.
Dr. J. S. Kitching and Dr. R. A. Walton have joined the staff of the Metropolitan
Health Committee.
A A A A
Dr. G. L. Sparks has opened an office at White Rock.
GOLF
At the Fall Golf Tournament, held at Shaughnessy Heights Golf Club on September
29th, the Division of Venereal Disease Control covered itself with glory. The Worthing-
ton Cup was won this year by Dr. S. C. Peterson. Dr. Jack Wright won the Low Gross
and Dr. S. A. McFetridge was Low Net in the Handicap 11-18 Class.
The Ram's Horn Trophy was won by Dr. H. H. Pitts, who made the best Aggregate
Low Net in the three games played for this trophy.
Others winning were:
Dr. W. T. Ewing, Low Net in the Handicap 1-11 Class;
Dr. J. A. McLean, Low Net in the Handicap 19-23 Class;
Dr. A. R. Anthony, Low Net in the Handicap 24 Class;
The "Hidden Hole" contests—Drs. A. C. Frost and D. McLellan.
Presentation of the permanent replicas of the MacDonald's "3, 4, 5, 6" Trophy were
made to Dr. G. A. Davidson, who won it in 1937, and Dr. G. E. Seldon, who was the
winner in 1938.
Page 27 LIBRARY NOTES
For the sake of new and incoming members of the Association (and some older ones),
the Library Corrimittee would like to draw attention to the following regulations regarding
the borrowing of books, and the' use of the Library generally.
1. All members using the library in the evenings are requested to sign the register.
2. All Journals must remain on the shelves for ONE MONTH after they are received.
The "Received" date is stamped on the front cover.
3. All books and journals taken from the library must be signed for in the register
at the door.
*r *»• *r ^r
At a recent meeting of the Library Committee it was decided that a list should be kept
of books which have been suggested for purchase, but which it was thought should be held
for further consideration. This list will be posted on the Bulletin Board in the Library, and
any member of the Vancouver Medical Association is invited to make recommendation
for or against the books in question.
The 1938 Yearbook, which is an additional volume to the Encyclopaedia Britannica,
has been ordered for the Library and will be here in about one week's time.
The following books have been purchased recently from the Nicholson Fund:
The Diary of a Surgeon in the Year 1751-52, by John Knyveton, who was, among
other things, Surgeon's Mate, H.M.S. Lancaster.
Das Denken in der Medizin (On Thought in Medicine), by Hermann Von Helmholtz.
An address delivered August, 1877.
The Horse and Buggy Doctor, by Arthur E. Hertzler.
Chevalier Jackson, an Autobiography.
Items from the Journals
Progress in Nutrition, by Francis L. Burnett, M.D., Boston. Dr. Burnett reviews recent
work done on Nutrition in general, and then in relationship to Pregnancy and the nourishment of children; Ophthalmia, and disorders of the eyes; Disorders of the Nerves; Scurvy,
Ascorbic acid and Skin Diseases; Rickets, Dental decay and Arthritis; Goitre, Kidney
disorders and Cancer. New England Journal of Medicine: Oct. 6, 1938, p. 524.
Recent Advances m Knowledge of Vitamins, by H. K. Butt, Mayo Clinic. A brief
review, mentioning only some of the work done, but containing recent information concerning some of the less well-known vitamins, their sources and uses. Proc. Mayo Clinic:
Sept. 21, 1938, pi 601.
Eye, Ear, Nose and Throat Symposium, ed. by /. N. Evans and L. W. Dean, Jr.
Amer. J I. Surgery: October, 193 8.
*■
A Monograph on Veins (De Venarum Ostiolis 1603, of Hieronymus Fabricius of Aqua-
pendenta (1533-1619)), translated by K. J. Franklin, D.M., has been presented to the
Library by Dr. D. E. H. Cleveland.
«•
The following books are on order and should be here very shortly:
Grant—Method of Anatomy.   1938.
De Lee—Obstetrics. New edition, 1938.
Boyd, Wm.—Textbook of Pathology. New edition, 1938.
Boyd, Wm.—Surgical Pathology. New edition, 1938.
Piney and Wyard—Clinical Atlas of Blood Diseases.  New edition, 193 8.
Page 28 ancouver
Medi
cal
ssociation
VANCOUVER MEDICAL ASSOCIATION
At the forthcoming regular meeting of the Vancouver Medical Association, the paper
of the evening will be given by Dr. J. Ross Davidson on "Some Aspects of Contract
Practice." The discussion will be led by Drs. A. C. Frost and A. J. MacLachlan.
The Annual Dinner of the Association, which will be held on November 18 th at the
Vancouver Hotel, promises to be bigger and better than ever. Dr. Clement, who is in
charge of arrangements, says "Cocktails at 7 p.m." Dr. Jack Harrison is to have charge
of the entertainment, and Dr. D. D. Freeze will be business manager. Put a red ring around
this date on your calendar.
At the Anniversary Dinner of the Association, held at the Georgia Hotel on October
2nd, about one hundred and twenty were present. Among these were men who had
been members of the Association for many years. The Executive were particularly
pleased to welcome Dr. W. B. MacKechnie, who came from Armstrong on purpose. Dr.
F. X. McPhillips was another guest for the evening. The birthday cake, resplendent with
forty candles, was cut by Drs. Riggs and Burnett. An interesting coincidence was brought
to light when it was found that exactly forty years before these two doctors had shared
offices here in Vancouver and had done many an operation together. Dr. Riggs spoke
briefly concerning his remembrance of Vancouver in those days, and Dr. Burnett followed
with a very witty little account of his early days in practice here.
In proposing a toast to the Association, Dr. MacDermot spoke of the progress that
had been made in medical practice in the past forty years; he felt that this was a suitable
occasion to follow the counsel of the old Hebrew essayist, quoted by Kipling, in his essay
beginning "Let us now praise famous men, and our fathers that begat us." He reminded
us that the Vancouver Medical Association had^been a most potent factor in promoting
unity and harmony amongst medical men, and that it had served not only the medical
profession but the city at large, and concluded by asking all those present to rise and
drink to the Vancouver Medical Association.
Dr. W. D. Keith seconded the toast and took the opportunity to give a short account
of some of the men who took a prominent part in forming the Association, many of whom
gave generously of their time to matters of public welfare.
Telegrams of congratulation on the 40th Anniversary of the Association were received
from Medical District No. 3, and from Drs. Baird, Huggard and Thomas, who were on a
lecture tour in the Interior, and from Dr. L. H. Leeson, President, who was unavoidably
absent.
The regular monthly scientific meeting of the Association followed the dinner, and
after routine business was transacted Dr. Frank Turnbull gave a paper which is printed
elsewhere in the Bulletin. Dr. Glen Campbell and Dr. B. J. Harrison contributed to the
discussion of the paper, Dr. Harrison showing some excellent slides illustrating his remarks.
The Association has recently purchased a very fine Projectoscope, which will show
ordinary slides, micro-slides, film slides, and postcards, or pictures from books.
A most generous donation to the Association has been made by Dr. T. F. Saunders in
memory of the late Mrs. Saunders. Dr. Saunders has given the sum of $500.00, which is
to be used, at his suggestion, as the nucleus of a Sickness and Benevolent Fund, the interest
of which is to be added to the Sickness and Benevolent account which the Association uses
at the discretion of the Trustees.
Page 29 TUMOURS OF THE PITUITARY AND
PARAPITUITARY REGION
By Dr. Frank A. Turnbull.
(Read before the Vancouver Medical Association, October 4, 193 8)
[While this paper may have a fearsome title, it is really a very readable one, put in simple language.
The author is to be congratulated on his technique in the arrangement of his subject. By classifying the main
types of syndrome, and quoting cases to illustrate each of these, he has put in compact and usable form the
information he wished to give.
The enjoyment of the paper was, of course, greatly enhanced by the slides shown in the course of its
delivery. We cannot reproduce these here, unfortunately, nor can we reproduce the discussion, so ably led by
Dr. I. Glen Campbell and Dr. B. J. Harrison, but Dr. Turnbull has brought out clearly in his text the immense
importance of careful perimetric examination of the eyes, and x-ray examination of the pituitary area, whenever any of these syndromes, with failing eyesight, appear.—Ed.]
I feel honoured in being asked to read a paper on a neurosurgical subject at this meeting
which commemorates the fortieth anniversary of the founding of the Vancouver Medical
Association. Practically our whole knowledge of neurosurgery has developed during the
intervening forty-year period. In no part of this special field can the march of time be
better illustrated than in the progress which has been made in the diagnosis and treatment
of tumours of the pituitary and parapituitary region. I shall attempt to portray in a.
sketchy fashion something of the advance in our knowledge of the physiology of the
pituitary gland, outline briefly the evolution of the modern surgical approach to this region
of the skull, and, finally, describe several syndromes which result from tumours in this
neighbourhood.
Physiological Advances.
Nature saw fit to enclose the central nervous system in a bony case lined by a tough,
protecting membrane, and within this case she concealed a tiny organ which lies enveloped
by an additional bony capsule like the nugget in the innermost of a series of Chinese boxes-
No other structure in the body is so doubly protected, so centrally placed, so well hidden.
Galen, the Greek physician who was the founder of experimental physiology, believed that
the gland secreted was a mucous substance, pituita, which entered the nose. In the middle
ages the great Vesalius expressed the same opinion. The complex region between the brain
and the sella turcica remained a complete puzzle until Willis in the 17th century disentangled it to the extent of recognizing an arterial circle surrounding the pituitary stalk.
By the end of the 18 th century someone had discovered that certain parts of the human
body are useless relics of bygone ages, and as nothing was known about the pituitary gland
it became conveniently accepted as a vestigial organ. Interest was not reawakened until
near the close of the 19th century when several clinicians, notably Marie, described a condition, termed acromegaly, which was usually accompanied by a pituitary tumour. Moreover, pathological gigantism was soon recognized as a corresponding condition which
differed merely in commencing earlier in life. Marie interpreted acromegaly in the presence of tumour as a state of glandular insufficiency. The truth was not established until
Cushing (1908) showed that animals who survived for long after partial extirpation of
the gland, exhibited a picture which was the reverse of acromegaly. In the year of the
founding of this society, Schafer (1908) demonstrated that when extract of the posterior
lobe of the pituitary gland was injected there resulted a rise of blood pressure. Within
three years Babinski (1900) and Frolich (1901) had attributed adiposity and sexual
infantilism to a disturbance of this area resulting from neoplasm. Far from being a vestigial organ, it was coming to be regarded as the very "mainspring of primitive existence.'*
The pituitary body is now recognized as a combined neuro-epithelial organ. Its anterior
portion, the epithelial lobe, represents the first of the endocrine organs to be differentiated
in the embryo. Certain cells in this area have an affinity for acid dyes and are related to the
function of growth. Others, which are best stained by basic dyes, have a positive influence
on sexual activity. The remaining group of feebly staining cells have a purpose which has
yet to be discovered. The posterior portion or neural lobe arises as a downward expansion
of that part of the brain which deals with vegetative functions and instincts. In the adult
human it sill remains connected with demonstrable neural fibres with cell stations in the
Page 80 floor of the brain. Whether the posterior lobe produces various effects by virtue of dispersing one chemical substance or many is unknown. Certainly an extract of this lobe has
a diversity of functions, serving not only to increase blood pressure, but also to contract
the pregnant uterus, counteract polyuria, and, under certain circumstances, display galacta-
gogue, antipyretic, pigmentary and sudorific effects. The metabolism of fat and also of
water is controlled by cell-stations located at the point where the pituitary stalk joins the
floor of the brain, so that these are not, strictly speaking, functions of the pituitary gland.
Surgical Advances.
This growth in physiological knowledge has been paralleled by equally noteworthy
advances in the surgical treatment of pituitary tumours. Both fields of endeavour have
seemed to stimulate and improve the other. Early experimenters found that access to the
pituitary gland of an animal, for example a dog, was a simple matter of elevating the
temporal lobe and approaching from the side. But in the human patient the temporal lobe
was not so easily dislocated and such an approach was very hazardous. The earliest operations on record were undertaken by this route. It is likely that the pioneer members of this
society were familiar with a report in the British Medical Journal of the first attempt to
expose a pituitary tumour. This was undertaken in 1893 by Caton and Paul, acting on
Victor Horsley's suggestion. The operation was never completed, as the patient died before
the second stage was performed. Horsley himself is said to have consistently followed this
route and by 1906 had done ten hypophyseal operations with two deaths.
During the first two decades of this century, imaginative and daring surgeons proposed
a variety o£ means of gaining access to the pituitary region. The gradual evolution of the
modern operation may be illustrated by the experiences and changing points of view of
two great American neurosurgeons, Harvey Cushing and Charles Frazier.
With his first patients, in 1902, Cushing attempted the lateral subtemporal approach.
In only one of six cases was he able to even partially extirpate the tumour. He then tried
Eiselberg's operation, in which the entire nose was reflected to one side and everything in
the upper third of the nose removed to provide a path to the sphenoid sinus and thence to
the sella turcica. By 1912 Cushing had devised a modification of the less mutilating
inferior nasal approach. He approached the floor of the nose from beneath the upper lip
and gained access to its depths and the sphenoid sinus by means of a submucous resection
of the nasal septum. This remained the operation of choice, and that which was most
widely performed throughout the world, until 1926.
