History of Nursing in Pacific Canada

The Vancouver Medical Association Bulletin: October, 1955 Vancouver Medical Association Oct 31, 1955

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Full Text

 THE
BULLETIN
VOLUME XXXII.
OCTOBER, 1955
NUMBER 1
t?l
J898.
ro
VANCOUVER MEDICAL ASSOCIATION
AND OFFICIAL PUBLICATION OF
British Columbia Division - Canadian Medical Association
In This Issue:
THE OSLER LECTURE, 1955 -   By Donald H. Williams, M.D.
ANTENATAL CARE - SOME COMMON COMPLICATIONS -
By A. B. Nash, M.D., Victoria, B.C.   -
28
The Biological Dressing
H ERISAN
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with the addition of Bacitricin and Tyrothricin.
Topic and safe treatment of microbial infections: pyogenic dermatoses,
degenerated, damaged or infected tissues, etc. . . .
Tubes of Vt and 1 oz.      •      Jar of 1  lb.
Over half a century of devotion to medical advance in Canada.
1955
iP £ I? V
CIRCULATION 1950
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1952
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1954
Alflorone*
1955
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2.5 mg.-5 mi
(scored)
Indications:
BRONCHIAL ASTHMA
INFLAMMATORY SKIN CONDITIONS
IIHHPijW
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ward hormonal effects*
SHARP^
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is supplied as 2.5 mg.
and 5 mg. scored tablets
in bottles of 30 and 100.
TORONTO 16. ONT.
OF
♦Trade Mark This is the Osier number of the Bulletin, and it is with great pleasure that we
publish in it the delightful and inspiring address given by Dr. Donald H. Williams,
the 1955 Osier Lecturer. We cannot say more in praise of this lecture than to say that
in our opinion it is fully up to the highest standards set by other Osier Lecturers.
It is well, once in a while, to pause in our busy medical life and refresh ourselves
by drinking of the Pierian Spring which gushes out from the life and example of this
great man, William Osier. What is there about him that so constantly inspires us? He
was a great clinician, he was a great teacher, he was a vivid and delightful speaker
and writer: he was, above all, a good man, a good friend, a good physician. But this
is not enough to ensure immortality and Osier bids fair to be one of the immortals.
In his book, Heroes and Hero Worship, Carlyle says this of the great man:
"One comfort is, that great men, taken up in any way, are profitable company.
We cannot look, however imperfectly, upon a great man, without gaining something
iby him. He is the living light fountain, which it is good and pleasant to be near.
jThe ligljt which enlightens, which has enlightened the darkness of the world ... in
panose radiance all souls feel that it is well with them. On any terms whatsoever, you
will not grudge to wander in such a neighbourhood for a while.
That is what we do at these Osier Lectures, and "do not grudge to wander in
such a neighbourhood for a while." It is good for us all, good for the Lecturer, who
interprets to us a facet or aspect of this great man's character and life—good for us
who hear and receive inspiration.
One of Osiers great gifts to us, is his insistence that a full life is not merely a
busy life—that many other things enter into it—that we should have other interests
beside our work, important as that is—and that these other interests will lead us into
paths of plenty and paths of peace and genuine happiness. As one reads his life, and
his writings, one stands appalled at the immense variety of things in which he was
interested. Books, of course—one often feels that he must have read every book that
was ever written—but more than books, he was interested in people. To him, his
friends and his friendships, were an absolute necessity of life—one reads how in the
middle of a crowded day, he must needs stop and go and see some friend of his, and
have a chat with him: he felt the joys and the sorrows of all the world thick on him.
He was possessed of an enormous vitality, and as we read his life, we see that he was
always starting something. To quote Carlyle again, he was the lightning spark to
handle the fuel of other men, the spark without which the fuel would not ignite. Or,
in more modern language, he was the perpetual hormone—the starter. He was always
starting a library, or a museum, or a club, or something where knowledge could be
fostered. And always he was the first to contribute to such efforts, as we of Vancouver
know.
So it is that everywhere we find groups of medical men commemorating the life
and doings of this great man, gladly spending time to sit at his feet and "gain something by him" and so we feel that this Osier Lecture is the highlight of our association's
year:to be looked forward to each year with keen anticipation.
Page 9 LIBRARY HOURS:
Monday to Friday. p 9:00 a.m. to 9:00 p.m.
Saturday 9:00 a.m. to 1:00 p.m.
RECENT ACCESSIONS:
Practical Obstetric Problems by Ian Donald. Lloyd-Luke. 1955.
A History of Medicine by Ralph Major. C. C. Thomas. 1955.
Casimir Funk - Pioneer in Vitamins. Dodd Mead & Co. 1955.
Abdominal Operations by Rodney Maingot. 3rd edition. Appleton-Century. 1955.
Modern Practice in Anaesthesia by Frankis T. Evans. Butterworths. 1955.
Connective Tissues, Transactions of the Fifth and Final Conference, February
8th, 9th and 10th, 1954. Josiah Macy Jr. Foundation.
Advances in Pediatrics, vol. 7. edited by S. Z. Levine. Year Book. 1955.
Surgical Forum. 40th Clinical Congress of American College of Surgeons. W.
Saunders.  1955.
Adventures in Physiology by Sir Henry Dale. Pergamon Press. 1954.
■A-
BOOK  REVIEW
MYOCARDIAL INFARCTION
In 1946 the American Heart Association established a committee on anticoagulants with the mission of evaluating this form of therapy in myocardial infarction.
This book is a full report on this committee in the study of 1,031 cases by 100 men
in 16 centres in the United States. The major hypothesis was that anti-coagulant
therapy could influence favourably the prognosis in myocardial infarction and the
figures presented are of convincing interest. Patients admitted on even days were
controls and were not given anti-coagulants. Those admitted on odd days were
members of the treated group. All were observed for six weeks and the study took place
in the years 1947, 1948. The book affords the very fullest description of myocardial
infarction as a clinical syndrome and of myocardial infarction as a pathological process.
The use of Dicumerol is detailed along with Heparin. Tromexan is adequately
described in the appendix. (In the series Dicumerol was used throughout and it was
initiated with Heparin in 1/5 of the cases). Briefly the figures of the series are:
1. The control group showed 41.8 thromboembolic incidents as against 13.1 in
the treated group.
2. Even during the first three days of anti-coagulant therapy (before satisfactory
prothrombin levels were established) the treated group showed a complication
rate of 7 per thousand days as compared to 16.4 complications in the control.
3. After the fourth day to the end of treatment the complication rate per thousand days were 2.8 treated versus 12.3 for the untreated.
4. Mortality in control group 23% versus 16% in the treated group*
Page 10 Their conclusions are based on their findings and experiences as follows:
Since thromboembolic complications were high during the first week after the
attack (10%) and reached a peak during the second week (14%) anti-coagulants
should be begun as soon as possible after the attack and fast acting anti-coagulants
(i.e. Heparin or Tromexan) should be used at least until adequate prothrombin levels
can be secured with Dicumarol. Also in view of the incidence in succeeding weeks
(9% down to 3%) anticoagulants should be continued for four weeks.
Although this work was done in 1947 and 1948 as previously reported but less
briefly it is stimulating to see the well prepared tables and charts. The original wave
of enthusiasm was supported by their preliminary presentations. Since this work was
done considerable experience has been acquired in the use of anti-coagulants in myocardial infarction. The most recent publications call for a somewhat more conservative
exhibition of these drugs. Nevertheless this book will remain the recognized reference
for the whole subject.
£3 e. c.
POSITION VACANT
The Canadian Arthritis and Rheumatism Society/ B.C. Division,
requires a full-time Assistant Medical Director to assist in an expanding treatment and education program within British Columbia. Duties
to commence not later than December 31, 1955. Applicants should
have a special interest in rheumatic diseases and have or be eligible
for certification or fellowship in Internal Medicine. Applications
sfhould'be directed to the Executive Secretary, C.A.R.S., B.C. Division,
645 W. Broadway, not later than November 30, 1955. Further information upon request.
MEDICAL SUPERINTENDENT REQUIRED
* (FULL TIME)
Excellent opportunity for Psychiatrist who will find complete and modern facilities
for treatment and study of acute psychiatric problems in sixty-five bed private
psychiatric hospital.
Dynamic psychotherapy and all recognized therapies are used as indicated. Accommodations meet varied individual needs. Facilities for the continued care of progressive
disorders requiring medical, psychiatric, geriatric, or neurological supervision.
Facilities include modern office in Vancouver to conduct diagnostic services and
therapeutic treatment for selected cases desiring non-resident care.
Member of National Association of Private Psychiatric Hospitals.
Our medical staff are aware of this advertisement and all replies will be treated
confidentially.
Please direct your inquiry to:
Secretary (Confidential)
HOLLYWOOD   SANITARIUM,
NEW WESTMINSTER,  BRITISH COLUMBIA.
* Appointment will  be made on or before Jan.   1,   1956.
Page 11 OSLER LECTURE
The lecture was inaugurated in 1921, during Dr. Fred Brodie's term o£ office as
President. This was shortly after Sir William Osiers death in 1919. It was DrJ
Brodie's idea that in view of Osiers interest in the Vancouver Medical Association!
and its Library, and as a permanent memorial to him, an annual lecture, to be known
as the "Osier Lecture", should be established.