It is obvious that by the trans-sphenoidal route one can remove only portions of a
tumour within the sella turcica. The capsule of these growths within the sella, or tumours
which lie above the sella, cannot be removed. With this in mind, and aided by greatly
improved technical methods in neurosurgery, Frazier in 1925, after eleven years' experience with the trans-sphenoidal operation, returned to an intracranial operation. Instead of
approaching from the side, he chose to approach from the front. It is interesting to recall
that this transfrontal operation had been devised and described in detail by Krause in 1900.
But, like the operation of Caton and Paul, it had not proved successful in thei hands of
surgeons untrained in neurological surgery. Frazier gradually improved the operation
which has come to be the accepted standard. By concealing the scalp incision behind the
hair line and turning down flaps of the scalp and bone separately, it is now possible to perform the operation without deformity or visible scar.
Through the use of the intracranial approach a large group of tumours about the
pituitary gland and optic chiasm has come to be recognized. Seventeen different types
might be enumerated. They vary in their pathological characteristics but are clinically
similar in that they all cause visual disturbance. In the early reports of pituitary surgery
interest was centred on improvements of the glandular symptoms, but it has become
apparent that surgical results in this respect are not worth while. The chief concern at
the present time is with the serious visual disturbances which may be caused by this variety
of tumours. Immediately above the pituitary gland lie the optic nerves which are passing
backwards from the orbits to the optic chiasm. All tumours in this neighborhood press
on the optic nerves and eventually cause loss of vision.
It is usually possible to recognize, prior to operation on one of these tumours, not only
the exact location in relation to the sella turcica, but also its pathological nature.  Being
Page 81 forearmed in such a manner may mean the difference between surgical success and failure.
Whether the tumour be an intrasellar chromophobe adenoma, or a parasellar meningioma,
or suprasellar cyst, for example, is usually indicated by certain individual characteristics,
which painstaking examination should elicit. For convenience of discussion the clinical
aspects may be grouped into several syndromes. The conclusion of this paper will be taken
up with a consideration of four of the more common of these syndromes.
Syndrome of Skeletal Abnormality, Headaches, Optic Atrophy,
and Enlarged Sella Turcica.
These are the commonly known cases of acromegaly and of gigantism. They show
excessive growth of the skeleton, particularly in the face and extremities, and overgrowth
of the soft tissues.
Case 1.—F. H., a youth, aged 20, referred by a school doctor, has been under our observation in the Out-Patients and In-Patients services of the Vancouver General Hospital
since 193 5. At the age of 13 he began to suffer from severe headaches and he has been
troubled with them periodically ever since. His adolescent growth was phenomenal. By
the age of 18 he was 6 ft. 6 in. in height, with big hands and big feet. Since then he has
grown another inch. X-ray plate of his skull shows a greatly enlarged sella turcica, which
is definitely indicative of tumour. Repeated examinations of his field of vision have been
negative. Deep x-ray therapy has been given periodically, with resultant lessening in the
severity of his headaches.
The tumour in this case is undoubtedly an adenoma comprised of acidophilic (growth
factor) cells, arising in the anterior lobe of the pituitary gland. These tumours respond
fairly well to x-ray therapy, but whether such treatment can always hold them within
bounds is problematical. The important feature from a surgical standpoint is the degree
of pressure on his optic nerves. It is certain that his optic nerves and their point of junction,
the optic chiasm, must be riding upwards over the tumour and must be tightly stretched.
Unless his vision fails, however, there is no indication for operation on this tumour. Vision
may fail with alarming rapidity in these cases and thus bring about a situation which should
be regarded as a neurosurgical emergency. It is important that he should always remain
under medical observation.
Syndrome of Failing Vision, Bilateral Optic Atrophy, Field of Vision
Defect and Enlarged Sella Turcica.
Case 2.—Mrs. C, aged 49, was admitted to the General Hospital under Dr. Colin
Graham in August, 1937. One year before admission her vision began to fail. This disturbance of vision gradually progressed until she was unable to read even the largest newsprint. Neurological examination was entirely negative except for bilateral optic atrophy,
diminished vision, and field of vision defects. With the left eye she was barely able to
distinguish movement of her hands, and with the right eye could only count fingers at
fifteen feet. Perimeter examination of the right eye, by Dr. Graham, showed vision
remaining only in the left upper quadrant. X-ray showed an enlarged sella turcica, indicative of tumour.  The situation as regards her vision was obviously critical.
Operation was performed in two stages, approaching from the left side through a
frontal bone flap, using the usual concealed scalp incision. The tumour was curetted out
except for a very solid portion which was lodged beneath the optic chiasm. Following
operation she was given deep x-ray therapy. Six weeks later examination showed that she
could count fingers with the left eye and read 3 mm. print with the right eye. The visual
field in her right eye was now comparatively full. She reported by letter in May, 1938, no
appreciable change.
The tumour in this case was a chromophobe adenoma, arising from the "inactive"
cells of the anterior lobe of the pituitary gland. If her symptoms had occurred prior to the
menopause she would have complained of amenorrhcea as a result of diminished activity of
the basophilic (sex-factor) cells. Chromophobe adenomas respond to x-ray therapy and
in certain instances surgery may not be indicated, or may be safely deferred until x-ray
treatment has been given a trial. I believe that all of these cases which have a marked defect
in the visual field should have operation in addition to x-ray therapy.
Page 82 Syndrome of Headache, Failing Vision, Homolateral Optic Atrophy,
Contralateral Choked Disc.
Case 3.—Mrs. C. G., aged 33, Italian, mother of five children, referred by Dr. W. H.
Lang, was admitted to Vancouver General Hospital from the Out-Patients Department
in May, 1934. She had been subject to fits for three years. These occurred at least once
a week, occasionally several times a day. They took the form of generalized convulsions
with loss of consciousness. Occasionally after a fit she was unable to speak for several
hours. For eighteen months prior to admission she had complained of a constant headache
and gradual failure of vision. She also noted that her menstrual periods had become irregular and of shorter duration. Examination showed an obese, rather lethargic woman. The
abnormal neurological findings were: (1) loss of sense of smell on the left side; (2) ability
to read only 3 mm. print with both eyes; (3) optic atrophy on the left side with choked
disc on the right side, and (4) slight lower right facial weakness. X-ray picture showed
absence of the left anterior clinoid process. It was apparent that something which had
caused erosion of the bony anterior margin of the sella turcica on the left side was also
pressing directly on the left optic nerve, and indirectly through a rise in intracranial
pressure causing choked disc on the right side. The relative amenorrhcea suggested pressure
on the pituitary gland with a resultant lessening of function of the sex-factor cells. The
anosmia and contralateral facial weakness indicated pressure aginst the brain just to the
left of the sella turcica.
At operation a medium sized meningioma attached to the floor of the skull at the inner
end of the lesser wing of the sphenoid bone was disclosed. In order to deal with it adequately,
a portion of the left frontal lobe of the brain was resected. The tumour was then removed
except for its attachment to the floor of the skull. Recovery was uneventful. She has
remained in good health and free of headaches during the subsequent four and a half years.
Her fits are only fairly well controlled with phenobarbital, as she continues to have them
at one to two months intervals. Lately her vision has commenced to fail in the left eye and
I fear that she may be developing a recurrence of the tumour.
Meningiomata, if well removed, offer a better prognosis than most brain tumours. This
case illustrates that removal of a brain tumour will not always cure fits which have been
caused by the tumour. She has been saved, nevertheless, from an incapacitated state
approaching a fatality, and enabled to carry on her home duties.
Syndrome of Headaches, Failing Vision, Bilateral Optic Atrophy,
Field of Vision Defect, Normal Sella Turcica.
Case 4.—Mr. H. F., a logger, aged 32, was admitted to the Vancouver General Hospital
in January, 1936. He related that in February, 193 5, he began to suffer from severe frontal
headaches. In July his vision began to blur, but the headaches became less severe. In
September his vision began to fail rapidly and on this account he was forced to give up
his work.  During the month prior to admission he was always very drowsy.
He had a somewhat acromegalic appearance, with heavy lower jaw and prominent
supraorbital ridges. Neurological tests were entirely negative apart from examination of
the optic nerves. There was no central vision in his right eye but some vision in his upper
temporal field. Vision in left eye was 18/200. The field of this eye was restricted to a small
area entirely in his nasal field. There was marked atrophy of both optic discs. The sella
turcica appeared normal in x-ray plates.
An operative approach was made from the left side and a yellowish transparent cyst
was found projecting upwards between the optic nerves from beneath the chiasm. When
the cyst was opened thin fluid poured out, and it collapsed so entirely that there did not
appear to be a scrap of tissue large enough to remove for section. He recovered uneventfully, and one week after operation vision was 20/30 in the left eye and 4/200 in the right
eye. There remained slight constriction of the right temporal field and blurring of central
vision of the right eye. He left hospital on the twelfth day. Three weks after operation he
was seen again, and stated, to my consternation, that vision had gradually failed during the
third week until it was practically the same as before operation. Tests confirmed his statements. Operation was repeated the next day, by reopening his barely healed wound. The
cyst had reformed and refilled with the same yellowish fluid. This time the whole top of the
Page 88 cyst was torn off and as many fragments of the wall as were visible were teased out. After
operation he was given a course of deep x-ray therapy. This time the post-operative
improvement in vision was maintained. In the late Spring he resumed his former work in
the woods. In January, 1937, re-check of his visual fields showed them to be full, and
he could read small print with either eye.
One and a half years later he returned and stated that three months previously he had
again been forced to give up his work because of failing vision. He was now totally blind
in the right eye. With the left eye he could read small print but he was completely blind
in his temporal field. A third operation was performed, on this occasion approaching from
the right side. The cyst had of course refilled, but this time its walls were thick and fibrous
and its cavity could be seen extending backwards beneath and behind the optic chiasm.
After operation he was given another course of x-ray therapy. At the last examination,
on August 15 th, he had a complete field of vision in the left eye. In the right eye he had
a central scotoma and could barely see to count fingers. Somewhat shaken, but full of
courage, he has again returned to work.
This was an epithelial lined cyst which arose from a remnant of the embryonic Pouch
of Rathke. They are more commonly found in children and treatment of them is notoriously unsatisfactory. X-ray therapy in these cases probably does more for the feelings of
the doctor and relatives that it does good for the patient. Of the combined treatment,
surgical and roentgenological, at least it can be said in regard to this patient that his vision
has been temporarily restored and his working years prolonged.
Discussion.
A greater number of syndromes could be described, but they would merely present
minor variations of the four which have been discussed. An exact diagnosis of the nature,
location, and extent of these tumours is only made after a painstaking study of all the
ophthalmological, neurological and roentgenological findings. These illustrations which
have been cited show how precisely these jigsaw bits of information may be fitted together
to form a composite picture.
My personal experience with these neoplasms in Vancouver during the past five years
comprises nine cases, six of whom have been operated upon. The boy with gigantism,
mentioned in this paper, and a lady of fifty with acromegaly, have not undergone operation,
but both have been told that they must return regularly for tests of vision. I have recently
examined an acromegalic man of thirty-two, who was operated upon by Dr. Cushing in
1930. At that time the patient was almost blind in the left eye and had a gross field of
vision defect in the right eye. Dr. Cushing's operation was immediately successful in
restoring vision and now, eight years later, vision is 15/15 in both eyes and the visual fields
are normal.
The story of three of our six operative cases has already been related. The only fatality
in the group was a lady who was already blind in both eyes as a result of a huge pituitary
adenoma, and on whom operation was undertaken because of intolerable headaches. Of the
remaining two cases, one was a patient with a chromophobe pituitary adenoma, for whom
operation and x-ray therapy have greatly improved vision but have not widened the visual
fields to any extent. The last patient was found to have an unusual tumour of the optic
nerve, about which a report will be made in the future.
Conclusions.
Success in the treatment of tumours of the pituitary and parapituitary region often
depends on how early the diagnosis is made. They occur more frequently than is generally
recognized. As the majority of these patients complain of failing eyesight before any other
symptom, it is generally an ophthalmologist who is first consulted, and the members of this
specialty consequently may have an opportunity of detecting such cases at an early stage.
It cannot be overemphasized that few gross mistakes would be made if all cases of optic
atrophy were subjected to roentgenological and perimetric examination. Either enlargement of the sella turcica or a defect of the field of vision would reveal the cause of the
failing eyesight. Unfortunately, even when optic atrophy is recognized and adequately
investigated, vision may be so impaired that removal of the offending tumour does not
Page 8k restore function completely. It should be possible to recognize these neoplasms before optic
atrophy occurs. To ensure early recognition, all cases of failure of vision for which no local
ocular cause can be found should have a careful charting of the fields of vision with a
perimeter and x-ray investigation of the sella turcica.
REFERENCES
Cairns, H.: A study of Intracranial Surgery. 1929, London, H. M. Stationery Office.
Cushing, H.: The Pituitary Body. 1929, Lippincott, Philadelphia.
Cushing, H.: Pituitary Body and Hypothalmus. 1932, Thomas.
Heuer, G.—The Surgical Approach and the Treatment of Tumours and Other Lesions about
the Optic Chiasm. Surg., Gyn. & Obst, 1931, 53: 489.9
Frazier, C.: Resection of Pituitary Adenomata. Surg., Gyn. & Obst., 1932, 54: 330.