In 1935, during Dr. Vrooman's presidency, it was decided to replace the honor!
arium then given to each lecturer with some permanent form of recognition. Permis-j
sion was obtained through the good offices of Dr. W. T. Ewing and Dr. W. W.I
Francis, Librarian of the Osier Library at McGill and a nephew of Sir William's, to
have reproduced the design of the Vernon Medal as a presentation plaque for the
Osier Lectures.
The bronze plaque, in its present form, inscribed with the name of the Lecturer
and bearing the inscription:
"Let us now praise famous men and our fathers that begat us." (Ecclus 64 verse
1.) has been adopted and a replica is presented each year to the member chosen for
this honour.
v-"-vl
Ml
n
m&wmm
ihy Tl
-m?M
wgieTmeroim
ymmiMMmmtiUMknniL-
mimAtA OSLER
In 1908, two years after the Library of the Association had been incorporated,
Osier sent the sum of $100.00 to Dr. J. M. Pearson to help towards the establishment
of the library. The letter which accompanied this donation has been framed and now
hangs in the library. Various photographs and other Osleriana are contained in a
small showcase in the library. These have been received from time to time as gifts
from those interested in the Osier association.
Page 12 THE OSLER LECTURES TO DATE
Lecturer
Title
(Founded 1921)
1921 Dr. W. D. Keith—Sir William Osier, Physician and Teacher.
1922 Dr. J. M. Pearson—Style of Writing Exemplified by Osier.
1923 Dr. G. S. Gordon—History of Medicine.
1924 Dr. B. D. Gillies—Recent Advances in Liver Function.
1925 Dr. F. J. Brodie-Aphasie.
1926 Dr. E. D. Carder-The Thymus Gland.
1927 Dr. G. E. Seldon—Medical Education.
1928 Dr. C. H. Vrooman—Development of our Knowledge Concerning Tuberculosis.
1929 Dr. H. M. Cunningham—Ourselves (Retaining the Art of Medicine).
1930 Dr. J. J. Mason—Study of a Personal Series of Hysterectomies and Myomectomies.
1931 Dr. R. E. McKechnie—Reminiscences of Forty Years' Practice.
1932 Dr. F. P. Patterson—Benign Tumours of the Bone.
1933 Dr. Glen Campbell—the Eye.
1934 Dr. J. G. McKay-Psychiatry.
J J J J
1935 Dr. Wallace Wilson—Goitre and the Background of its Ancient History.
1936 Dr. A. W. Hunter—Glimpses into Urology of the Past and Present.
1937 Dr. W. A. Whitelaw—Facts and Fancies in a little tour of the Gastro-intestinal
Tract.
1938 Dr. L. H. Appleby-Quo Vadis, Medicinal
1939 Dr. J. H. MacDermot—The Layman and the Doctors.
1940 (No lecture).
1941 Dr. G. F. Strong—Some Observations on Coronary Artery Heart Disease.
1942 (No lecture). 	
1943 Dr. D. E. H. Cleveland-The Fear of the Skin.
1944 Dr. T. H. Lennie—Goitre.
1945 Dr. Howard Spohn—The Employment of Leisure.
1946 Dr. A. L. Lynch—Sir William Osier and some of his Contemporaries.
1947 Dr. Bede J. Harrison—Medicine and Some Orthodoxies.
1948 Dr. Murray Blair-A Priest of Lucina (The Life of William Smellie.)
1949 Dr. Murray Baird-A Hundred Years Ago.
1950 Dr. George Davidson—Men of Osier's Time.
1951 Dr. H. A. DesBrisay—Dry Bones of Antiquity.
1952 Dr. Ethlyn Trapp—Modern Alchemy.
1953 Dr. Harry Pitts—The Influence of Pathology on Osier's Career.
1954 Dr. Frank Turnbull—Vancouver and Menzies or Medicine, on the Quarterdeck.
1955 Dr. Donald H. Williams—The Maimonidean Code.
Page 13 THE OSLER LECTURE FOR  195 5
THE MAIMONIDEAN CODE j|:..
By DONALD H. WILLIAMS, M.D.
"Inspire in me a love for my art and for Thy creatures."
This evening marks the thirty-third occasion upon which the Vancouver Medical
Association has commemorated the life and beneficent influence of Sir William
Osier. No Canadian physician has ever evoked more warmth of professional feeling, —
a response amounting to worship and adoration — as witness our presence here
tonight, thirty five years after his death. Osier, brightest gem in our professional
crown, was shared with our great and friendly neighbours to the south at John
Hopkins University and with our English compatriots at Oxford.
The fearful novice preparing himself for the Osier Lecture goes through the
purification ritual of drawing deeply of the inspirational waters from Cushing's "Life
of Osier", "Aequanimitas", and the "Memorial" volume, that moving tribute of
students and associates from across the face of the earth. After this humbling experience, selection of a subject for the lecture follows, and it seems natural to turn to
history, — to our rich medical heritage for the comforting re-assurance, and the
pleasures of reflective retrospection of accomplishment that it gives. Although I
propose to make reference to the past, it is mainly with current history that I would
like to deal this evening; and this because we are all acutely aware of the ground
swell of great events pending, of momentous change in our midst, and of an
engulfing threat of terrifying immensity.
Under the title of "The Maimonidean Code" I would like to refer to the
increasing breadth of the field of medicine and its changing scope, with special
reference to the position of the physician and the qualities required of him to play his
traditional role of leadership. It will become apparent as this subject is developed
what a great influence Maimonides, that prince of Hebrew physicians as Osier
called him, brings to bear upon the contemporary scene 750 years after his death.
Consideration of the dynamics of history requires the selection of comparative
arbitrary vantage points of time and place, and for our special purposes it suits to
relate these to Osier's life and to our own British Columbian locale, with some
specific reference to the Vancouver area. I would like to draw three comparative
pictures of medicine: that at the time of Osier's birth in 1849, at his death in 1919,
and at the present. It is proposed to outline significant changes and trends, certain
problems and perplexities facing us, suggest an answer to these, and hazard a picture
of medicine 35 years hence.
"1849 A.D." — The Shamanism of the Salish
Fifty-seven years after Captain Vancouver and Dr. Menzies sailed into English
Bay, Osier was born on the 12th of July 1849 in the tranquillity—slightly disturbed
by an Orange parade—of the Trinity Anglican Parsonage one mile north of Bondhead,
Ontario, a community of two hundred stump farmers on the edge of the brooding
primeval forest which stretched north over the Laurentian Shield to the Hudson
Bay. Two thousand miles westward on the Pacific coast of Canada the only evidences
in Burrard Inlet and English Bay of the white man's earlier visits were the effects of
his disease, his alcohol, and the "death Stick." The Salish Indians who had numbered
15,000 in Vancouver's time, were now reduced to 4,000. They lived on rocky
prominences of the elevated foreshore, their long split cedar log houses with gentle
roof pitch and without gables hidden in the evergreen forest edge. Here they made
baskets of dog and goat hair, wove blankets of geometric design, dug clams, fished,
and ate goat, deer, and berries.
Page 14 &
In 1849 the form of medicine among the Salish was essentially psychosomatic,
and intimately associated with the religion of Shamanism, whose unorganized priesthood of Shamans, or priest-doctors, cured the sick by clairvoyance, and controlled
ghosts and shadows. The Shamans of whom there were ten or even up to twenty
in a village were held in high respect. Even in those days the Vancouver area was
"over-doctored"! By exemplary conduct, severe discipline, and fasting, they attained
the strength to wrestle with evil and repel it. Their power lay in the possession of a
sacred bundle of eagle claws and split animal tongues imbued with supernatural
powers to cure illness, which they believed to be caused by the intrusion of a piece
of wood or stone into the body. Whooping, beating a bearskin drum, swinging
rattles with extravagant gestures, bowing, singing, dancing and weaving his body,
came the Shaman doctor from the forest to minister to his patient. After sprinkling
water from a wooden bowl, and sucking the painful area with a hollow tube, by
sleight-of-hand he produced the foreign object. No surgical tissue committee checked
on the nature of the specimen! Remuneration was on a "fee-for-service" basis with
immediate payment. The most prized possessions of the Salish — elkskin, slaves,
blankets, baskets, copper — were the media of payment, indicating the high value
placed on the medical care.
Thus, just over one hundred years ago at the time of Osier's birth the mysticism
of aboriginal medicine held sway in Vancouver where this evening we sit in modern
materialistic comfort. Darwin's "Beagle" was home and the famous account of its
voyages was being recorded. The scientific era on earth was just opening.
"1919 A.D." — Western Civilization and Scientific Medicine
In 1919 the sands of time ran out at the appointed three score years and ten
for the abundant life of Osier, just at the point in history when the earth's greatest
war had ended and a weary victorious population was returning from the battlefields,
assured of peace upon earth forever! In the seventy years since Osier's birth the white
hordes of western Christian civilization had poured onto the shores of Burrard Inlet,
overwhelming the complacent native Indian and squeezing him into the "reserves"
around the mouth of the Fraser River and along the north shore of the Inlet.
Science had become a religion for many. The "ding-dong" battle of evolution
was on. Out of the coffers of munitions profits, the coveted Nobel prizes were
being awarded to Jules Bordet for his work on immunity, and to August Krogh for
his studies on the motor regulation of capillaries. The Vancouver Medical Association
had been in existence 21 years and its library, started by Osier's gift of one hundred
dollars, was growing. The Shamans of the Salish were replaced by 703 persons
registered by the College of Physicians and Surgeons of British Columbia under
Provincial Government enactment to practise surgery, medicine, and midwifery.
The Provincial government was spending $15,000,000 on 507,000 citizens and,
not being too interested in preventive medicine, was employing only one full-time
medical health officer, besides twelve other persons, and spending a meagre $73,000
on public health. On the distant tip of wooded West Point Grey, Dr. Westbrook,
President of the University of British Columbia, had plans for a department of
bacteriology. Little general interest in health matters existed. The only voluntary
health agencies were the Victorian Order of Nurses, the B.C. Tuberculosis Society,
and the Canadian National Institute for the Blind, which was just starting its
merciful work. The modern concept of health insurance was non-existent, except for
a few contracts sold by private insurance companies, and a few doctor-contract
practices, sonje of which sold medical services for as low as twenty-five cents a month
per person.
Who among the prescient of 1919 could have foreseen the changes in the face
of medicine that thirty-five years were to bring—a period of time half that of Osier's
lifer* The seventy years from his birth to his death had seen mysticism replaced by
Page 15 #
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tiK^ijej^ajidwtgJ gkofires^rjesse^tial? elements! eofcitH^ healltfoi care
today, require large numbers of highly qualified persons.aaafevprofessionalBstaiusFU
I nurses, social workers, administrators,  statisticians,  sanitary engineers,  technicians,
J and a vast number of other personnel.  In 1919 the ph^kaan^^vgSj no^^u^teyt Jgjj:
I almost, alone professionally in the health field.   Today,H3y contrast/;!.5/0 doctors
to' Britlsn^Cohffi^gsg'onsrat^^ ^smal^^ou^ ^rnBftg^^he^^OjOOO
persfchfe p^«lferf^t|^l^ ^|^espd3p1 YiHidi2noq2ar
^^btlrer recfenr rjfeneffic^nt ^cnatmefir emiffiasis, f pne •, of degree rather man
rM<fAn^?fSviha¥rrjP tne7 ||roW& ;J6r7 flie c&ncijfft of7 . social medicine , firiot to be
confused with, "socialized Medicine ,na ferm wiffi ariermrery different connotafeiorO.
^^for^ost71]^^^ jp. vj. Iwle. who
§b^ri£ffie3iir^tdShai£ 6¥ 88Sar)^em8ine Ja ^Ene" Uriiversity of f6Sfo^nrc^oWiri3
twenrjFrive years of mstinguished clinical practice as an rnfernist. r Inione otrthe
most, significant medical presentations in recent ■yearsjn)tte rin ins paper,r   Social
j Me'ffidrM^fr^^ean^ crapty °^' *^^§j> t    li^tB^l^rr? wisdom.
alSP/ieauw7/q£ llfii^ra^e 2TC^recte6?^imerestt   with   classic   simpncary rtOr ar>  olq
I conceprr lheM>asis or.tne Dest, Type or tamily practice through the years.   %Fms
envisaged mana£ a  ooeius   or spciaTr being, .and viewea nim ni* the perspective of
\ An.   jilt JrTfiiu_2ia[H2nffl3  3fl    irw  anureesb  vcT. vlrnnv■ bfiBte Drre sxBm  ,223n
thelwnole1JmanJ^9ody, rrnnu ana sour, in relationsnip- to nis entire environment-r
thait>^^1hrjn§err, 10 ras^ramify; ana to his community.  Tnfe concept or scientific
humanism  is ^creasingiy  permeating  thought  and  action   throughout Hie Trieiti
oi'Bfie4r)3^/1and,>^Qpompanym u& Jcome ^an ^extension . or its a^piicationr wifth
I ^reaftr emJfK u^rafrjine nealtH jproWems.of jsc^ic^rjaictionar^oups lncmdmg
fl&fese ofvrhe 'fam3yf Tne mocfier aiia ebila, the DreaawninerSb me agins ana otners.
yaHsbnor^aifiri&iiotoiJ   ziru   bnB   ,2^orn^|qqfirini^r arTj   gJnjK^9ggufi> ;f33iirw
The Position 0f..tMgMf&tcaJ^J£rpfe^
The medical profession is faced with the paradox thalfiiafcit becomes1 ojfelativeH*
IsBtialler in numbersi-smongp^r^npel'ji^
I r^t^ftsibiUty jfe,fian ^ig^eralbroadgstibg osirga oj^fcbespordibihty./illiEendafrtger of the
profession losihg i^qidgiiti^sand posiiatwrnof jteadefsfeipl is/amBaaijrJnei ^tdfushfentfe
fie an$ ed^catadnabgsquai^fcationsrliiareijaclear^ riifc£ne^3ifc^|x4he[liIfeiveTsitiesj
thejlMedieil (SounciJriefcjX^jada, therrespecjt^e prjoeraneitt Colleges rof Physicians
|and Sujrgeonfe ^eb^og^^MJegei^fcBhysicaahSimAdsSurgeoniil^lCI^ada^f^
thec^oU^ge of;iC^Bierjdl)iPxac|ito€>bers{ Q&ijGanada. rltsris ,essdiitral!3tha6i(witfeb similatu
claril^iSfld liwiif^ wenniake well known oun^lhcip'lesp r]olkries lanid ob|ebtBvesqoh>
important publi^ m4tfers^/and rissuesriiib3the: healthiBfieldil J^jthisinregardBwe musd
^ldu.Qt<:>ourselves{BWtlirT[gr6at Twfis^om anoVBdiscrj^tiojoij siigAadnheid'Lhalhniar^sfDioii
«K)high endeajfqWr mayqlm cjiyfetaliclekhjtt) tHe l^u^d^^^|i#®.^ii#^l§^^^^^^
We?are acipTofessioii labhieviia^i oui3 ^usefeit rn^manii^ufcposeffhy fiallcfimierita^
oiitb various furicticmsritxalis^ecific fgr6up^iof our! meTnbersinWlJqgjefupi(cbfselvgg^as]
teachera^sifesearchf. workers] gen^ra^/qjtabfitioners^lspeciaijslti, admlflistratofi^^ pltMici
! health officers,  and medical officers  in  defence of  the  nationlraSflhi^fl^j^ioHd^
Pdgeot^ responsibility carries with it the hazard that among ourselves as functional groups \
of a greater whole, we may regard the affairs of the part as of more consequence than
those of the whole, and thereby lose sight of the general good in health matters.
The respect with which the profession is held, and the increasing responsibility <
which is being placed upon its shoulders have been viewed with mounting concern
p| the cultists, the quacks, and the charlatans who are pressing their claims with
increasing vigour for recognition in the health field.   There is a real danger that•
they may ride in on our coat-tails to a position of professional status.
We face another danger—that of the possible unfavourable implications in the
public mind  arising from  the  thoughtless  airing  of our  profession's disputatious '
economic problems.  There is danger of confusion arising in the lay mind between
economic matters which are specifically those of internal concern to the profession =
and to the welfare of its individual members, and those which have a bearing upon
the greater public welfare.
Responsibility to the Public
The individual physician, as well as his professional organization, is becoming
more and more aware of his responsibility to the public in health affairs. He no
longer can live unto himself in the seclusion of his private practice. The challenge
of service in the arena of public welfare must be met. If it is not, others, without our
qualifications, are only too anxious to step in and take over.
It is foreign to our natures and to our traditional ethics to strive for public
recognition on health matters. Times have changed, and today public education is
our duty, distasteful as certain aspects of it may be. We are beginning to slake the
avid thirst for health information.
A difficult, impelled task borne upon our shoulders is that of making decisions
and recommendations regarding privileges and benefits associated with illness-
hospital beds, disability payments, compensation benefits, and so on. Occasionally in
the face of unfair pressures the physician must, with forthrightness and trustworthiness, make and stand firmly by decisions that he considers right and truthful,
but which are unpopular and which stir up unwarranted personal resentment
against him. lit
In the negotiation strife of management and labor, our medical services have
placed us in the unwitting role of pawns in the "capital-labour" conflict. We see
our humanitarian care associated with the instrument of strike/ We find our
services dragged into this unhappy morass, and this unfortunate tendency is
increasing. It is an unhappy business for us! We love our work! "We hate strife!
Corporately and as individual doctors we are being dragged through a mire of conflict
that is not of our making.
The commercialization of medical science presents us with a clear unmis-
takeable responsibility to the public. The drug trade has made outstanding
contributions to humanity; however, it cannot be denied that part of this business
has shamefully exploited much basic scientific medical research. The vitamins
are a case in point. The restrained scientific pronouncements of the Federal
Department of Health and the American Medical Association are in sharp contrast
to the deceptive cleverly written advertising brochure which is within the realm
of plausibility, but not of truth. There is too great a tendency for the public to
be used as a guinea-pig for hastily released new therapy. The drug trade often
reaches the public through the doorway opened by the medical profession. Are
we sufficiently on guard on behalf of the public in this respect? Where is the long
line of much vaunted drugs of yester-year that under commercial pressure we
prescribed for our patients? Time has weighed many of them in the balance and
found them wanting? Most of them could have been found wanting before the
public bought them!