Frazier, C.: Lesions in and Adjacent to the Sella Surcica. Am. J. Surg., 1932,16:199.
Frazier, C.: A Review Clinical and Pathological of Parahypophyseal Lesions. Surg., Gyn.
& Obst., 1936, 62:1,158.
BRITISH COLUMBIA MEDICAL ASSOCIATION
ANNUAL GOLF TOURNAMENT   |
Dr. G. Elliot won the Mead Johnson Co. cup for Low Net at the Annual Tournament
in Victoria this year.
Other prize winners were: Low Gross, Dr. R. Scott Moncrieff; runner-up Low Gross,
Dr. Colin Graham; Dr. Geo. Hall won the Low Gross for the first nine holes and Dr. E. L.
McNiven for the Low Gross for the second nine holes; Dr. D. F. Murray, Dr. F. S. Parney,
Dr. Geo. Wilson, Dr. A. T. Henry, Dr. J. H. MacDermot, Dr. F. C. Dunlap, Dr. W. T.
Lockhart, Dr. W. M. G. Wilson, Dr. R. J. Nodwell, Dr. F. S. Hobbs, Dr. M. Baird. The
Consolation Prize was won by Dr. R. A. Gilchrist.
VANCOUVER MEDICAL ASSOCIATION
Founded 1898
Incorporated 1906.
GENERAL MEETINGS will be held on the first Tuesday of
the month at 8 p.m.
CLINICAL MEETINGS will be held on the Third Tuesday of
the month at 8 p.m.
Place of meeting will appear on the Agenda.
General meetings will conform to the following order:
8: 00 p.m.—Business as per Agenda.
9: 00 p.m.—Papers of the evening.
1938
October
Programme of the 41st Annual Session
4th—GENERAL MEETING.
Dr. Frank Turnbull: "Pituitary and Para-pituitary
Tumours."
October   18th—CLINICAL MEETING.
November 1st—GENERAL MEETING.
Dr. J. Ross Davidson : "Some Aspects of Contract Practice."
November 15th—CLINICAL MEETING.
December 6th—GENERAL MEETING.
Dr. Kari/ Haig : "Diagnosis of Congenital Dislocation of
the Hip, with treatment of those which are reducible."
December 20th—CLINICAL MEETING.
Page 85 British  Columbia
President—    ~      	
Medical  Association
  Dr. D. E. H. Cleveland, Vancouver.
First Vice-President	
 ! Dr. F. M. Auld, Nelson.
Second Vice-President  	
Secretary-Treasurer	
—     Dr. E. Murray Blair, Vancouver.
 Dr. A. H. Spohn, Vancouver.
In addition to the officers as set out above, the following were elected as Directors at
the Annual Meeting held in Victoria September 15th to 17th, 1938:
Directors at Large: Dr. P. A. C. Cousland, Victoria; Dr. Anson C. Frost, Vancouver;
Dr. Stewart A. Wallace, Kamloops; Dr. Geo. T. Wilson, New Westminster; Dr. Wallace
Wilson, Vancouver.
Chairmen of Standing Committees, 1938-1939: Committee on Constitution and Bylaws, Dr. H. H. Milburn; Committee on Programme and Finance, Dr. G. F. Strong; Committee on Study of Cancer, Dr. Roy Huggard; Committee on Public Health, Dr. A. H.
Spohn; Committee on Medical Education, Dr. D. M. Meekison; Committee on Study of
Economics, Dr. W. A. Clarke, New Westminster; Committee on Maternal Welfare, Dr.
W. S. Turnbull; Committee on Pharmacy, Dr. C. H. Vrooman; Committee on Credentials
and Ethics, Dr. J. D. Moore, Chilliwack; Committee on Osier Memorial, Dr. T. C. Hilton,
Port Alberni; Committee on Medical History, Dr. M. McC. Baird; Committee on Editorials,
Dr. J. H. MacDermot.
BRITISH COLUMBIA MEDICAL ASSOCIATION
COMMITTEE ON PUBLIC HEALTH, 1938-1939
Dr. A. H. Spohn, Chairman; Dr. D. H. Williams, Secretary.
Dr. D. E. H. Cleveland, ex-officio; Dr. M. W. Thomas, ex-officio.
Dr. D. Berman, Dr. K. F. Brandon, Dr. C. E. Brown, Dr. D. A. Clark, Dr. J. S. Cull, Dr. J.
R. Davies, Dr. Richard Felton, Dr. J. J. Gillis, Dr. L. Giovando, Dr. E. S. James, Dr. A. Y.
McNair, Dr. G. O. Matthews, Dr. H. H. Milburn, Dr. Stewart Murray,
Dr. E. K. Pinkerton, Dr. H. H. Planche, Dr. E. Therrien.
The B. C. Medical Association, by appointment of its Committee on Public Health, has
recognized its responsibility in giving consideration to and playing an active role in the
solution of problems pertaining to public health in British Columbia. The scope of the
problems confronting this committee is as broad as the field of preventive medicine.
The increasing interest in public health on the part of our citizens is evidenced by the
active participation of lay groups in these matters. It behooves the B. C. Medical Association, out of its knowledge and experience, to give voice and practical assistance to
measures of preventive medicine which will result in increased health and happiness to the
people of British Columbia.
The Committee on Public Health asks that the members of the Association bring to
its attention any problems in this field which may arise at any time in their community.
They will receive consideration, and recommendations relative to their solution will be
forwarded to the executive of the Association.
The opening meeting of the Committee was held on Wednesday, October 19th, and the
following Public Health problems were suggested as worthy of immediate attention:—
1. The compulsory pasteurization of raw milk;
2. The prevention of prenatal syphilis by routine seriodiagnostic tests and adequate
treatment instituted early in every pregnancy;
3. The smoke nuisance in Vancouver.
4. Expectoration in public places.
Page 36 THE BRITISH COLUMBIA CANCER FOUNDATION
A letter from the Chairman of the Board of Directors
■   v      Plllp     f :| -1   I w
THE BRITISH COLUMBIA CANCER FOUNDATION
to
THE MEDICAL PROFESSION OF BRITISH COLUMBIA
I am very glad of the opportunity extended to me by the Editor of your Bulletin to
say something regarding the present status of the British Columbia Cancer Foundation,
and its plans and hopes for the future. Before doing so, however, there are one or two
definite statements that I desire to make on behalf of myself and my fellow directors.
The first one is this: The B. C. Cancer Foundation is an entirely independent organization. Due to the fact that we are without sufficient funds to set up a complete unit of our
own, we are receiving, either by donation or by purchase, certain services from the Vancouver General Hospital, but we are in no way connected with or controlled by that, or
any other institution. Further, our policy for the future is that we will continue to maintain that independence, for we believe that in that way we can best serve the interests of
the cancer patients of this Province.
The other statement is: The members of the Board of Directors, knowing something
of the present state of knowledge concerning the cause and cure of cancer, realize that
radium is but one of the weapons available in the great war against cancer. But it is a
weapon that is of value in certain cases and under certain conditions, and as such we believe
it should be made available to as many suitable cases as possible. With this statement, we
think the medical profession will be in agreement, and we therefore ask for your help and
co-operation.
Now as to the Foundation itself: In April, 1938, the Foundation received a gift of
$50,000 from an anonymous donor, on condition that some of the Foundation's radium be
made available immediately to cancer sufferers in this Province. After careful consideration, the Foundation decided to use $30,000 of this gift to repay part of the loan, under
which the 3J4 grammes were purchased in 1935, and thus to release one gramme of the
radium for use in a clinic; $10,000 was set aside for the processing of this one gramme of
radium, and the remaining $10,000 for the furnishing and equipment of a suitable building. The Vancouver General Hospital agreed to provide free of charge, for a period of one
year, the former Internes' Building at 11th Avenue and Heather St., and also offered to
contribute certain essential services.
With the assistance of the anonymous gift, the contribution from the General Hospital, and other donations, principally from the Rotary Club and the Lions Gate Riding
& Polo Club, the Foundation has been able to establish a clinic, to be known as The British
Columbia Cancer Institute.  This institute will be officially opened on November 5th.
Until further financial resources were available, it was decided to restrict the activities
of the Clinic to two fields: radium therapy and diagnosis.
It has been agreed that the minimum regular staff for the Institute should include:
1 Radium Therapist (full time); 1 Radium Nurse; 1 Nurse; 2 Medical Officers (part
time); 1 Stenographer-Secretary; 1 Orderly.
It is hoped that with the assistance of your organization it will be possible to appoint
an attending staff and an honorary consulting staff, to assist with the diagnostic work of
the Clinic.
Shortly you will receive, if you have not already done so, a letter from the Foundation
telling you of this Clinic, and outlining certain regulations for the handling of patients.
We know that the cancer population of the Province goes through the hands of the
medical profession, and we desire to care for only those patients who are referred to us by
the medical profession. We do not want patients coming to our doors of their own free
will. At present, and for a long time to come, you can supply us with more cases than we
can deal with in conformity with our regulations and facilities.  The doctors throughout
Page 81 the Province, and not the patients, should decide which are the suitable cases to be sent in,
either for the clearing up of difficult points in diagnosis, or for active treatment.
The opening of the Clinic will entail a certain amount of unavoidable publicity, but
it is not the policy of the directors to publicize the work of the clinic in the lay press. We
realize that any publicity concerning a form of treatment for cancer is apt to be misinterpreted by the people at large, and is extremely liable to raise unduly the hopes of
cancer victims and their relatives. They then look for results which in so many cases
cannot be obtained, and the end is sorrow and disappointment.
At some future date we hope, with your assistance, to put forward, with all publicity
possible, a campaign for funds to provide a fully equipped and modern institute, with
adequate research and other facilities. At that time we hope to be able to tell of what we
have done and of the need that we have been unable to meet because of lack of adequate
resources.
At the regular meeting of the Board of Directors of the Canadian Medical Association
(B. C. Division) on November 9, we are inviting your directors to submit to us a panel
of names, and from that panel we propose to appoint our Honourary and Active Medical
Staffs. We look forward confidently to the co-operation of your directors in this matter.
We intend to look to these two staffs, not only for active participation in the work of our
Clinic, but also for advice and counsel in directing the policies of the work, so that in our
field the greatest possible advance may be made towards bettering the lot of the cancer
patient in this Province.
In conclusion, may I take this opportunity of congratulating your branch of the
Canadian Society for the Control of Cancer for the excellent work it is doing under the
vigorous charmanship of Dr. Allan McNair.
Its work, our work, all work aiming at the control of cancer, is indivisible, and worthy
of the most cordial support of every layman and every doctor in British Columbia.
W. H. Malkin,
Chairman of the Board of Directors,
British Columbia Cancer Foundation.
QUESTIONS TO BE CONSIDERED PREVIOUS TO GOING
APPRENTICE FOR AN APOTHECARY
Requirements laid down in the time of Edward Jenner—not altered much today.
Can you bear the thoughts of being obliged to get up out of your warm bed, in a cold
winter's night, or rather morning, to make up medicines which your employer, just arrived
from attending a labour, through frost and snow, prescribes for a lady just put to bed, or
a patient taken suddenly or dangerously ill? Or, supposing that your master is not yet in
sufficient business to keep a boy, to take out the medicines, can you make up your mind to
think it no hardship to take them to the patient after you have made them up?
Are you too fine a gentleman to think of contaminating your fingers by administering
a clyster to a poor man, or a rich one, or a child dangerously ill, when no nurse can be found
that knows anything of the matter? This is a part of your profession that is as necessary
for you to know how to perform as it is to bleed or dress a wound; or are your olfactory
nerves so delicate that you cannot avoid turning sick when dressing an old neglected ulcer;
or when, in removing dressings, your nose is assailed with the effluvia from a carious bone?
If you cannot bear these things, put surgery out of your head, and go and be apprenticed
to a man milliner or perfumer.
(Extract from Professional Anecdotes, edited by Dr. E. Jenner, 1802.
(Father of Vaccination.)
Page 88 [An interesting paper received lately, through the courtesy of Dr. H. M. Cassidy,
Director of Social Welfare, is that of Dr. A. E. Larsen, Medical Advisor to the California
State Relief Adrninistratioru We believe it will be of interest to our readers, especially in
his conclusions as to the feasibility of giving a full medical service, paid for on a fee basis,
to the indigent. He finds that the cost of this service would be about four times as great
as when the service is given through a clinic.
This is, however, a rather one-sided statement. The "clinic service" includes social
service work, employability examinations, home care nursing, appliances, special diets,
housekeeping service, etc. Presumably all those who do this work are paid, but they are
not all medical men. For the medical work, certain physicians are paid on a salary basis
for part-time work.
This opens up a whole new line of thought. It will be noted that the physicians chosen
to do this work get a very small remuneration, as standards go. This feature is in need of
improvement. But it does afford to the young physician certain things. It gives him work
to do, and pays him something for it; it gives him a start in the community; it keeps him
in touch with clinical work, and gives him plenty of opportunity to become a better
doctor. These are all things that are sadly lacking under our usual method of beginning
practice.
We have two loose ends: the doctor starting practice that needs work and pay therefor,,
and the indigent who need medical care and cannot pay for it. The connecting link may
very well be some system, perhaps inaugurated by the Government, which must ultimately
meet the cost of medical care of the indigent somehow, along lines such as those suggested
by Dr. Larsen. This may lead to a solution of that most obstructive problem, the medical
care of the indigent on terms fair to the medical profession, and yet calculated to ensure
adequate care to the indigent. It is worth our earnest consideration. There is no doubt
that the ideal method from our point of view is payment for services rendered according
to a schedule of fees, and this has been proved to be feasible, in Ontario, and, as far as a
simplified system of office and home practice goes, in Vancouver, but the schedule is
altogether too moveable to be satisfactory.
While we may, for reasons adduced above, question Dr. Larsen's conclusion that a
system of practice on a fee basis would cost four times as much as the clinic system—and
while we may feel that if this is true it is probably because the doctor is so very much
underpaid under the clinic system—we must yet consider whether perhaps the latter, as
administered in the plan described by Dr. Larsen, may not have sufficient merit to make
it worth trial, and sufficient opportunity for improvement and expansion in detail to
suggest that along these lines we may eventually reach a satisfactory solution of some of
our problems.—Ed.]
CALIFORNIA STATE RELIEF ADMINISTRATION
180 Montgomery Street, San Francisco, California.
Dr. H. M. Cassidy, August 26, 193 8.
Director of Social Welfare,
Parliament Building, Victoria, B. C.
Dear Dr. Cassidy:
I am sending you a copy of the paper which was read in Seattle, which is based on the
observation of the operation of a panel system in Los Angeles and a clinic system in San
Francisco Over a period of the past four years.
It is difficult to compare the two completely and accurately because of the different
nature of the services that are rendered. For instance, in Los Angeles County, under the
panel system, there is an average of a little over one visit per case per month, whereas in
Page 89 San Francisco the visits per case are nearer three. However, it is possible to take the services
rendered by the clinic system in San Francisco and compute them in terms of what they
would cost under a panel system. This is really the only way that they might be compared
on a sound financial basis. We have done this for the San Francisco plan and found that
to duplicate the services provided in the clinic system would cost approximately four times
as much by the panel plan.
There is another factor to be considered besides the question of cost which I think is
equally important, and that is the social benefit derived from a central unit which understands the work of the welfare division. The clinic system is able to concentrate and
standardize certain matters which are of interest to the welfare division. As you know,
there are many accessories to medical service for an indigent person. We have to give considerable thought to medical reports to the case worker, to employability examinations,
appliances, home care nursing, housekeeping service, special diets. All of these functions
may be departmentalized within a clinic system with uniform standards and with proper
thought of the conservation of funds, so that the maximum benefit to the patient as well
as to the fund may be achieved.
The clinic system is able to direct its attention to specific problems that may arise in
the case load. As an instance of this, we are able to pay particular attention to the psychiatric phase of the relief client. Such work is not easily obtained with a panel system.
We have found that the people willingly accept the clinic service, although we do
allow them choice of their own physician if they so desire. In the latter instance we provide drugs and nursing supplies, but we do not compensate the physician. This phase of
clinic service has been shown to be almost negligible, as less than 1 per cent of all the
patients we have seen have had a family physician with ,whom they desire to continue
medical care.
I am in the process at the moment of writing a detailed analysis of the San Francisco
clinic system and at some future date I shall be glad to send you a copy of this.
Thanking you very much for your inquiry, I am,
Sincerely yours,
A. E. Larsen, M.D., Medical Advisor.
MEDICAL RELIEF BY THE CLINIC AND PANEL SYSTEMS
Albert E. Larsen, M.D.
(Read before the conference of the American Public "Welfare Association in Seattle, June, 193 8.)
The results of many excellent surveys have shown that (the medical problems of the
indigent are greater than in any other population group. There are implications in these
surveys that these medical needs are not being adequately met. The Federal Government
in 1934 recognized this, but withdrew its support. Many states continued with their
medical programs, but began to modify the original to meet local conditions. This caused
the growth of a variety of medical plans.
In California two plans have developed to care for the medical needs of the unemployed
relief group: the clinic in San Francisco, and the panel in Los Angeles. I shall attempt to
give a bri^f description of each.
The panel system, as used in Los Angeles and the rest of the state, began with the
co-operation of the state and local medical societies. They agreed upon a fee schedule and
all licensed physicians in the community were invited to participate. A physician was
appointed to direct their programme. To secure medical care, the prospective patient consults his case worker and is allowed to select his own physician. If there be no preference,
cases are rotated among the panel. Forms necessary for social service and accounting
purposes are sent to the physician for completion. This material returns to the local medical
department, is certified as to correctness, and then forwarded to the central accounting
office for payment and budget adjusting.
The Central Medical Bureau originated in San Francisco in 1932 from the recommendation of a committee composed of the Director of Public Health, physicians who had
been presidents of local or state medical societies and the president of the local medical
(Italics in this copy are ours.—Ed.
Page hO society, and interested lay persons representing the Community Chest and labor. With the
policy determined, a physician was appointed to design and direct the programme: a home
care service for the acutely ill, a clinic for chronics, and existing community services compensated on a visit basis. Physicians were offered part-time work on a salary basis for home
care and the clinic for chronics.
To secure medical care the patient is issued an identification card by the case aide and
may then use the clinic facilities at any time while he is on relief. A master file of active
cases in the Bureau checks eligibility. This file is identical with! the accounting files of
local and state offices. Each patient has a medical chart, which is correlated with his social
service record by name and number. This chart contains all information of medical and
social interest and is used by all the departments within the clinic.
Social service directs all inquiries of a medical nature to the clinic. Information is
returned interpreted in lay terminology and in accord with the policies of the administration.  The major part of the expense of the clinic is for personnel.
A medical programme for the indigent must be considered from the point of view of
the patient and the medical profession, social service and the administration. I shall discuss
some of the advantages and disadvantages of the panel and clinic systems in relation to
these points.
The panel system meets with the approval of the medical profession because of presumed service on the physician-patient relationship. This is functioning very well in the
rural areas, but its application to a metropolitan centre is questionable. A survey of the
free choice experience has shown that in Los Angeles, though the clients were encouraged
to choose their own physician, less than one per cent availed themselves of this privilege.
Medical care is limited to the acute stage of a disease. Cbjronic conditions are referred
to a clinic resource. Therefore, from the M.D.'s point of view, there cannot possibly be a
successful continuity of treatment.
The idea of a fee schedule was not always acceptable because of the danger of establishing a precedent on the value of physicians' services. (! Ed.)
Most physicians object to the amount of paper work they have to complete. As many
as nine forms may be referred to satisfy the social worker and the accountants.
A few of these reasons may possibly account for the shrinkage in the size of the panel.
In February, 193 5, in Los Angeles, 2,300 physicians out of 4,150 applied for panel service.
There are now about 200 remaining. The average income of each for panel service is
approximately $10 monthly.
The clinic system does not imply the physician-patient relationship in the true sense of
the word. However, patients are allowed to continue with their private physicians1 should
they desire. Drugs and sickroom supplies are then provided for these patients by the clinic
facilities.
The profession was of an idea that clinic service would influence the patient to become
clinic minded, but a survey showed that this was unjustified, as less than one per cent of
patients had sought the services of a private physician in the year previous to registration.
It was also shown that the people on relief rolls in the metropolitan area always had been
accustomed to using clinics.
Physicians for the Medical Bureau are selected from approved medical schools. Marriage, dependents, their economic need and residence are factors considered. They average
$65.00 a month for nine hours' work a week. This has been a great help in aiding many
young physicians to become established in the community. The same percentage of practising physicians is employed by the clinic as is on the Los Angeles panel.
In the present-day structure of relief a physician's responsibility extends beyond the
actual care of an illness. By reason of contact with a relief client, he actually becomes
part of the social service personnel. The person whom he treats is living in an artificial
environment. His existence has been made possible by legislation, in which there are many
rules and regulations. These must be considered in relation to housing, special diets, housekeeping services, and employability. The quality of- medical service produced by the
^vsician is often dependent on adjusting these needs. It therefore becomes essential for
xun physician to co-operate and work with the medical social workers and the case aide in
Page Jfl use of limited funds. The size and diffusiveness of the panel system renders this phase of
medical service difficult.
The clinic is able to centralize all medical information and to train its personnel in these
regulations. Therefore, a maximum of benefit to the client may be secured within the
imposed limitations.
It also provides the physician with a trained staff of special workers to follow their
cases.  The quality and efficacy of medical care is directly related to this effort.
The third factor in medical relief is adrninistration. The panel requires a staff to
control the extent of services, eligibility, and authorizations. It must maintain locally an
accounting department to handle this detail. This overhead amounts to about 2 5 per cent
(depending on the load) of the total medical expenditures. A percentage of this cost is
duplicated in the central accounting office.
Since the panel treats only the acute stage of a disease, it is caring for only one-fourth
of the medical needs of the case load. The remainder are cared for in county clinics where
the physician usually is not compensated for his services. It has not been possible to say
what the cost for complete medical care would be, due to the lack of actual experience.
Theoretically it may be computed // services provided in the clinics were extended to a
panel system the cost would be approximately four times as great.
The clinic in San Francisco has an overhead of about 10 per cent. It is practically self-
sustaining, in that only a small part of its accounting necessities are duplicated in the state
office. This releases a comparatively larger sum than the panel system affords to be devoted
to pure medicalcare.
Statistics show the average incidence of illness per month to be about 18 per cent and
reveal the actual medical needs of the relief group. The cost per person on relief for complete medical and dental care varies1 inversely according to the load. In 1935, with a case
load of 70,000, this cost was 2 5 cents per person a month; in 1936, with 20,000, the cost,
was 50 cents a month.
From available figures it is therefore possible to predict with accuracy the cost of
providing medical care to any case load. There are also figures whereby it is possible to
compute the number of physicians, nurses and clerical help necessary for a given case load.
It is the policy of the Medical Bureau to vary its staff according to these changes. This is
based on a basic standard established of the number of minutes per patient consistent with,
good quality of medical care.
In conclusion, the medical needs of unemployed relief clients are greater than those of
any other population group. There is an economic and a public health, as well as the
humanitarian challenge to meet. The quality of medical care given should equal the standards as practised throughout the nation. It should draw a minimum from the tax structure
consistent with this service. The present theory of meeting medical needs supplements
local resources, where physicians are usually not compensated. Should responsibility for
medical care follow the source of funds, because of overburdened local resources or policy
changes, new methods would have to be considered.
From the foregoing it would seem that the panel system would be the method of choice
in the rural areas. In metropolitan centres with populations of 100,000 concentrated
within a radius of 10 miles, the clinic system as described could include adequate compensation to the medical profession and render efficient medical service to the patient, and
social service, with simplified administration at a minimum cost for all home and ambulatory needs of the entire case load.
R_HANDS OFF
[Below is a copy of the article in Collier's Magazine referred to editorially.—Ed.]
Copy of Editorial in Collier's Magazine, September 10th, 193 8.
Of all the many activities of our government, the suggestion by the Department of
Justice that the American Medical Association is fair game under the antitrust laws is quite
the maddest.
Not that we are taking the part of the doctors in their quarrels with some of the brain
trusters in Washington. Our belief is that the doctors are well able to fend for themselves.
Page 42 But the long attack of Assistant Attorney General Thurman Arnold on the doctors is
just too extreme. The antitrust laws seem to be against anything except trusts. As Thurman Arnold himself said somewhat extravagantly in his book, The Folklore of Capitalism,
"the actual result of the antitrust laws wast to promote the growth of great industrial
corporations by deflecting the attack on them into purely moral and ceremonial channels."
Yet years ago the Danbury Hatters' Union was prosecuted under the antitrust law.
The Sherman Act had not done much toward breaking up trusts but it was a sixteen-
inch gun where the hatmakers were concerned. The small Danbury union felt the full
force of the governmental fury. Poor little men lost their homes and savings. The hatters
were crushed.
Or, at any rate, such was the general impression thirty years ago. Perhaps that conclusion was wrong. Maybe there is some connection between blind partisanship exhibited
in the prosecution of a small local labor union under the antitrust law and the subsequent
adoption of the frankly partisan Wagner Labor Act. Injustice breeds injustice and partisanship gives rise to more partisanship as in time the wheel of fortune turns.
It is tragic to see important matters so mishandled. It is also too bad to see the bright
young idealists at Washington getting slick in the application of statutes. It is possible to
be just too smart. Arnold's scheme to fight an imaginary medical trust is much too cunning.
Very plainly there is a medical problem with which the government sooner or later will
have to deal. The problem is as simple—and as complicated—as poverty. The poor do not
have enough, or good enough, medical service.
The doctors and hospitals have provided much free service for those unable to pay.
Most good doctors give generously of their time and skill to patients unable to pay. The
generosity of doctors with the poor is proverbial.  Still, better arrangements can be made.
The most pressing needs exist among the vast number of families unable to pay for
competent medical service but unwilling to accept charity. Different methods have been
tried to meet their requirements. Corporations, voluntary co-operative associations and
other organizations have been formed to provide medical service.
The present controversy arose over the creation of a co-operative medical agency in
one of the governmental bureaus at Washington. By paying a small sum monthly the
government employee was given medical care for himself and family. Regular physicians
opposed this scheme.
Doctors who worked for the co-operative were not favored by the medical associations
nor received by the hospitals. So the Department of Justice's Thurman Arnold decided that
the medical associations could be brought to terms by using the antitrust laws against them.