Page 18 The Growth of Public Interest
"Phenomenal" best describes the growth of public interest in health matters
in British Columbia. Whereas in 1919 there were only three voluntary health
agencies in the province, today fourteen agencies employ 495 persons and disburse
$2,700,000 annually. In 1953, the voluntary health agencies throughout Canada
spent $30,000,000, a sum twice the total amount expended by all governments at
all levels for all services shortly after Osier's death! The voice and action of
tens of thousands of women through the medium of their fine organizations
has been a most powerful public force in health progress in our nation. The
participation of management and labor in health affairs has been referred to already
in respect of conflict, but there is a broader constructive field where each has
special reasons for a keen mutual interest in the provision of medical services.
Our affairs are health affairs, and health affairs have become public affairs.
This is good. It is as it should be. We as a profession are recognizing the value
of this weight of general public support and interest.
Prepaid Medical Care Plans
Recent years have seen a growing awareness in Canada of the value of medical
care insurance. With a high and rising standard of living and with expanding
industrial activity, prepaid medical care has become an integral condition of employment. In British Columbia, the Medical Services Association, hanging by a slender
thread at its inauguration in 1937, and in its earlier years housed in a cubby-hole,
rose to meet a public need and now, with a high degree of efficiency of which its
founders and present administrators can be jusdy proud is arranging for medical
i services to cover 295,000 persons, involving the payment of accounts for these
I services which amounted last year to $5,400,000. A recent survey indicates that
596,000 persons, 47 per cent of the population of the province are covered by
some form of prepaid medical care plan. Surely tribute is due to those who
pioneered these plans, rendering thereby a great human service, a service which,
though not perfect, has been a fine partnership of the medical profession, the
employer, and the patient. Many a sickly little child, many a worn and ill
homemaker, many a disabled breadwinner has received good medical care that
might not have been sought if it had not been for the prepaid plans.
I Government Participation in Health Affairs
Few physicians appreciate the almost awe-inspiring composite role of Gargantuan
I proportion which government at all levels is playing in health matters—a role, direct
and  indirect,  which  has  the  phenomenal  growth  of  Jack's  beanstalk.    No  one
I has depicted as yet the full extent of this participation, but a few contrasting figures
I of government annual expenditures will speak for themselves.  In 1919 the City of
Vancouver spent $700,000 on public health and in 1954 $8,000,000. The corresponding figures for the government of British Columbia are $3,300,000 and' $60,900,000
and for the Federal Government $900,000 and $45,000,000; and the last figure
does not include the $25,000,000 health "pump-priming" grants-in-aid.
Governmental provision of such large sums stems from the mounting pressure
of public interest and enlightenment, from the impact of scientific humanism on
the march, and from a demand that festering socio-medical problems of the "body
politic" be healed.
Global tension has strengthened the government's power in every respect and
particularly in health affairs. War organized a large segment of our medical services,
and the government thereby gained valuable experience in dealing with mass medical
problems.   The  power  of provincial  governments  in  the  matter  of  licensing  to
! practise medicine rudely disturbed us out of complacency when in Alberta recendy
Page 19 the Government threatened to take back unto itselfizdm^powe^wRid^D 1^ eflac&ifenT
it had entrusted to t^prpjFesaioru %, i&§*M 's^^& Bi ^o^fii^^^B AQnh
TlSJjBnT TO BtMl   fjr  J?3l5jTrrTillu u u.   IO   rtJWQlg   3Q3t 23GCI323D   i23Q-' iBasfliorion i
rblfisy ^fS^iiJ^SWPWntr^isvP Pffi?S]W?r* A^^yi^W ^.j^cffSloB sHSfe-j§Feari
%^SftM%nW^n^^rf4^
^b^b3 %§$^u^ onIy !¥I8iinrfiuaib6{fef §1
4e j&^5rn%3^ W WP fB^fefAl)rpfirj^fe&- IrSSPsW @(^?Q^0{n,&
fe^TO^^irrrPSSfo^^iT ainteYrn?Ti3lk]6^ ^^U^fW^m-
%oi!%ir%^^fo°^31nTu,li?nffffl5ten^dfnTio,?frj11^] fT3Yr^^^iva^9ift8d^f§^^uM
esJeptiatb-Mut^0 ^r^lta^rV? rWlB^Prfas^-&09ifcrfe?r Mtffojfe^ ifen^^ Jfi^i tiA
learlonJviq&ctiQn w^^h^gfenfcsffeat^ut none Wrrfc$rM9^<&,WQ^&rfowaTA,Fr,
'JulB^nt gnrsmg033T pM .ffoizlSioiq B-%$m8$$ffl blupffe li aB^^fe^OOWl&iHl
lo us to whom medicine ^fttjart fa$d j^^j^cej^jS^g^st^oii^tJ^f^ o^n^ qf,
its broadest senses it has become a ^business* is naturally repugnant? This repugnance
may stem in part from the notoriously poor business acumen of the individual
physician, and this feeling is readily understood when we c^m^?^r]e^!finerenraatere
<?£#fPSff§dfe) whteQl^$^thfeiie^ngia#3a8alMS/hf^ w©^^ Berthat as'itlraaf^^iiwfcwHether
Wgiy^&^oj l!$wh&aith h&k/keckmfe aimighr^busmessdnfr^iilfish Q^mbiiffBaLivi^rous)
^^c^wlipgioM&nwitfcipai^ahmssetiS'jffll ap£>mxiiriatelj8fi$ liQOp3€|,QQfi;/it0itH£ianm,iali
<|$fr^ture§j ©fc%WjOp&QQ&caad wifihiem^ojfmeatsdf ^C^OioSiillflahieapealsorineln
Fs^-v&foStapdpQJg&r^ assets,i3ekpenditiaare^riandH^rsoriir^LBdj%ui^kh jhubinesfe
siandsisl^u^erotoashoulder w^ ^bntbdaTGah5iia. § isom
JBoibWe ^%rtoiri^wdyditHe!iiafippJiJHaj^u9(jargon dbbusinwiaffiditbeaiista'scefu^
iii^fic -as^egfriofctlie feusinesa^pmfatitgrji feoiibraMs^jdollsQQ^n^ statistics-; iKeome^
e^ens^Fiefe^hed«Ie^,idis<a»iirit, talS^^fe^cpeiJiencesratin^, Eeerfcrr>ser^irieirie«pJtstSoi^
an$ fe^-^np^rej-fipnaerQ&cthe e<^,1har^teii3m!S)fi5>f this^^5itr5s^qpvh^lr^Q§'f^rQasfe&J
s^Fusejaw^i (ejnnffifeling motfvfltio^isi^npafee^iomndersthnddnyGtlsQqmM lefiohuaaei®:
lglAe^sg^n^gincer^iseiflessfeffDri;. jB3ig b ^flfe^^^^febnsi ,zadq SSi^^M^tM
3rtJ   frioi283ioiq  iBOfhsm^nl   lo  qrdaisnlTBq mkm^iissa  ?.fid ^D3tr^Cloto|p^»p"
%^fhstTiWi or ^rfif^fmida|3[3nl|tH3f2  btoeM   .inabfi^fj  bnB  |I§1§
iHdiH8KWg(£k&$m mecfocihe/asDaJiferfoodriiti^ $e*^iseriori
one to be confrorj^d[qvftte<t}he^qDrjol^ a^j^apinaiegfaband escapade!
part of this work. We find ourselves face to face with the impact of profound socioeconomic forces upn the practice of rne^o^cirg; ^^W9^ea^r^^.^qti^^^e/fc
nical advances; with an organizing, active, and vociferous public sent|nent; ancLwith
a^f*«p$u3^0ve^ we
tfo^^'ve%^3Eh^edke^
herflessJinWI^spirfefng. depffis^°^|JP^mon3n^ #i3  *fif*   doidw ,133:
_^^^^p2Bi?noo;;^^^Mrd ,noil|gr^^K^pt io Jn3lx^l{ui:^^^p|?&?|^g)iir^
^Tbe'iDegdc^ iff Ithi Levdtttf&sdi "t^0^^ IU^23iulrbn3qx3 ;^no^^nam0
an
mp^s-rorrrruja W't&e ,gl
decay of dvilia«fc^?-&$F^^ ffiWft&ifty arW
endangejimgi threats d^ennmes^thei§udc^ss ^^ildr^^|foii^kie'd3e^ll%Ms^o^^1iioSe.
no rWiifltrratritU)d£lw^l^v3e bfiMgr^a^sg^iqMgm^^i^We^&ii^r^rSo^
Wbal* orrfigirichngj^mci^esla W^l>^e^$eibo^pic} faridfeset^fey ffrSifeiesl^^ar^,^^ t^ej
bias of self-interest, or will we rise with nobility of purpose and wi&iign^iSeaisi^
ra&ptiaj&ilke ^feiQiiali^igh^jofea^evemejato oS^uirfi^QfessiojartjasfcSani    tado!