Maybe so. The Danbury hatters certainly took a beating. On the other hand, maybe
the doctors are not quite so vulnerable. They at least can hire plenty of counsel to argue
the point. Perhaps, also, in the struggle public opinion will support the doctors. They have
many friends, and, as individuals, they have rendered valiant service.
But it won't be wise for the doctors to get too technical or too self-satisfied. The
Department of Justice would not be sticking its nose into the policies of medical associations if it were not persuaded of the public interest. Somebody, somehow, must devise a
way of making good medical service available to the entire population under reasonable
conditions.  The doctors themselves would be wise to take the leadership in this effort.
Many promising experiments are already being conducted. The mutual insurance plan
of providing for hospital expenses is being widely adopted with the approval of both doctors
and hospitals. Other ways of adapting the insurance principle to medical care are being
tried and some doubtless will work.
Meanwhile, the doctors will do well not to be too much annoyed at being denounced
as a medical trust.
The courts or Congress can take care of the farfetched accusation of a medical
monopoly. Only the doctors themselves, however, have the information necessary to evolve
a comprehensive policy under which the best possible medical care may be available to the
largest number of people. If the doctors do their part, they will have little to fear from
Washington or elsewhere.
Page >,$ Vi
ctoria  Medical   Society
Officers, 1938-39.
President Dr. P. A. C. Cousland
Vice-President Dr. W. Allan Fraser
Hon. Secretary  Dr. W. H. Moore
Hon. Treasurer Dr. C. A. Watson
The Annual General Meeting of the Victoria Medical Society was held on October 3rd
of this year. The chief business was the receiving of reports of committees for the previous
year, and the election of officers. The Library, Indigent, Publications and Public Health
Committees were all re-elected with the same personnel as last year.
An Editorial Committee, to provide material from Victoria for the Bulletin of the
Vancouver Medical Association, is to be appointed by the incoming Executive.
RADIATION THERAPY
By Dr. H. H. Murphy
Director, Department of Radiology, Jubilee Hospital, Victoria, B. C.
(Address given before the Victoria Medical Asciety on January 11, 193 8)
Mr. President and Gentlemen:
To address this society is a privilege which I appreciate, and I trust that a brief review
of Radiation Therapy may prove of interest to each one of you: and if such a review is to
prove of interest it must, I think, be conducted with a telescope rather than a microscope,
so that you may be able to detect the broad underlying trends which we can follow from
year to year or from decade to decade. In radiation therapy, as in most things, such underlying trends will come, I think, nearer to the truth than do the surface variations which
are cast up from year to year.
You will all remember that Professor Wilhelm Conrad Roentgen, Professor in the
Institute of Physics in the University of Wurzburg in Bavaria, discovered the x-rays in
November, 1895. You will also remember that when he made this momentous discovery,.
Professor Roentgen was working with a Crooks tube excited by an induction coil; so that,
obviously, Sir William Crooks produced x-rays but did not recognize them. It is of
interest to us that the late Dr. Pepperdyne of Toronto—who, ass some of you know, died
a martyr to science, losing first one arm and later the fingers of the other hand as a result
of skin carcinomata developed through this early work, and later dying of metastases—
worked with Sir William Crooks during this period before Professor Roentgen's discovery,
and that we have working with us in Victoria one technician trained under him. As I look
around this meeting I see many who, like myself, began medical training and practiced for
some years before this "new ray" was sufficiently understood to be known outside the
laboratories of the experimental physicists.
I have just spoken of a "new kind of ray," and this was the title of Professor Roentgen's
original paper announcing the discovery on December 28, 1895, before the Wurzburg
Physical Society. The discovery was announced in England in the lay press on January 6th
and in New York on January 9th. On January 10th the first scientific announcement was
made in England through the medium of The Electrician and the good news was carried to
the medical profession on January 11th in the issues of the Lancet and of the British Medical
Association Journal. So, Mr. President, the time is singularly fitting for a review such as
I contemplate this evening, as we are opportunely marking an anniversary. For this reason
you will, I am sure, be interested in hearing the brief editorial from the Lancet announcing
the discovery. I would here thank the Library Committee of this Society, as their work
enabled me to find this here in Victoria. McGill students will be interested to know that
this particular volume of the Lancet is from the library of the late Professor James Bell
of Montreal.
Page U "The Searchlight of Photography"
"Everyone remembers what Mr. Samuel Weller said in reply to the question put by
Sergeant Buzfuz: 'Have you a pair of eyes, Mr. Weller?' 'Yes, I have a pair of eyes,' replied
Sam, 'and that's just it. If they wos a pair o' patent double million magnif yin' glass micro-
-scopes of hextra power, p'raps I might be able to see through a flight of stairs or a deal door,
but bein' only eyes my wision's limited.' In Sam Weller's day it is safe to assert that such
an instrument was not available, and many will be sceptical even in these enlightened days
as to whether it is possible to see or to bring to view an object situated behind a deal door.
Yet this has been virtually accomplished, if we are to believe an announcement from Vienna
this week. Thus it is reported that Professor Roentgen, the Professor of Physics at Wurzburg University, has discovered that a certain kind of light, while it will penetrate wood
and the flesh of men and animals, will not penetrate bones and metals. The special kind of
.light which appears to be endowed with this remarkable differentiating property is obtained
by passing an electric spark through a vacuum tube. As far as we can gather, a photograph
may be obtained of metals enclosed in wood or of the bones of a man's hand, by simply interposing these objects between the luminous vacuum tube and sensitized paper. If this be
so, then, bones and metals being impervious to this light, a print will be produced which
will represent the object in white, and the wooden or fleshy covering, as the case may be,
as a sharp dark border in strong relief. Such results, we learn, have actually been obtained,
both with metals enclosed in wooden boxes and with the bones of a living hand. In how
many ways such a discovery might, if it be true, be turned to the highest account we cannot
at this juncture pretend to say. For us, it much possess the greatest possible interest, even
though it contain only the shadow of a promise of affording a means, to quote one instance,
of finding the locality of a bullet embedded in the flesh without causing the pain necessarily
inflicted by probing for its whereabouts. At any rate, whether these applications are practically impossible or not, we have evidently advanced since Mr. Samuel Weller's time, since
it is announced that means have been found for bringing objects enclosed in wooden cases
to view, and that, to all intents and purposes, amounts to 'seeing through a deal door'. . . ."
While speaking of the various magazines which announced the discovery, we must not
overlook Punch. In the issue of January 25, 1896, we find a so-called poem of five verses
—I shall quote only one of these to you.
"We do not want, like Dr. Swift,
To take our flesh off, and to pose in
Our bones, or show each little rift
And joint for you to poke your nose in."
The year 1896 saw the "new kind of ray" used in medicine both for diagnosis and
treatment, and before the year was out the sad results of the, as yet, not understood dermatitis made themselves known. It is also interesting to note in passing that, in this same
year, x-rays were used in industry, in the Carnegie steel works, to detect flaws in castings
and weldings.
It was thought that the x-rays were present in sunshine, and, as sunlight was then
inown to be bactericidal, the first experimental work done with x-rays was to try and
establish the discovery as a new bactericide, but this was soon abandoned. However, during
1896, malignant conditions of skin and breast were treated empirically by medical practitioners of various nationalities, and it is of geographical interest to us here to note that
in this same year (1896) the first case of x-ray dermatitis with histological study of the
affected skin was made by A. B. Kibbe, of Seattle.
Soon the possibility of producing epilation was discovered, and this, rather than dermatitis, gave the clue to modern therapy. An Austrian named Leopold Freund heard of these
epilating effects and decided to treat a large hairy nasvus. The nsevus, according to
Freund's report, extended unilaterally from the neck down the posterior part of the thorax,
and he treated it two hours a day for many days—so many, in fact, that one area received
42 hours of irradiation. He gave his type of coil (20 cm.) and distance (10 cm.) and was
greatly pleased when epilation occurred on the seventh day. However, his enthusiasm was
■dampened a bit when, later, the child was admitted to hospital with albuminuria and
evidence of toxicity from the extensive tissue ulceration, which later required several
Page 45 excisions; but five years later he reported the case as healed, and only a lesion "the size of
a guilder" remained. (Science of Radiology, pp. 214, 215.)
This case had wide publicity, and physicians knew that they had now a potent, if as
yet little understood, therapeutic agent. Freund had described his current as of an intensity that "permitted a hand to be photographed in one minute," and the first attempt at
a dosimeter was when someone took a skeleton and mounted the hand on a block of wood
and used this, rather than his own hand, for estimating dosage. This was to develop into
the Ionization chamber, and the "R" unit of today, with all its exactness. By 1905 something was known of the value of filters and the problem of quality in radiation therapy.
Marked improvement in equipment, such as the development of the interruptless transformer by Clyde Snook of Philadelphia (1906), and the Coolidge hot cathode tube by
W. D. Coolidge (1913), placed in the hands of radiologists equipment of precision and
accuracy, and the advancement from that time on was rapid.
In 1920 L. Seitz and L. Wintz of Berlin announced the massive dose technique for
treating malignancies that were deep seated—that is, administering as large a dose as possible in as short a time as possible—so to speak, a cancericidal sterilizing dose, and, as it
was only shortly before that the idea of a massive dose of 606 held the field, it was not to
be wondered at that this system, fundamentally wrong as it was, should have had such a
general appeal. Everyone talked of a "lethal dose" or a "critical dose," and thought only
of a direct depressant action on the tumour cell. This idea ia still widely held and no one
yet has the final answer, but there are many observations that make us think a great deal
today of an indirect action. In connection with this question of indirect action, I will read
to you a short extract from a symposium from the annual Congress of the British Institute
of Radiology on December 8, 1933, and I am quoting from the contribution of Dr. F.
Hernaman-Johnson (The British Journal of Radiology, March, 1934, pp. 142-144):
"I began to believe that the killing of all cancer cells at one time by the direct action
of x-rays or radium was impossible. This belief saved me from any exaggerated hopes when
the so-called Erlangen method was introduced more than a decade ago. The heavy 'lethal
dose' seemed to me but my old friend the 'critical dose' under another name, and no more
likely to be justified. Nevertheless, I still thought that direct depression of malignant cells
played a large part in the disappearance of any tumour.
"Steadily, however, my belief in the importance of direct action has diminished: it
seems to me that during the past few years a large amount of evidence, both experimental
and clinical, has been obtained which emphasizes the indirect factor. Experimentally, there
is the work of Bainbridge and Murphy in America, and of Russ in this country, on the
irradiation of tumour sites before implantation. Transplanted cancers do not take well on
irradiated tumour sites. Murphy further states that when a tumour fails to grow under
the above circumstances, the degenerating malignant cells pass through a series of phases
identical with those which occur under treatment by x-rays in situ.
"Modern research has provided us with no proof whatever of direct selective activity
in hi vivo experiments. Let me quote again the cautious words of Dr. Finzi: 'After an
irradiation which is not excessive, some change takes place, causing the growth cells to
disappear and the healthy cells to remain'; and the more positive statement of Dr. Shaw:
"X-rays act mainly as a stimulant to the healthy cells of the body.' At a recent cancer
congress, slides were shown of a spontaneously regressing mouse cancer, and of one disappearing under the action of radium. Microscopically, there was no difference in the
appearances.
"Tissue culture experiments in vitro present great technical difficulties, and the results
have the appearance of being conflicting; malignant cells are found to be sometimes more,
sometimes less, sensitive to radiation than normal cells, according to varying conditions.
"It is said by some that because certain forms of sarcoma almost 'melt away' under
x-rays, that action must be direct on the cells. It does not follow. We have all seen large
gummata rapidly disappear under the internal administration of potassium iodide—an
action which is certainly not direct.
"Direct action is also unlikely on a priori grounds, in view of the multiplicity of disorders in which x-rays are of service.  It must surely be the names of the disorders which
Page 46 are multiple rather than the disorders themselves, for it is inconceivable that nature should
have, say, fifty different ways of responding to the same agent. We know, in fact, from
pathological and biochemical studies that the means of defence which the body possesses,,
though highly complex in themselves, do not, in fact, differ greatly whatever the morbific
agents. Elimination, inflammatory reaction, phagocytosis and the mechanism of immunity
in its widest sense almost exhaust the list. Nor can any remedy, apart from chemical antidotes, act except through these processes. Even so-called specific remedies like salvarsan
and quinine have been shown to require the co-operation of the body tissues if they are to
be successful. Now I do not think it will be claimed that x-rays are a specific remedy. Are
we to suppose, then, that their action, whatever it is, is essentially different in two such
apparently diverse cases as, for example, a fracture due to a secondary deposit in the upper
end of the femur and an osteoarthritic hip joint? Precisely the same dosage may cause the
healing of the cancerous lesion and the arrest, and to some extent the reversal, of the osteoarthritic process.
"It is, I believe, taught that x-rays have a selective action on white blood cells, and that
this accounts for their good effect in splenic leucaemia. I have tested the effect of the same
dosage scheme on cases of leucaemia with the typical increase of leucocytes, low red cell
count, and deficient haemoglobin, and on patients suffering from polycythaemia, showing
an excess of reds. In the one case, the whites are, rapidly reduced and the red cells go up.
In the other, the red cells are brought back to normal. In both, the patients are restored to
a symptom-free condition. Yet the same dosage applied for some other purpose to a patient
with a normal blood picture caused no change in the red or white cell count. Obviously,
selective action on white cells does not explain the good effect of x-rays in leucaemia. All
one can say is that in some way they assist the body to regain, for the time being, a proper
balance, and it is quite probable that direct destruction of cancer cells, if and when it
occurs, is, with regard to the process of healing, of secondary importance, or even of the
nature of a mere epiphenomenon.
"Let us take another line of argument. The effects of x-rays on the body are of the
nature of electrical phenomena. Electricity in various forms has been found to be of use
in rheumatism, exophthalmic goitre, many skin diseases, rodent ulcer, and, in fact, in a
list of disorders similar to, though smaller than, that for which x-rays are employed.
Rodent ulcer, which is truly malignant although it does not metastasize, may be caused to
heal by galvanism—which you may call ionization if you wish—or by daily mild high-
frequency sparking around its margins. These measures call into being our old friend
inflammatory reaction. They stimulate healthy tissues. But can anyone with a microscope
tell by examining the deeper layers of such a growth whether the therapeutic agent is electricity or x-rays?
"I venture to suggest, in all humility, to the laboratory worker, that the limit of progress as regards study of malignant cells per se has been nearly reached. On the other hand,
the reaction of the surrounding healthy tissues and of the body as a whole have not been
fully investigated. Researches not confined solely to the study of radiation effects in cancer, but extending to their action in various non-malignant conditions, also comparative
studies with regard to other remedies, might lead to fresh discoveries, or at least to a fuller
understanding as to how x-rays and radium act."
I have referred to the temporary popularity of the massive dosage system, but that was
only a surface variation. As early as 1914, C. Regaud of Paris suggested that, in view of
his studies on the effect of radiation on cells during the process of division, a more valuable
plan would be to treat with comparatively small intensities over a very long period so as
to irradiate cells during all phases of division when they seem most directly vulnerable.
This idea was first applied to radium and later to roentgen ray therapy. With the increased
knowledge that we now have on the question of the quality of radiation (wave length),
this idea has been further developed by Professor Henri Coutard of Paris. At this point
I would just mention his observations on "Periodicity": he found that under radiation
therapy there was a normal cyclical response, and that, to a certain extent, the same rule
held true of malignant conditions, and he tries to plan his treatment so as to deliver large
doses during the period of maximal sensitivity.
Page 47 This whole problem of cell sensitivity is the subject of an immense amount of research
work at the moment, and, in passing, I would just ask you to remember the important
work done by Dr. Maude Slye on the question of heredity amongst her mice—the relationship of heredity and malignancy is a very close one in the mouse—and she thinks that it
is probably closely associated in the human race. I am sure that the mere mention of the
possibility brings to your mind many families you have attended where the possibility
seems to exist. While speaking of research work, during the last couple of years the combination of radiation therapy and the repeated elevation of tissue temperature by shortwave treatment seems to offer a better result. However, this is still just a laboratory
procedure.
In those cases where it is necessary to combine any surgical procedure with the treatment of malignant disease, I would remind you of a recent (Am. J. Rod., Sept., 1932)
statement of Dr. James Ewing of New York, that he had seriously tried to estimate the
number of cells that were present in a lymph node about 1.5 cm. in diameter in a case of
cancer of the breast. To use an expression that the legal fraternity is fond of, he gave it as
his "considered opinion" that there were a little over 8,000,000,000. Does this not call
for the greatest possible care to determine that, when operative measures are taken, the
case is suitable and can be dealt with satisfactorily. In this connection I would also remind
you of those cases that we all see from time to time (I myself saw at least one during the
past year) where the malignant cell is transplanted on the surgeon's knife. You will find a
very important article on this subject in Surgery, Gynecology and Obstetrics for December, 1936.'
The question of supervoltages is one that is much before the roentgenologist at the
moment; by this I mean voltages above 200 K.V.P. Very interesting adventures in higher
physics and therapy have been going on in many centres for some years without any
definite findings as to the ultimate value of 400,000, 600,000 or a million volts. When
I was in Chicago, the offices of the General Electric received a telegram from the works
in Schenectady that a new 1,500,000-volt installation had just completed 120 hours of
continuous operation without breakdown. The completion and release of this type of unit
for therapy on an experimental basis will probably give us the answer in the next few
years, as the wave-length from this unit is so close to that of radium that the element of
error in measure could equal the difference.
Now what does all this mean to the victim of cancer today? It means that all your
malignancies fall into three categories:
1. The radiosensitive group—the embryonal growths and certain growths of uncertain
origin, such as the leucaemias;
2. The resistant group—such as osteogenic sarcoma and the differential sarcoma such
as fibro-, chondro- and myxosarcoma, and alimentary adenocarcinoma;
3. Tumours of intermediate sensitivity—squamous cell, transitional, basal cell, and
breast carcinoma.
Curative radiation treatment is one for the early and not for the late case, and if it is
to be successful it must be given to the absolute limits of tolerance. There is no place for
half-hearted treatment, or half-hearted reactions. Any permanent results that surgery
had has have come through the development of radical surgery, and the same is true of
radiation therapy.
Palliative radiation therapy is, of course, quite a different story, and much smaller
doses may relieve pain,,and occasionally we are more successful than we expect to be, but
I wish to register very emphatically that I do not consider that radiation therapy should
ever be given just "to do something." This can be accomplished in much simpler and less
expensive ways, and without prejudicing the method when it is really showing some real
successes. For the advanced case, the problem is still that of clinical medicine, with perhaps certain well-considered surgical procedures for the relief of pain, or mechanical difficulties such as obstruction.  Here I would remind you of the dictum of Trudeau, that the
(Continued on page 50)
Page ',S We are happy to present herewith a short synoptic presentation of The Physician and
Venereal Disease in British Columbia, by Dr. D. H. Williams, the Director of the Venereal
Disease Control Department of the Provincial Board of Health.
In the course of an address at Victoria, given at the B. C. Medical Association meeting,
Dr. Williams offered, with evident sincerity, that the fullest help and co-operation by his
department would be available to any practising physician at all times.
This is excellent, and we cordially thank Dr. Williams. But this entails a definite
response on our part. If the people of British Columbia are to obtain the best in preventive
and curative treatment from the medical profession, they can only do so if there is a true,
honest interchange between these two branches. The preventive side cannot do it all: nor
can the curative side.
Dr. Williams referred, courteously but unmistakably, to some of the duties that devolve
on the practising physician.  These are:
1. Diagnosis—Use of the Kahn test; a chronically suspicious habit of mind: a constant
keeping in mind of the possibility of syphilis.
2. Adequate reporting of cases.
3. Use of consultative services provided by the Government, which proposes to send
out regularly information for the physician's use. A travelling consultant is now
employed, and consulting teams will some day be available.
4. Adequate treatment—continued for a sufficiently long time to ensure cure. For
treatment purposes drugs will be supplied by the V. D. Control Department.
5. Painless methods of treatment, especially in intravenous therapy, as this has a distinct bearing on the attitude and co-operativeness of the patient.
6. Lumbar puncture regularly. Of 300 cases of syphilis done in Vancouver, 46%
showed neurosyphilis.
And other details. Dr. Williams has kindly agreed to furnish us with several short
papers similar to this, and we heartily applaud his action in this regard.—Ed.
THE PHYSICIAN AND VENEREAL DISEASE CONTROL
IN BRITISH COLUMBIA
Contributed by Dr. Donald H. Williams, Director, Venereal Disease Control.
The Problem—A challenge to the physician and the Division of V. D. Control.
1. It is the major problem in the field of communicable disease.
2. It ranks with cardiovasculo-renal disease and cancer as a major cause of morbidity
and mortality in the second half of life.
3. It renders many sterile, and spells disaster to the products of many conceptions.
4. The economic loss to employee and employer is great.
5. The social consequences to the individual, the home and society, expressed in loss
of happiness and undue burden on the innocent, cannot be overemphasized.
Page 49 The Solution—Close co-operation between the physician and the Division of Venereal
Control is essential.
1. Diagnosis—Depends upon a high threshold of suspicion for venereal disease.  The
diagnostic services of the Division of V. D. Control are available to the physician.
(a) History;
(b) Physical examination;
(c) Laboratory tests—facilities provided by the Division of Laboratories, Provincial Board of Health:
i. Blood serodiagnostic test—Kahn;
ii. Spinal fluid examination—Kahn and cell count most important;
iii. Smears for gonococcus.
2. Treatment—The function of the Division of V. D. Control is to make treatment
readily available to all and to facilitate the physician in its administration.
(a) Consultative Service:
i. Outline of treatment prepared by consultants of the Division of V. D.
control upon request from physician for any patient;
ii. Distribution of practical therapeutic information to all physicians—to be
prepared and distributed shortly by the Division of V. D. Control.
(b) Medication—Available upon request at Central Office, Division of V. D.
Control, 2700 Laurel Street, Vancouver:
i. Arsenicals—Neoarsphenamine, Tryparsamide, Bismarsen,;
ii. Heavy metals—Bismuth salicylate, Bismuth potassium tartrate, Mercury
succinimide;
iii. Sulphanilimide;
iv. Silver proteinate;
v. Miscellaneous—Potassium   iodide,   Potassium   permanganate,   Amniotin
suppositories, Malaria parasite, etc.
(c) Clinics of Division of V. D. Control—The provision of diagnostic, therapeutic
and educational services which are available to the physician.
3. Public Health Responsibility rests on the shoulders of the physician, health officer
and the Division of V. D. Control:
(a) REPORT ALL V. D. INFECTIONS;
(b) Trace the source and contacts of every venereal infection;
(c) Encourage premarital examination and blood Kahn;
(d) Take a routine Kahn early in every pregnancy;
(e) Utilize the services of the Local Health Officer in preventive aspects.
RADIATION THERAPY
(Continued from page 48)
function of medicine is "to cure sometimes, to relieve often, but to comfort and support
always," and coupled with this I would add an epigram of Harrington Sainsbury: "When
Death would come as a friend, let us not compel him to hostility since he must prevail."
Page 50 ancouver
enera
Hospita
pathological conferences
In view of the great variety of pathological material passing through the Laboratories
of the Vancouver General Hospital it was felt that some use should be made of this material
by presenting it in some fashion to the profession at large.,
Finally chiefly due to the efforts of Drs. A. B. Schinbein and G. F. Strong, it was decided
to hold weekly pathological conferences. Accordingly, on January 26th, 1938, the first
conference was held.
Through the co-operation of Dr. A. K. Haywood, a projectoscopic lantern for gross
-specimens was purchased and several alterations made in the Chemistry Building, such as
the hanging of dark curtains to better facilitate the use of the projectoscopic machine.
Since that time, weekly conferences have been held each Wednesday, from 12 to 1 p.m.,
and three cases from the preceding week's autopsies presented along with a resume of the
history and pathological findings on the other cases for that week.
It has been the aim to present cases of general interest, as much as possible, and also at
times rather unusual cases. These conferences are open to the profession in general, and
while they are in a sense an experimental endeavour, we are anxious to receive any suggestion which will make them more interesting or generally beneficial to all concerned.
Dr. Donald Munroe has very kindly acted as registrar and has been of paramount assistance in synopsizing histories and organizing the material for presentation. We are extremely
anxious to make these weekly conferences as interesting as possible and it is only by the
attendance that we can judge whether or not this endeavour is meeting with success.
The final meeting for the summer was held on Wednesday, June 29th; the meetings
were resumed this fall, being held each Wednesday at 12 noon in the Chemistry Building.
CLINICAL CASE
Chinese, aged 60; admitted with severe epigastric pain, normal temperature, and a
Tiistory of loss of weight, with the pain being present for one month—worse after meals.
Epigastrium rigid on admission. Sippy diet and morphia were given for the pain, which
gradually lessened with bed rest, and he was discharged in 20 days feeling well.
Investigation at that time:
(a) K.U.B. plate—no stones;
(b) Barium series—no filling defect, ulceration or obstruction.
(c) Barium enema—normal.
(d) E.K.G.—some evidence of coronary sclerosis.
(e) W.B.C.—on admission, 15,000.
Differential Dignosis on this admission was perforated peptic ulcer, coronary occlusion
and ca. of the liver.
Patient admitted one week after discharge with severe intractable pain in the epigastrium. Maximum tenderness over gall bladder area. Epigastrium rigid, pain only slightly
relieved by morphia grs. %. A few crepitations and soft friction rub were heard over the
left lower lobe in the anterior axillary line. Surgeons saw the patient and advised medical
treatment in view of chest findings. Differential diagnosis was now: (1) Ruptured peptic
ulcer; (2) perforated ulcer on previous admission, patient now having subphrenic abscess
with overlying basilar pneumonia; (3) primary lobar pneumonia, lower right lobe, with
referred symptoms to epigastrium.
Signs of pneumonia increased, and x-ray showed density at the right base. With sinapisms, cardiac stimulants and oxygen tent, the pneumonia cleared. Six days after admission
patient began to fibrillate and became dyspnoeic. On slowing the heart with digitalis,
"when the normal rhythm was resumed the patient developed a right hemiplegia, following
which the chest signs again increased.  The patient this time developed basilar pneumonia
J*age 51 on both sides. This again cleared on treatment; patient's breathing became easier and he
again became quite rational. On the twelfth day after admission patient again collapsed
with severe pain in the epigastrium. Shortly after this friction rub was heard 1 inch inside
the apex in the precordium. The patient died in 6 hours.