)i^*fwj|fj^ai^^t)^1|^§0i|g«i feefe^rt^e-^nicalite&hrfi^ofi oiir/ihilrBiood!
milife a,8gEP?^F^ ^f§§f?litoowM:iS^j^d^Wt)s|)3M^^/t6taiHaria^ te
tfe^frfi^M© a^SMat^fe (^er^ikfth-mi^owitlbitmate^^
HftY&Wf fmMAn?P^kl5yO(^f^aM5foio^\^^t^ajtc,wa,iditlfe li^fejuof JnfflgHwrtechhkali
Rage ,20 flndi^ieimficjachie^maaaBfrdo wotaeaOlteikdat^afa^&driestra^^ mind
iirjfjyamilr} -b-rti tfehihoaoitfiM 3o sonsufini insorbnsd bnfi viomarn 3fll ol sludhi T/Bq ol ai
^rVFiiorifcytHesdksleriforMedit^^ ^crimes ithe
Usgdcy ^ifcfoe^fetw^ir^^ocheiita^esrrtwx^
the ^^t//fc*3fiighteous3res9/B6u3r3ttebrew rh^ti^^^^*Weifl<i««®a^e^bfenMosesoilsalah)
j^hri^, faoidiMahambtp'aTH^ itheijothef^rtiieiquesfi fonlkndwIedge^fotLriiGredanijfoetitii^e',
gmoflgi s^hijf e, 3^Esdforfc Aristd^
thelJSvlant5fOjmfi^3ddir3BaRz:in^ik>^eiijdff westei?di(^iifzarioMl iteoS^oc&h $miericaiiw©
as acjaiofessionc&i wet flne^orieAte^kcaderrja^ fof -^edicirisnBitilaiii^ have^ojeebidedsbaj
JtBbdtejztarr these/ herita^sboRdcrrayddiiirriaBold .grjeinStorie bsrlqtfoeirputefc wUIl zrrsl^
impressive position is the figure of Hippocrates symbolizing theiHa:knQef o£lJiaje^iffl&}
the critical sense ,the skeptical attitude, the quest for truth in medicine; and in the
entrance hall embossed in warm bro^e^o^^e 4^4^&^^^^
Jewish heritage of righteousness, recording.thebeautiful wqrds.pt Maimonides from
l^PPK^iiuisGjjp*ii7^S;/?c32 sboD fiBSDifiomiBlvi snl icnl nodBQilqqB air ni at JI
flrnainoD.radl noc
. Moses Maimoiuges, the inspired auffior t)t the peautitui prayer incorporated, in
.3fiprt23nT D3SMB210 io ^f^qirf^ODeaFanl .Qi^inijil Dns noriBStrbs^fcrDOsisxr 3lBJJD£ig
part, in our.Af.oqe rot. Jitnicsi. wasrBoniLin?L^ra©ya, TSpain mr 115!), tne^soguof g
j       i3iil viifib jifl <h .nxVi3i2viio iBybiviDHi sill lo   ra333ia PnB 3LrjmBX3 3fn   ^nB
learned and resrjectearaDDi, who was driven by persecution to tne Levant — to rez
sail enhKii^mv/KCr^UiflknTKigSB mm,j; «^;^i^ T^ia^fliluQvraliaaminy ML-n,^
^FMffiomfJe^lieaJSfJ
Bt^)^^^iie^mTI^TOrCT6^1ro^is ir^irr^Kce. VHe^Ja^^p^srcia^ wff}i?tne^^rrlu6us
—wrjj~i   Bo I   Ttorrrf
■bsissgers .121:3 jEti sonia b3daiic      23101112
Now„ Goa? Mnows £M« in order ,to write this to von I have escaped to. a secmdeajspot^
)d,?riel^^r>Pe3wyul8^otvfindI^y^s3fA|tffi ^^r^a^ainit8^!!!1^}^ ^Sfiet&iSiP^
O&ymgi dotfft dftGacttW^Oj£)in^eieSs^eliwBaliflaf/ifcK)l foatefgro«ln Uo^akd tfe^flOWSl^felpeWOn;:
i>Hl tftiyc5*?r'JBisHjto/Pl]?4?i'b^r?;.t9 nie,^'; qaijnet butj say{ fhbrtjfj gfeitly yonr^vijitj (Vfgjuld, <fohgh.fc[i$je,flfiorn   1')
than you.   Vet, I must  advise  you  not  to expose yourself  to • the perils  of^ the voyage,. for
beyond seeing me and my doing all I could to honor you, you woulcriaor ae^pveyiiy advantage
(fil^FfofllouE/Wfitf[2^geS?sf^
|_f bv
early">ti the imof ning^Jahd iSie^fl4/Wpn^26»llS2 c&flIre83&rOihy^3j|3th^^Sima
i^sfi^^/lCPagfdifttlkj® 8«»bjr?3b^rim^: J^fcB^r^jtb?i(afBaJe©Id?gtvof^htee3[4ai)i8il8b93lni
people,; judges: and Jbail(i$ft3fr^n<Jf[^d,^o^3i^jH(TOixejcBTj^ .tiu!£/i3fjLPiy2rioo
[3£dflB^Jbse^e^3aitee«ls.3rfeadekw gp3^hngrib%q©^il,rH^lfami^ atfd53s6VngfciiMeslTev^iliX3{q
;pjsplgmn;5gj assjire>ry^!gqunfi| gyo/jli6Mi2JS©4[2StPr^0 ifKJtffee Wgfijfwlfj^til^rfeprL^JShrish^ritiqa^drO "lo
n^^fefev^rTb^follrrr^u^rl1! oT^rtecrfrfj^ brJr^2%lbrf^i/^fdlfft^iif bnB
.exhausted that I xan scarcely rspeak.    In (Consequence qf this no Israelite can/ have vany pnyace.
!ntB.&ii^uaila£.ibi£U2JiJ3i fiJoSrlcOi, 2S&iM3i ^ro Mm&S&JiaihWQXUJl^ak&ZLZypiitJOSlnOD
exhausted  thar 1 "can scarcely rspeaK.   in (Consequence at tnis no Israelite canf nave "any private
B8£rVfW*;tM>l&J£!£$r. fSflSfefl^^ ISPM W^3$w&&ffig4^(tfWl^t
the iriajorityy*come into meia>fter *ne morning*service', wiheh Pnisifcu'ttfjthem a¥>t#^»eii*iproefee^m"g5  '
during the whole week;   we stay together a little until noon, when they depart.   Some of .HfeefEBvbB
return and .read with me after Jthe->afternoon service yunntil evening prayers. .In jhis manner J
[ spena^kPtfa^ ?£«avlrh1eVe i^ftd tS^c^^W^/t gf^Vha^^oWcSfcP^le^VoS wWev"V
o^islt3me.^>nB quoig 'iLfO 10 T3lDBiBn3 bffB vlilErom lBnoi223loiq snl-lBril noilBorlqqB The principal purpose of this thirty-third Oslerian commemorative presentation
is to pay tribute to the memory and beneficent influence of Maimonides and to suggest
that in his inspirational recognition of the love of the Art and of the love of Man,
out of the dim, distant past of 750 years ago, he has provided us today with a Code
of Ethics — the "Maimonidean Code", an unwritten law of conscience, which can
with assurance carry us as individual doctors and as an organized professional group,
through uncertainty, turbulence, tension, and the challenge of change, perpetuating
in the future our great heritage of the past. Surely these were the elements of Osier's
code — his love of his Art and his love of God's creatures. It was this motivation in
Osiers life that prompted the tribute when it had closed that he was "most loved
for his great humanity".
"The Maimonidean Code" and Its Application
It is in its application that the Maimonidean Code serves its useful purpose.
Whereas its influence should permeate our entire professional life and deeds at all
times, there would appear to be critical points of application where its effect can be
most influential upon the contemporary scene. These are — the university undergraduate period of education and training, the leadership level of organized medicine,
and "the example and precept" of the individual physician in his daily life.
The University would appear to have a key responsibility in motivating the
future physician. The careful selection of students not only to determine the intellectual factor on a scholastic record basis, but also to seek those with humanitarian
instincts, is a fundamental first step. Gradually the fetters of the Marley's chains of the
clutter of the past are being severed and dropped. The breath of humanism is vitalizing
medical teaching. The "curricular astigmatism" of the specialty interests of medicine
is gradually being corrected by increasing doses of the humanities and the social
sciences. There is a proper increasing emphasis upon pediatrics, preventive medicine,
and psychiatry. Even the skin is being recognized as a mirror reflecting the underlying
health of man's soma, psyche, and pneuma. The Goodenough Report on medical
education and other related studies published since its first appeared, give an indication
of the shape of things to come and augur well for the future. At no time have teachers
shown more concern about the need for inculcating the love of the art and the love
of man than in recent years, and I think this concern is particularly evident in the
new teaching programme of our University, an effort of which we are all proud and
for which we are grateful.
Never has leadership in organized medicine had greater responsibility. In health
matters we must lead or be led! There is evidence that the profession is not being let
down. The highest qualities of inspired and forthright leadership are clearly discernible. For those who have eyes to see, the selfless qualities of courage, free from self-
interest are clearly visible among the leaders of the British Columbia Division of the
Canadian Medical Association. Often we see those whose professional demands are
the greatest contributing the most to organized medicine. It is essential that the "rank
and file" of the profession choose their leaders well, and support them loyally and
constructively. They are our corporate conscience. This evening I would like to pay
my personal tribute to the high statesmanship of these men. They see the magnitude
of our inescapable professional duty. On our behalf they face our problems and perplexities. It is not easy for them, grappling closely with the headache and heartache
of our problems and filled with a sense of responsibility to the public, to take a wise
and justifiably unpopular stand — unpopular to the uninformed physician — on a
contentious issue. It would be easier for our leaders to fight a rearguard action against
the inexorable forces of progress, but they choose the bolder steps of courageous
advance.