Autopsy Explanation.—On the first admission patient had a coronary occlusion, with
the development of a thrombus at the site of the infarct in the wall of the right ventricle.
The severe pain on the second admission was due to a piece of the thrombus forming a
pulmonary embolus, pneumonia developing on top of the lung infarct. When patient's
heart was slowed with digitalis, after having been fibrillating for two days, a piece of
thrombus from the left auricle lodged in the brain, causing his right hemiplegia. With the
diminished movement of the right chest hypostatic pneumonia developed, signs of which
cleared with treatment. Following this the patient developed a second caronary occlusion,
this time apparently the descending branch of the left coronary, as a friction rub was
heard anteriorly.  The patient died of myocardial failure.
A SURVEY OF EPILEPTICS FROM OUTPATIENT DEPT.
Dr. S. E. C. Turvey : Dr. F. Turnbull.
Dr. Turnbull:
"Dr. Turvey and I have recently conducted a survey of epileptics in the Outpatient
Neurological Clinic. We have been able to procure the records of 61 cases treated in the
past four years by ourselves. During the last two years the work has been done almost
solely by Dr. Turvey. Regarding the type of investigation of cases of epilepsy, the records
kept in the Outpatient Neurological Department are probably more complete than those
in any other department, and if the survey has done nothing else it has at least served to
indicate where we might improve our records. It seems as though, if our Outpatient
records are to serve any purpose at all, legible diaries must be kept.
"There were approximately 70 cases during this four-year period. It is a very small
group considering the size of Vancouver. About one in 250 is subject to convulsive
seizures, so that there must be well over one thousand cases in Vancouver. Of these, possibly two-thirds would fall into the Outpatient category. These patients do not come to
the Outpatient Department for two reasons: (a) they may be unaware that there is a
clinic for epilepsy, and (b) the doctors do not consider it worth while for the patient to
attend the clinic.
"There is a high percentage of mental deficiency in the patients who come to the clinic.
On the other hand, in private practice the percentage of mental deficincy is low and the
epileptic seizures are mild. A large percentage (over two-thirds) of the patients are over
21. However, not more than 20% of epilepsy starts after 20. It merely happens that we
get cases late in the disease.
"Regarding the case history, it is surprising to note the number of cases where the
physicians have insisted that the disease was not epilepsy: this only amounts to delaying
proper treatment.
"An x-ray/of the skull was taken in 45 cases and should have been taken in all. One
showed calcification which pointed to a brain tumour. Encephalography was done on only
eight of these cases and four showed abnormal findings. This unfortunately means four
days' stay in hospital and some patients have to wait months for admission. We should
have a better system of admissions. Blood Kahn was found to be positive in only two cases.
Most of the syphilitic cases are treated by their own physicians and are not sent to the Outpatient Department. Of the 61 cases, a satisfactory diagnosis as to the exact cause of the
disease was arrived at in only 15 cases (25%). In a further 12 there was obvious mental
deficiency, indicating that the brain was congenitally below normal. Regarding the diagnosis of "birth injury," we were very canny about making that diagnosis because of the
possible reflections on the profession. There was not sufficient justification to consider
arteriosclerosis as the cause of the fits. The brain cyst case was the most interesting case in
the group—this child had a congenital hemiplegia. The examination included an encephalogram which showed the cyst to be taking up most of one lobe. There was one case of
encephalitis made on the basis of the encephalogram.  If more encephalograms were made,
Page 52 more patients of this type would be found. Following an infection the patient develops
severe headaches, and following this there is the development of fits. There was one case
of encephalitis associated with measles."
Dr. Turvey:
"Most of these patients only come to Outpatients after they have had epilepsy for a
long time—months or even years. Not one patient had had adequate treatment before
coming to the Clinic.  Not one case was controlled.
"When the patient comes to the Clinic the history is taken from the patient, and if a
relative or friend accompanies him it is explained what they must watch for in each subsequent fit. It usually takes about three visits before you have all the data you want. The
patient is asked how he feels after the attack, i.e., headache, weakness, etc. The physical
examination must be painstaking. One case came in with a field defect in one eye, which
pointed to a brain tumour. This man eventually died from a brain tumour—he had to wait
three a"nd a half months for admission to hospital although his slip was marked urgent.
Young and new cases are given x-rays and lumbar punctures. The old cases are not done—
this is a gross error. A lumbar puncture was done on one of these latter today and a positive Kahn found. Usually the patient is started on phenobarbitol, not because it is better
than bromides but bromide starts a rash. Tablets are much more easily dispensed and
handled by the patient. Grains 1 l/z once a day—if necessary up to six times a day—are
given. It is put up until they are so drowsy that they can hardly carry on. This is combined with bromides and the patient is continued on this combined therapy for six to
nine months.
"Treatment.—Bromides, 5; phenobarb., 34; both, 22; brom. rash, 8.
"Results of treatment.—Cured, 1 year, 10; improved, 33—total, 43.
"Age group.—0 to 10, 6; 10 to 20, 8; 20 to 30, 21; over 30, 26—total, 61.
"Two died from brain tumour. Some cases contiriued to have fits on both phenobarbital
and bromide. These patients were put to bed for three months in a quiet room and kept
half doped. In all three cases of this type the patient was free of fits in the three months
period, but on going around the house again had a recurrence of fits. This brings us to the
question—how long should treatment be continued? Three years. If you finally get free
of attacks after two years the cause may still be there. One boy was free of fits for three
years and five months. The treatment was stopped and he has had twelve fits."
Dr. Lowrey: "What are your experiences regarding the use of phenobarb. and bromides in the treatment of petit mal and grand mal? A doctor in the East says that phenobarb.
should be used for petit and bromides for grand mal, and that very little effect is obtained
when they are used vice-versa."
Dr. Davidson: "Regarding the complications, I should like to ask about the x-ray of
the skull. How many had positive findings? In doing mental work (mental deficiency
with epilepsy) probably the deficiency is there, or probably, as Dr. Turnbull has said, there
was a congenital defect in the beginning. One young girl was completely free of seizures,
and then a brain tumour flared up.  She had no seizures when on bromides."
Another doctor asked how much ideopathic epilepsy is hereditary, and Dr. Palmer
replied that ideopathic epilepsy usually occurs in a patient with a family tendency to
migraine.
Regarding the bromide rash, Dr. Hunt remarked that luminol will give a rash too.
Dr. Turnbull: "There were only two cases of petit mal. Experience shows that
phenobarb. is more effectual in petit mal. However, a man in the States got excellent results
with bromides and used hardly any phenobarb. You can detect patients who will develop
a bromide rash. Phenobarb is much more convenient to handle. Regarding Dr. Davidson's
question re x-ray of the skull, the percentage was very low. Yet in those cases where the
x-ray did show something the information was of paramount value; one was a brain
tumour. Regarding luminol rash, we did see it sometimes, but not nearly as frequently
as bromide rash. We have had to change some patients back to bromides because of the
rash. It is very rare."
Page 58 Dr. Turvey: "In private practice I have had only three cases out of a series of forty
rhich were run on a ketogenic diet alone. They were given no drug. It is a very expensive
iet and it is very hard to get people on it, especially children. It is not very reliable. In
tie matter of migraine being associated with epilepsy, I do not think there is any association
etween the two. In the Eastern States they do report allergic epilepsy." *
Regarding the question of hereditary epilepsy, Dr. Davidson was of the opinion that
: is a matter of the individual and not of the stock. Dr. Coburn asked whether in-breeding
tad anything to do with it and Dr. Davidson said that he did not think so.
III.—TWO CASES OF DISEASE OF THE LIVER.
Dr. F. N. Robertson, Dr. A. W. Bagnall.
Dr. Bagnall was unfortunately unable to be present. The cases were presented by Dr.
^hristopherson.
A) Toxic hepatitis.
This patient was admitted on August 22nd, with the chief complaints of nausea and vomiting for two
lays, pain in the right lower chest. He had had diarrhoea for two or three-day periods in the last two months.
Jp till two weeks ago this man was employed in a cannery. Since then he dissipated his earnings on alcoholic
leverages—a bottle of gin a day—and at the time of admission to hospital had developed quite a marked
remor. In the last week he had developed a cold with cough and pain in the right lower chest. The nausea
md vomiting had become worse in the last two days. His family and personal histories were negative. He has
10 history of syphilis or GC. Physical examination showed a well developed, well nourished adult male with
i high colour to his cheeks and a very definite tremor. He was quite rational. Head and neck were negative
ixcept for a head cold. The chest showed slight diminution of breath sounds and diminished motion in the
right lower chest with distant breath sounds and a distant to-and-fro rub was heard. There was no evidence
>f any moisture. Abdomen: The abdomen moves freely. It was resistant over the whole right abdomen with
tenderness in the lower right quadrant with some rebound pain. No masses were felt in the right upper quadrant. The liver was palpable 4 inches below the costal margin and quite tender. Reflexes hypoactive; rectal
negative. A diagnosis of toxic hepatitis was made. On discharge on September 14th the liver had decreased
in size to one finger breadth below the costal margin.
The patient was re-admitted on October 17th with the chief complaints of nausea and vomiting and
pain in the abdomen developing throughout the past week. This time the patient had been drinking loganberry wine, which resulted in the gradual onset of the above symptoms. Examination on admission showed
the liver to be down again four finger breadths and quite tender. Laboratory findings—Kahn and urinalyses
negative.  Icteric index 5.  On the first admission the Brandenberg was negative.
On the second admission the icteric index was 13; N.P.N. 93; creatin 9.3. On October 26th—N.P.N.
53; creatin 2.5; blood urea .4; W.B.C. 10,100; eos. 4; monos. 2;; polys 48; lymphs 47.
(B)  Gumma of the liver or luetic cirrhosis.
This patient was admtited in March of this year for a pleurisy with effusion which was tapped and subsequently found to be of tuberculous origin. On routine examination he was found to have a positive blood
Kahn and enlarged liver to four finger breadths below the costal margin. This liver condition was considered
to be of luetic origin. He was started on adequate treatment of pot. iodide and bismuth, with subsequent good
results. While in hospital in March and April he had six injections of .13 gms. of bismuth. He was discharged
on May 29th and appeared at the Government Clinic. He has since had the following injections of metallic
bismuth: six l/z ccs, four % ccs> six 1 cc- Today his general condition has improved a great deal, showing a
gain in weight, and he has been able to resume his occupation. The liver is now one finger breadth below the
costal margin. The improvement in his general condition is not considered due to the antiluetic treatment
but to the clearing up of the tuberculous lesion. The diagnosis made in this case is gumma of the liver or
luetic cirrhosis. Laboratory findings are all within normal limits.
(A) Dr. Robertson remarked that this was the beginning of hepatic sclerosis. Because
of the high N.P.N., he said, you can rule out infective processes in this man.
In reply to Dr. Hodgins' question about the infective idea, Dr. Robertson said that the
leucocytes would certainly behave that way. It is a curious thing, he said, that in both it
was preceded by an alcoholic bout— "I would take it that the alcohol was the cause."
Dr. Harrison: "Because he had an infection, alcohol would do this?"
Dr. Robertson: "Yes."
(B) Dr. Harrison remarked that it is quite interesting to contrast these two cases of
diseases of the liver, regarding which there is such a great amount of detail.
Dr. Hodgins said that the patient had improved markedly and is now apparently well.
Regarding the treatment, Dr. Hodgins asked whether the bismuth should be stopped
now, and enquired as to the proper time and amount—presupposing the diagnosis is correct.
Page 54 NEWS AND NOTES
Dr. W. T. Kergin of Prince Rupert returned from Eastern United States and Canada.
Dr. L. W. Kergin of Prince Rupert leaves for a visit to Eastern Canada and hopes to
take in the Interstate Post-Graduate Assembly at Philadelphia.
Dr. W. Leonard of Trail has returned from a week in the Happy Hunting Ground
around Vernon.
Dr. M. E. Krause of Trail is taking a well-earned holiday for a couple of weeks.
Work is progressing rapidly on the new hospital wing and nurses' home in Rossland.
It will be completed this winter or in the early spring, and will be one of the best-equipped
and finest buildings in the Province.
*
Our correspondent, Dr. J. S. Daly of Trail, noticed in Spokane over the Thanksgiving
week-end the familiar faces of Doctors W. Leonard, M. E. Krause, J. M. Crawford and
H. R. Christie. He also called on Dr. Dave Harten, who asked to be kindly remembered
to all the doctors of the Province.
Our genial friend Dr. W. Laishley of Nelson, in his Silver Bullet, ran into and terminated the life of a fine buck. The impact smashed his grill and fender, but the doctor
states that the steaks were delicious. However, it does seem to us an expensive, though no
doubt very novel, way of hunting.
GENEROSITY AND BENEVOLENCE
(From Professional Anecdotes, edited by Edward Jenner.)
A surgeon, in bleeding a lady of quality, had the misfortune to prick an artery; the
result of which was the death of the patient. In making her will, she had the generosity to
leave the surgeon, who was extremely affected, as may well be supposed, a life-annuity of
eight hundred livres, as much for the purpose, said the will, of consoling him, as to oblige
him never again to bleed anybody so long as he lived.
There is a similar instance almost to the above in the Journal Encyclopedique of the
15th of January, 1773: A Polish Princess having experienced the same misfortune, two
days before her death, she caused the following to be inserted in her will:
"Convinced of the injury that my unfortunate accident will occasion to the unhappy
surgeon who is the cause of my death, I bequeath to) him a life-annuity of two hundred
ducats, secured by my estate, and forgive his mistake from my heart. I wish that this may
indemnify him for the discredit which my sorrowful catastrophe will bring upon him."
One sighs for such patients and such a forgiving spirit. The "follies of 1938" would
hardly, in these days of litigation and liability insurance, meet' with such lenient and generous treatment.—Ed.
Page 55 MEMBERS of THE GUILD
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valuable synthetic vasoconstrictor
NEO-SYNEPHRIN Hydrochloride
Neo-Synephrin is more sustained in action and of lower toxicity than epinephrine or ephedrine, is so stable that it may be sterilized by boiling,
and is comparatively free from side reactions.
EMULSION
SOLUTION
%% (1-oz. bottles with dropper)
% % (1 -oz. bottles)
1% (1-oz. bottles)
JELLY        l/2% (in collapsible tubes with applicator)
Sample and literature on request.
EMULSION
SOLUTION
JELLY
Frederick Stearns & Company of Canada, Ltd.
WINDSOR ONTARIO
Makers of Kasagra.
Detroit, Mich. New York, N.Y. Kansas City, Mo.
San Francisco, Calif. Sydney, Australia. Some Medical Aspects of
ALL-BRAN
as an aid to elimination
1 Medical authority concedes that
"bulk" provided by iood residue
assists efficient elimination.
2 Medical authority ascribes to
vitamin Bi the important property oi
improving the tonus oi the intestines.
Regular use of Kellogg's All-Bran
supplies helpful "bulk." This food
also contains vitamin Bi in appreciable quantity.
These facts provide a sound medical basis for recommending Kellogg's All-Bran as a valuable aid in
the prevention or relief of constipation due to lack of "bulk." All-
Bran is made by Kellogg's in
London, Ontario.
*****
■FOR' W
CONSTIPATIONS
DEPENDABLE
EFFECTIVE
SAFE
# URASAL is a non-toxic urinary antiseptic which truly acts like a flash. The
presence of formaldehyde in the urine
can be demonstrated within 11 minutes.
• URASAL dissolves uric acid and relieves the pains of rheumatism, sciatica
and gout. It has long been used in
treating high blood pressure and general auto-intoxication.
• URASAL attacks hidden foci of infection. It is useful as a preventive of
urinary and bladder infection. It rapidly clears up cystitis and pyelitis.
• URASAL presents, in the form of a
granular effervescent salt, a balanced
combination of Hexamine, Piperazine,
Lithium Carbonate and Benzoic Acid.
• URASAL is entirely safe in all dosages. Yet its action is rapid and dependable.
FRANK   W.   HOR
MONTREAL
NER    LIMITED
CANADA A scientific adaptation of
the principles of vaccination
for use in surface lesions
An ointment containing aged
cultures of Streptococcus,
Staphylococcus and
B. Pyocyaneus
INDICATIONS    111.
Minor burns, Wounds, accidental or
surgical Bruises, Blisters, Frostbite,
Cracked skin, lips or nostrils, Varicose
ulcers, Bedsores, Long-standing ulcerations, Skin infections generally.
PROPIDEX is offered in handy tubes
of 1 oz.
?*&
6*1
/
POULENC FRERES
204 Youville Square, Montreal
Please send me at once a sample of Propidex Ointment.
Name..  . ..
Address.
This offer is g-ood only in the Dominion of Canada.
PROdUCt The New Synthetic Antispasmodic
Trasentin "Ciba"
(Diphenylacetyldiethylaminoethanolester-hydrochloride)
SUPPRESSES SPASMS OF THE GASTRO-INTESTINAL
TRACT, GENITO-URINARY SYSTEM AND
OTHER SMOOTH MUSCLE ORGANS
Tablets—bottles of 20 and 100. Ampoules—boxes of 5 and 20.
1 tablet or 1 ampoule contains 0.075 grm.
of the active substance.
CIBA COMPANY LIMITED
MONTREAL
lK"!*M'M*M"WM"N
13 th Ave. and Heather St.
Exclusive  Ambulance  Service
FAIRMONT  80
PRIVATE AMBULANCES AND INVALID COACHES
WE SPECIALIZE IN AMBULANCE SERVICE ONLY
J. H. CRELLIN
W. L. BERTRAND Nutttt Sc
®I|0ttt00tt
t
2559 Cambie Street
ancouver
, B. C.
Colonic
Irrigation
Institute
Superintendent:
E. M. LEONARD, R.N.
Post Graduate Mayo Bros.
Up-to-date treatment rooms;
scientific care for cases such as
Colitis, Constipation, Worms,
Gastro-intestinal Disturbances,
Diarrhoea, Diverticulitis, Rheumatism, Arthritis, Acne.
Individual Treatment $ 2.50
Entire Course $10.00
Medication (if necessary)
$1 to $3 Extra
631  BIRKS BUILDING,
VANCOUVER, B. C.
Phone: Sey. 2443
506-7 CAMPBELL BUILDING
VICTORIA, B.C.
Phone: Empire 2721
■
AN   ANCIENT   REMEDY
FOR  AN   OLD   DISEASE
SULPHUR >....
effectively
ADTUI
1 used
DITI
•
in
c
Hixinmno
.. especially in combination with cal-
cium, iodine and lysidine (ethylene-
ethenyldiamine) in the form of
LYXANTHINE
AST
IER
Relieves pain, subdues swell
ing,    removes    stiffness,    in
creases articular motility, se
cures rapid removal of peri
articular infiltration, promotes
active elimination of irritant
and toxic waste.
ADMINISTERED PER OS
Non-irritant, does not disturb
digestion. In usual dose, chola-
gogue; in larger dose, laxative.
Usually renders use of salicyl
ates,  aspirin,  or  other  anal
gesics unnecessary.
nflCI?* 1 teaspoonful,
UVOLf weu dissolved
in a glass of water, on
an empty stomach, every
morning   for   20   days.
Rest 10 days. Repeat, if
necessary.
Please send Sample and Literature
of Lyxanthine Astier.
Dr „
L2BVMA
Dr. P. ASTIER LABORATORIES
36-48 Caledonia Road, Toronto STEVENS' SAFETY PACKAGE
STERILE GAUZE
is a handy, convenient, clean commodity for the bag or the office. Supplied in one yard, five
yards and twenty-five yard packages.
ESTABLISHED   NEARLY  A
""   .CENTURY*""
B. C. STEVENS CO.
Phone Seymour 698
730 Richards St., Vancouver, B. C.
s.
BOWELL
&
SON
Distinctive   Funeral
Service
Phone 993
66 SIXTH STREET                                          1
STEW WESTMINSTER, B. C.
Breaks the vieious 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-p
normal menstrual cycle,   flfi
% MARTIN H. SMITH COMPANY
^ ISO  LAFAYITTE STMfT. NEW YORK,  N. Y.
Full formula and descriptive
literature on request
Dosage:   l 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.
1 of the
New G-E Modir F-3 IWlaBRrX-Ray Unit
WHY accept mere claims about
the worth of any portable x-ray
unit? G. E. doesn't ask you to take
its word for the value of the F-3 to
you in your practice. Rather, it would
have you judge this fine unit right
in your own office.
See for yourself how compact,
powerful, flexible, and easy-to-operate
the F-3 really is. Pick it up, carry it,
use and operate it exactly as it will
be used—on your office desk or table.
You '\fill get convincing, personal
proof—the F-3 will speak for itself.
To every member of the medical
profession who realizes a need in his
practice for a portable x-ray unit,
G. E. extends this no-obligation invitation: If you're interested in judging
the value of this fine unit by actually
seeing and using it, just sign and mail
the coupon, today. We will arrange
with you for an interesting demonstration at your convenience.
j-— SIGN AND MAIL TODAY—t
GENERAL @ ELECTRIC
X-RAY CORPORATION
1012 JACKSON   IIVO. CHICAGO,   IlllfiOIS
I'm interested in judging the
value of the Model F-3 Unit to
me in my practice. Without obligation, arrange with me for a
working demonstration.
Name	
Address .
A2011 MULTIVITE
(Vitamins A, Bi, C and D)
The deleterious effects resulting from a general all-round vitamin deficiency are
not always sufficiently apparent as to permit of exact diagnosis; they are,
nevertheless, often of so serious a nature as to cause a condition of general
malaise and subnormal health. Effective prophylactic measures are ensured by
the daily administration of Multivite, its contents of Vitamins A, Bi, C and D
exerting a far-reaching beneficial influence on health and well-being.
Vitamin A in Multivite fulfills the important function of aiding in the preservation
of the integrity of the mucous membrane, and Vitamin B^, in preventing the
accumulation in the tissues of pyruvic and lactic acids and the consequent impairment of nerve function (such impairment playing an important part in many
forms of neuritis). Finally, Vitamin C (the anti-scorbutic vitamin) and Vitamin
D (the anti-rachitic vitamin), fill important roles in the maintenance of physical
fitness.
Multivite is presented in the form of a palatable pellet, being particularly convenient for administration to adults.
Stocks of Multivite are held by leading druggists throughout the Dominion,
and full particulars are obtainable from:
THE BRITISH DRUG HOUSES (CANADA) LTD.
Terminal Warehouse Toronto, 2, Ont.
Mlvt/Can/3811
tIDount {pleasant XftnbertaMno Co. %tb.
KINGSWAY at 11th AVE. Telephone Fairmont 58 VANCOUVER, B. C.
R. F. HARRISON W. R. REYNOLDS s
ARTHRITIS
SYNOVITIS
FIBROSITIS
\J NE of the chief principles of treatment is the
local application of prolonged, moist heat—
efficiently supplied by the medicated cataplasm
Antipklo gtetine
|   It is also a satisfactory supplementary treatment to
ELECTROTHERAPY, to augment the efficacy
of the rays.
Sample on Request.
THE DENVER CHEMICAL MFG. CO.
153 Lagauchetiere St. W. Montreal
Made in Canada w
i^fe
Here
#*«^
"*?*-N*<8!®iSSS*#
1
^M
§»
Lest we forget—we who are of the
a vitamin D era—severe rickets is not
yet eradicated, and moderate and mild
rickets are still prevalent. Here is a
white child, supposedly well fed, if
judged by weight alone, a farm child Example of severe rickets in a sunny clime,
apparently living out of doors a good
deal.   This boy was reared in a section
having a latitude between 37° and 42°, where the average amount of fall and winter
sunshine is greater than that in the major portion of Canada. And yet such stigmata of
rickets as genu varum and the quadratic head are plain evidence that rickets does
occur under these conditions.
How much more likely, then, that rickets will develop among city-bred children
who live under a smokepall for a large part of each year. True, vitamin D is more or
less routinely prescribed nowadays for infants. But is the antiricketic routinely
administered in the home? Does the child refuse it? Is it given in some unstandardized
form, purchased from a false sense of economy because the physician did not specify
the kind?
A uniformly potent source of vitamin D such as Oleum Percomorphum, administered regularly in proper dosage, can do more than protect against the gross
visible deformities of rickets. It may prevent hidden but nonetheless serious malformations of the chest and the pelvis and will aid in promoting good dentition. Because
the dosage is measured in drops. Oleum Percomorphum is well taken and well
tolerated by infants and growing children. Rigid bioassays assure a uniform potency
—100 times the vitamins A and D content of cod liver oil*. Oleum Percomorphum,
moreover, is a natural product in which the vitamins are in the same ratio as in cod
liver oil*.
Oleum Percomorphum offers not less than 60,000 vitamin A units and 8,500 vitamin D units (International)
per gram. Supplied In 10 and 50 c. e. brown bottles, also in 10-drop soluble gelatin capsules,
each offering not leu than 13,300 vitamin A units and 1,850 vitamin D units, in boxes of 25 and 100.
*U.S.P. Minimum Standard
MEAD JOHNSON & CO. OF CANADA, LTD., Belleville, Ont.
"* enclose professional card when requesting samples of Head Johnson products to co-operate in preventing their reaching unauthorized persons. b
After 40 years**
In the same year that the British Columbia
Medical Association was formed—1898 —
Leslie G. Henderson came to Vancouver and
associate dhimself with the distribution of
pharmaceutical supplies; and as proprietor of
the Georgia Pharmacy has been serving the
Medical Profession for approximately 3 5 years
in Vancouver.
This store provides a pharmaceutical service
in keeping with the needs of the medical profession today.
OHM Me.
MIOKT
Open night and
day — Seymour
2263
GEORGIA PHARMACY
U I M  I
W.OGOROIA
STRUT
i&mtn $c Ijamra %tb.
Establish*** 1S93
VANCOUVER, B. C.
North Vancouver, B. C.   Powell River, B. C. Hollywood Sanitarium
Limited
For the treatment of
Alcoholic, Nervous and Psychopathic Cases
Exclusively
Reference—B. C. Medical Association
For information apply to
Medical Superintendent, New Westminster, B. C.
or 515 Birks Building, Vancouver
Seymour 4183
Westminster 288
ROY WRIGUCY PRINTING
>& PUBLISHING CO. LTD.

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