What of the individual and the Maimonidean Code? It is this basic level of its
application that the professional morality and character of our group and their con-
Page 22 tribution to the community are determined. The unwritten law of Maimonides applied
to the personal and professional life of each physician is the greatest assurance we can
have that the future will hold nothing for us to fear.
What of the Future?
Quo vadis? Whither goes thou) This is the eternal question for every generation.
On the basis of past trends and contemporary forces can we discern the pattern of the
future:' In retrospect, who in 1849 could foresee the changes that 1919 would bring —
all in the brief span of Osier's life. What prophet in 1919 could have foretold the
present which is so much with us! A span of 35 years, just one half of Osier's life, has
seen unbelievable medical evolution. What of another 35 years — what changes will
they bring? I shall hazard a very personal opinion, given as objectively as possible and
based upon a projection of what I believe are clearly discernible powerful trends
which are now well established and gathering momentum.
It is probable that we shall see increasing government control of health services.
Although we as a profession may see many good reasons to wish it otherwise, there is
not apparent today in Canada any strong force of public sentiment aligned against
the increasing dominant role of government in planned health services. Global
catastrophe or economic depression could hasten the momentum of this trend.
The growth of organized community health centres housing the family physician,
the public health nurse, the social worker, and essential diagnostic aids including
laboratory facilities and X-ray seems destined to provide the medical needs of rural
and suburban population in the not too distant future. Closely associated with each
unit there likely will arise the small hospital unit for uncomplicated illness. Models of
these community health services units are already in operation in England and in the
United States. Planned, organized, readily accessible, neighborhood community and
family health services are, in my opinion, an inevitable devolopment of the fairly
near future.
I envisage an increase in the movement of specialists out of competitive practice
toward large central hospitals, toward strategically placed medium-sized ones, and to
teaching centres, at all of which these highly skilled experts will serve the essential
functions of dealing with difficult and unusual clinical problems, of teaching, and of
undertaking research. In this way they will have the opportunity to act as a leavening
influence upon the standards of clinical practice, preventive medicine, and upon those
related to the active promotion of health. This trend is now unfolding with an
increasing tempo in our own community.
Some of you will discern with horror the oudines of socialized medicine in what
appears to me the picture of the future. Unless some unforeseen factor of great overriding power soon intervenes, forceful established trends, supported by the public
and government all seem destined to converge rapidly toward one objective — that of
socialized medicine. It is my humble personal opinion that this movement, good or
bad, is developing at a speed few of us appreciate. What should we do about it? What
can we do about it? Perhaps Maimonides has an answer for us.
Matters Eternal and a Vision
Surely these are times for us, as individual doctors, to hold firmly to the eternal
verities of.life: to God, to Freedom m freedom to choose between good and evil, and
to Immortality. It is pleasant to think, on this evening of the first day of March, in
the year of our Lord, 1955, of the immortals of medicine in the lap of eternity reflectively gazing upon us here assembled — of Hippocrates, the Greek, our symbol of truth
and the mind, 2400 years removed from this early sphere; of Maimonides, the Hebrew,
our symbol of righteousness and the heart, gathered unto the bosom of Abraham
750 years ago on December thirteenth last; and of Osier, the Canadian, the humani-
Page 23 jla^iarr^aj^w^GiMr/o^^^eg^ii^/lJiej 6l^ia;fey£flM§6i3!p§fc i^^ii^a^einjylpiijlVIedisi^j
$&§ i^^^QU&gj^gSjS^i^is^tl^ m
stone,  Maimonides' words in bro^leeja^d^^frlloW^^j^ig&vin)!^^ tol|§rMoAh£
Vancouver Medical Association library.
Let us move forward with a vision of the great role of c^Of^shin^^nd se^i$e
ahead, sure in the strength of the Maimonidean Code. Let us ,clearlv recognize as
nTO^JrMSS 'fflffl^aSPa Wb^s^iM1^up3tha¥fwe are^4ierS^drrri,%vthe2whYte!1iyht of
»ffiH^o#eVeryB^ A M       <    <m °2r2| BPi3n323fq
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bns 3idi22ogT2B v.Ipvil33fdo aB/iSWQ .soiriigo iBnoaiscr vxpV/B-biBSssf [ififfe I i^gnhd -/srfl
, ^^lnsptrerm us, on GparxCTove of ourf/yrtunaof L nv.X^reatures! r ?  ■•«
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ifidoIO   ^SDivis^dliBsd  bsnnslq  ni  insmnisvog lo  slor  Infinimob gni2B3ionr  sril
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,nBioi2vriq viimfil sdl gni2nod 23iln33 rflissd ylinumrnoo bssinBgio lo dlv/oig sdT
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flint lo I©^iii^^^\^|^©^^?29Pjh9ilfrj^.lf7r31i!^ an njC^£|ra^^^sM
■j
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rnfidBidA lo moaod sdl olntr beiodiBgj^iB^d adl bnB 223n2U03lrlgir lo Iodnr/2 ilio
-rriBrnod sdl .nfiibBrrfiO 3rll /fskO lo bns ;12b1 dlnssliidl rsdmsosQ no ogB 2'ibov Oc\
|Pag#o^ a nsvoMcM baB-KBDEOBU-jol 43D^3^ZZbaB jdl lBsLlJsxi'      A 20 insrnnEg!
r{&l  03303
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E Dii^lbr/fMei^b'HaaZtfecSera^^ tSoJttfM^afioilD^
RECOMMENDED ROUTINE 1MMUNrZAtlOricSCHEDULE
PRODUCT
'DOSAGE1
iSITE
3 monms DT^hth§R3-PeftasS§-
Tetanus (combined)
Bb.3ccq.Y
13V9"?   WOllsYf        iHii
Right a^^urtltaednelDnusly*"
HPH; apnebiaeP.
.   Lvm. *  .
m9nri9
QwsLs">ri9D!?0
armjyibcutaneously
5 months,        ~^pbthelh~Pt? l"3s,"s~c I' 1 cc« .Kight arm subcutaneously
odua^gn^i^^^^ < -nstu^ua atonic. y
iO£K
taetnt £uo9:
6 months' t       ^Smallpox Vac<tme.D
ft amino
Left arjon ahft-acutaneously
1 year
Diphtheria-Pertussis-
iGtuoduaJliD Ttetanusri ((combined)
-f-cc-
i61u:
-Subcutaneousjty-
I .edtnom
2 years
Diphtheria-Pertyfl^s^
JZetanus-Xcombtned)
Subcutaneously
21312QOC
 ■ ■j.n ol v.—tiM—io ggy ot yytaliA:
lql ae>birb|  , ■^*eSt*hcuiap(©ously
3 years
Diphtheria-Pertussis-
Tetanus-Xcombined)-
znotl&sibni&TinoO
ItSPT,
■$&4 y*fefip'2'v   ' Dfphffcjeria-Fertussisv $
loTeJandsffcombined) ere .akiOcttGa
^^Dipr^heria-Tetanys bliibri
(combined) ^3rfij5i«jc^
Sma 11 pox Vaccine
1 min.
^ifeitBipimnfa   }o!
n&Hi/SJ ^rfbSqpcutaneously
^UlrV^m Inffacutaneously
11 years
Diphtheria-Tetanus
(combined)
Smallpox Vaccine .
8HJ8&BM
1. min.
>t ; rrRrriTfH
Right arm subcutaneously
Left arm intracutaneous!^
lo nob
;v:        TJDitrfirtiffirja-Tetanus ^gn fficitM       E Slgrffnarm '4^dlrtarie^iaS*ym
BoBirMrri0?^1^^! ^fe^M^ .-^$s1t^>e| llj^^fa^jgndstfjttt pi Q^orfl hot n3ibi|ai
mUfiff. 2 3TEfefff6WrPW«-a'ciitaneoudWb
feBS^^:2b"Smaflp&x Vacciriet
M
Thereafter, immunity may be maintained by: Smallpox Vaccine, every 5 years, Tetanus Toxoid,
1.0 cc. every 5 years (1.0 cc. at time of injury), Diphtheria Toxoid every 5 years as indicfej^cj
by Schick and reaction tests^ TlawhMOTJMfe^
INTERNATIONAL TRAVEL
:^t)^R^
irio 0320^
be
a^Stf'SrrlWfio tfja.v^[rig  ^l^p^^j^^^j^or^aJjjg^nuniz^^^j^rqcf^Big
required: " radSi|^   ^|do ni 2>lB3idlo^
Ca) As a condition of entry into any particular country, and/or
(b) For their personal protection in areas where certainVQ^Ise^alre^enlMnlc:
It is obvious, therefore, that these requirements will varytfeftj^lF&ent^ountries,
but^OTOtecjt^pnj^gainst §jfos»i|j>ox^irrypb©}d^^^lJ^hoid^f^^lbwrjBep§5f|T^Hui, Cholera
^{M^gue^m^ ^g^hejf^jrjjand^ry) jqfr desirable.-jn in^ogjduaji {caseseiiEfeerilkst two of
these antigens are presently provided by th^;Divisi^|]D3l^'J^|ipfftt§r^ScbHtf2all others
will be the responsibility of the individual patient and shoul^ofjjej^aibiy fe^ given by
private physicians.  An exception is Yellow-Fever vaccination,): which j is ladministered
%Bljfjr?$3-$J# lfedej^(^D^artniej|£|bo£} Ifti?i^FWion3.fq©iB©iiPuffprdb S&55fJ$q^ancouver,
B.C., Phone PAcific 7371.
frjge,$5( In connection with immunization requirements for foreign travel, it should be
noted that the International Certificate of Inoculation and Vaccination as issued by
the Department of National Health and Welfare for Canada, and approved by the
World Health Organization, is the only one accepted by all countries. Prior to
departure, the traveller should obtain such an International Certificate and have all
immunization procedures accomplished entered thereon by tHe Health Officer or
Correction to article "Recommended Immunization Procedures" in August Bulletin:
IMMUNIZATION PROCEDURES FOR INTERNATIONAL TRAVEL
it£g&&
YELLOW FEVER
TYPHUS
PLAGUE
CHOLERA
Immunizing  Agent
Yellow Fever
Vaccine
Typhus Vaccine
Plague Vaccine.
Cholera Vaccine
Use
Residence in, or
travel   to,   endemic
area.
Residence  in, or
travel to, endemic
areas.
Residence  in, or
travel to, epidemic
areas.
Residence  in, or
travel to, endemic
areas.
Administration
Single subcutaneous injection of
0.5  cc.  freshly
prepared vaccine.
2 subcutaneous injections each  of
1 cc, at 7-10 days
interval.
2 subcutaneous injections each  of
1 cc, at 7-10 days
interval.
2 subcutaneous
injections,   0.5
cc, and 1 cc, at
7-28 days interval.
Boosters
0.5 cc. subcutaneously every 6
year's. ,
1 cc, subcutaneously every 6
months.
1   c, subcutaneously every 4
months.
1  c, subcutaneously every 6 mos.
Contraindications
Allergy to egg or
chicken  protein.
Allergy to egg or
chicken  protein.
Nil.
Nil.
Note
Administered only
by Federal Dept.
of   Immigration,
Foot of Burrard
St., Vancouver,
B.C. PAcific 7371.
These antigens are not provided by the Division of Laboratories.    They are  the  responsibility of the   individual
patient   and   'should    preferably    be   given    by    private
physicians.
MEASLES
IMMUNIZING AGENT
Immune Serum Globulin (Human) is available for the prevention or modification
of measles. While complete prevention may be necessary or desirable in very young
children or those in impaired health, it is usually preferable to attempt modification of
the disease only, since this procedure will minimize the illness and hazards of measles,
but not interfere with the development of naturally acquired immunity.
Not routinely
Indicated
(a) Exposed children, four years of age or under.
(b) Exposed children and adults with intercurrent illness or chronic disease.
(c) Outbreaks in children's institutions.
ADMINISTRATION
(a) for prevention
0.1 cc. per pound body weight injected intramuscularly within five days of
exposure to thejdisease, i.e., within five days of the onset of pre-eruptive
symptoms in the infecting child.
(b) for modification
0.02 cc. per pound body weight injected intramuscularly within five days of
exposure to the disease, i.e., within five days of the onset of pre-eruptive
symptoms in the infecting child.
Page 26 NOTE: At the present time the Health Branch, Department of Health and Welfare
is still issuing anti-measles serum for the prevention and modification of measles. As
it would appear that immune serum globulin has decided advantages over serum for
the prophylaxis of this infection, the Health Branch proposes as soon as more adequate
supplies of the former become available to discontinue the issue of antimeasles serum.
RUBELLA
IMMUNIZING AGENT
Immune Serum Globulin (Human) has been recommended for passive immunization against Rubella although its value under field conditions is not clearly established.
Since Rubella is ordinarily a benign infection and is only considered important
because of its demonstrated relationship to the occurrence of congenital defects in the
infant, prophylaxis is attempted only in the expectant mother who has been exposed
to the disease in early pregnancy.
USE , ||- J|: ,    .
Not routinely
Indicated only for the expectant mother in the first four months of her pregnancy,
who has been exposed to Rubella.
ADMINISTRATION^    %
0.1 cc. per pound body weight injected intramuscularly in divided doses.
INFECTIOUS   HEPATITIS
IMMUNIZING AGENT
Viral hepatitis is now regarded as a clinical syndrome caused by at least two types
of hepatotropic virus. Virus IH is believed to be the causative agent of epidemic
(infectious) hepatitis. Virus SH is associated with the syndrome that develops
following parenteral entry of the virus and after a rather longer incubation period.
Virus IH infections can be prevented by immune serum globulin (human) when
given after exposure and as late as six days before onset of symptoms. In practice,
however, owing to the wide range in the incubation period of this disease (15-40 days)
prophylaxis is attempted if the symptoms and signs of active disease have not yet
appeared. There is some evidence to the effect that immune serum globulin does not
protect against virus SH infections (Blanchard et al., 1948).
USE OF IMMUNE SERUM GLOBULIN
Routinely: for all contacts in relatively closed groups,*i.e. follow — one or more cases
cases in institutional, classroom, camp, military or isolated community groups.
Indicated: also for contacts with intercurrent illness or chronic disease.
ADMINISTRATION ||_
0.01 cc, per lb., body weight, injected intramuscularly.
ASSOCIATION DESIRED
Young doctor registered in B.C. seeks association with established
medical group or partnership immediately. For further information
call the Publisher, MArine 7729.
Page 27 ANTENATAL! <&ARBi^<Sa^
mMi&M^s0kmhB MpiooPl A^Mmfin^^^^^m
oiq dVrictOfia, r>.t£4 s
"Fne Mle of tnis 3]fTaperis Antenatal care —wim reference to "some common'
complications. It will be very obvious to you all, I am sure, that there are so many
"common" complications of pregnancy that it is only possible to attempt to deal with
a few of the more important ones in j^eihlrjlfiijtfiie at our disposal.
I would like to make a few observations concerning Iheliubject) of \EHBMAITA
m^pJ^iVBORTIOJ^.jjSome of my rerflaj^S in this; ]regarcl^Hta>r^||^3lifeenMresy,
byl^YMfe^^y provoke your disagreement, I jam prepareduto deferj^tjjfir2ai&uraf$.}
jttBj-jThey.bleedj^noJ threatened aborliori musbijbe djstingujsjjte^ ffonil^a/ylioiogi^
heeding su^afs^j^^,caused byrrijB^antagfen an4 oceftijinglijeforenthejiOlh $sry«ijElj(§$~
lftfi^jf; blee/|g5g>n^a]gr]be sj^^Bc^nt t^^imulate r|iie[jmen§lrual flow 4ndl#&ay th^el^i
responsible for miscalculations regardmg the durationjORn^estatj^fe^ Jfi is2fsj|!|s$if}ffentj
that in one study1 of 700 consecutive patients, about 28% recognized vaginal bleeding
some time between the 25th and 196th days of pregnancy and that abortion occurrect*
in only a third of these patients. The bleeding of abortion is usiMliyvc^reiter in
quantity tfapn pHysidbgic bleeding and may be r/recede^fe^^owni^^Iaeki^Kmarge
and accompanied by uterine cramps. .alfedjjJI |§ bsaoq^^
Recendy accumulating evidence very strongly suggests that/jl^e-^eatTmajorityrof
abortions are attributable to pathologic ova, which apparently constitute aboutn?0 -
40% of a?P£oncepti6rrs.nTriat tr2e'serrmust aboff^^nevWble Sna/OT course,"desirable.
There is no specific therapy of proved merit for threatened abortion and indeed
it seems unlikely that even bed rest has any value except perhaps to control the
amount of bleeding.2
The subject of HYPEREMESIS GRAVIDARUM p^npt perhaj^fjipct]^
qualify as a common complication of pregnancy, and although this; has become abi
relatively rare condrtfeh, it h&§1nQ£icea$8dl:>tb i^cdQr,ll^iit irSnirtfr^u^S£ylfrriay be
resfj®frs1ble fof a faikrr^t© pay^u^ re^eWSo^s 4emal ^tentMMHe^s^alftl^lfHMgfP
the°^n€ra^fprifirJiples undeMjirig^th^ftelifment- of^severfe' ano^mo^eratel^l^efe^
naul^I a^a3^femffirig§l)^ no *fyk$f >§ffilB££fk S^harigt?,
re^rit'ly cfe^toped^kaWSwlidg^ condeffifflPflufa a^ff^le^9ol^ei1Mavric^^::empha3iz^ithe
need fdgcSlreful atl^fibn^ePifie^^^ ?nu;rh^xH^f%ff^n^
recdrw Imr^ledge^^m^^t^lefes^Tsome of th^'fa^Sl ouSS^esPW^he^^asB^d^^rtS^'b^*
ek^dained^oKfthe basis of ftiifeire to^rScogriife^nd treat hypop6ta^ffiiMPTMs8lt'mu^rI^erl
emphasized t3ia^£hlsL'|^s3feilW^ minder?'1 trie* treai^melS^
of any patient with vomitingf in whom, particularly, 'intrav6rioulsrthera{)^fs[n^cess^f^3
ANAEMIA IN PREGNANCY. It/&iobTOus that\jM§ubJ6atJpfiAfia^©it^i0
pregnancv is a yexy broad and conmlex one, and ajrkough BQ^atibernpt can^be^ade,^?
deaT fwmLit comprehensively'• t do yja^to &aW^ practical
Because or the very large variety or unnecessarily complex and needlessly expensive haematinic preparations which are aggressively advertisecKand delalleB^id/^e*
medical profession, it seems appropriate to emphasize here tjia^jnsof ar as the. common
hypochronic, iron-deficiency anaemia of pregnancy is concerned, none of these
preparations is superior to, or in any way better than inexpensive Ferrous Gluconate
in-a dosage of five grains t.i.d,     '^^^^^^Mf':   •■'^^mM^M'M iS*—':a|l;tj^p
Iron-deficiency anaemias^^pregmnpp^ie coipmonsmiiall social strata, and as the
development of this condition is insidious and asymptomatic, I firmly believe that a
rlaemefleTOff^miaticitt dughtftPbe maefeSonce a^irfohth durih^f)re,gft?&ey.Bl
Failure to?respond promptly toffeimple Ironi T^fcdrapy should irfjmer^aldyi^Jtovoke
suspicion as to the presence of some other lesf ||if^^Jorm of-anaemia^n^piKrript a I
complete investigation of the blood picture.—Here it may be pointed outy-however^
PageagSi that certain irori*£gficie^c^a^&er^ e$ Iron,
but will respond to -iHlrSv^fe^^^^tto^f^lsteai.iGfn^n sdi zsrnii nsariijo^
.oi^hfs^fead^^gi^^g)pgfa^61^ii¥^mm^n^'^Mf:)f^^z^ arfbfi$2 recently
rejMJr&d t^tfm^^^egna^ey^a^eiiffe lwMf^3mus§3haW:)b£gri <^§ilooikedv^trequently
in the past, and whose recognition is very important if for no other rea&Sn^than that
in its severe forms it has grav^^s%iKflftiis7iqlB}^e^^^ of
pregnancy, described by Holry.^30 '
loThisiqeoridiricnjasIirefra^oriys tojjaU .'formsirif lxie^Fa^g3®dbberdthlanjfirihs6fcsiQm of
whffl^ffiliioinsfcSeGifiigatianijofif suehgpafiente s^awfe goiicsadenoe jpf liBiGnoql^cieiiJcytt
or of megaloblastic bone-marrow change.   There is sometimes a thrombocytopeniaai
aQ$iA r§JfttiYS tejffiPP6pift!ffl^fl#l§9/o^; W&WnffioiFikp ^^i^S^W3%i^n8bK^9ffi?ver>
is,<t,hat ,0§j ^KriQrnioblastic |hyE0pJ^i^f;O^citr^riWn^oi^3^>,w'i() fybi?//c&ai^t§ff£t^io9id
this anaemia that it is only seer^^gregna^y^r^^ ^$§}$^(8[}f?$h
pregnancies.,. Spontanepus^(remission;-; optJ^5Sri af>terj ^e^yerjf;} and; [ jt,$$; ^recommended
th^t ,• supplemental i^r^[; should r-l^f^j^rniniste^e^firi ^the,, puergerijinyy tOj^n^ure [ajjv,-;
a^gqu^fftfl^f1 ^v^^5bfefn^e hff&YCfil ^^ft^^i&gfi^PJ^rfB^SWir aiihdqonobvq ^iii3f>
thsiXji{jty.r:$ie,jpast; decade „anct,;,a; .half,Hrnaternalr:morbidity iand' rnortality have beeii,,
ve^a§>|>r^ia]^^'re^jy£a^
infeeuonby, means, of Sulfonamides ajodrAntibiotics and also iby, improved methods of;;
treating haemorrhage in pregnancy anj^dojg^pilsly'ia^ r4§§§SVrS$ ^bfe<^r^QI.cay^tialo
biUfS 9^ ^^^^^Q^feSi^Q^^felJn^olSoblofi^l tfMJr§risfitei($nyi nuz. 36 ^anMolSdT
Unforhanatelyb^ffere>fibag gdfo b§8Bri§ jggdil^flyaiSH^sfegJBr^r jrm^joy@me^%f^v^[C{
Te8Mff'ftirrit??r? ^r^^iirr>al?re8Pal}fl^ En^n^rf/anc'
babies.  There exists nere S great deal PrfB50ffl£rJw3TOfc to
increase in knowledge as to the nature^ ©ifvffflfc^f^^rni' iirrrT} TOVaraPffl^9lci0£ rmore
effective forms of treatment, and, last but not least, the necessi|^lr^£wg^^piMit be
termed "clinicaltSJgjJwce,''ot, Jn7^fe3$$lb{]9nn$r^
Because of the foregoing consideraqnrj& rftrffi^^/BPb^frHffto^^lD^^^S tne
remainder of this paper to a review of this whole subject. Lfj^.tha^th^ifcSaitieuIarly
^P^f^^^|p^T^?f|^^V tftnPfffflffitt £?£?!$ ~4&se^^:ea^ya11aj^fr]
accurate. recognition.an^; vigilant conscientious, antenatal f.c^rer, since the development,;.
or a superimposed pre-eclamptic toxaemia^, constitutes ^v/^f^ey^^s^^za^j^tQ^^e.^.
fi^tumkealtliL ani^^-gxpecjancy^^ of
'Briefly,, tlna,msease/,is. .attributable-, tofvascular^disease (^aracterizedKby. arteriolar0
spas^dfi£ i&qgnitHm is, x&a^^npn^^ rsr^StW
more than f^amaji^-maa^oiK, sJ^rBa^rfrrB *fl^i$^r6fe
toxaemia is avoided^  To this end every feffort should fe made, 1 to. dmHriisnqtIie
lil^fibooffWwarB: ai^r^^^rr^^l^.re^tentron bty^BM&yrQniorcecrlow.1soarum intake.
Vl^^fice^rK ffie8¥offii oT^frequenf opservarlon ofnplood prje^u^Lw^ht anaiurmar^p
outputis %qurJ^utonaeteeB  at 3tneJr earnest Ipossibidr time,  trie; development of
pre^laB^iav^In jtlie ^vejpt or tms {developing, ^atmenr must noeJrompt^ana
ade^fQSie: fr?%^^bse^e<^^rommirrmKK^ment,.tenrpog^lioiircan nave msaslffous .
re^tlI1in2ftl£ pi- of^jPfflaroni^feaVIrl^^ raraSWei:^
u?e^e|?8i^l3re
premature^r^tviti? eWn mot&n tlfe^De pftbr? af^.ilmSlIy,better tnan'me1 crMnces
or lntrautenne survival.
ni 32£3IDni D3^IBm
Tigs^H^^Iei^im^*^'feMrdWwW^oSs^^
£}^/Bjtx9 3ni >nir nOfJnsJO'i brntt^rir^ 9qvt.^a|p^ jboj
once a week af^e^Re0!I6^ri weelS
teorn
^» The hazards of this condition are summarized as follows by Jonesy.
(1) Fourteen times the normal expectancy of pre-eclampsia.
(2) Ten times the incidence of premature separation of the placenta (abruptio).
(3) Twenty times the chances of cerebral haemorrhage or convulsive phenomena.
(4) One-third the hope of obtaining a live baby.
(5) Thirty times the normal risk of maternal death.
In the light of the foregoing, I think we must all agree that we accept a very
serious responsibility in assuming charge of a pregnant patient with Essential Hypertension.
RENAL DISEASE. Any patient who shows albumin or casts in the urine
before the 20th week of gestation must be suspected of chronic nephritis, even
though there may not be an accompanying hypertension.
It is most difficult to differentiate clinically between the various types of chronic
renal disease. Most common is chronic pyelonephritis, probably originating with
acute pyelonephritis in childhood, and resulting in renal damage and a lowering of
kidney reserve, insufficient to impair health in the non-pregnant state, but sufficient
to produce manifestations of impairment when the load of pregnancy is superimposed.
This is a very serious complication of pregnancy, every succeeding pregnancy
causing additional damage to an already damaged kidney, and the life expectancy
of the patient being adversely affected thereby.
The chances of survival of the child are less than 50% and obviously the first
pregnancy of such a patient offers the best chance of a living child.
Antenatal care of these patients demands the following requirements be fulfilled:
(1) Prevention of excessive weight gain.
(2) Prevention of fluid and electrolyte retention.
(3) Adequate rest.
(4) High protein intake to avoid hypoproteinemia from albuminuria.
(5) Rigidly controlled low sodium intake.
(6) Vigilant supervision.
Only in the absence of deterioration in the patient's condition should any
attempt be made to delay termination of the pregnancy until the foetus is sufficiently
mature for survival. On the other hand, a patient with mild nephritis, in whom
there develops no evidence of increasing renal or vascular damage, no hypertension
and no toxaemia, may safely be carried to term.
Constant vigilance and frequent examinations are essential. Visual disturbances
and/or headaches are unfavourable symptoms. Untoward signs are excessive weight
gain, increased albuminuria, casts or red cells in the urine; increased hypertension,
especially the diastolic pressure; or a rise in nonprotein nitrogen, the latter suggesting
the development of a superimposed pre-eclampsia a most critical complication.
The sudden development of the foregoing signs, especially in the last trimester,
indicates renal failure, which in turn demands immediate termination of the
pregnancy before this becomes irreversible and before the* baby dies in utero.
PRE-ECLAMPSIA. More common than the foregoing types of toxaemia, but
certainly no less important with respect to its potentialities for harm, is pre-eclampsia.
This is defined by Tenney5 as a hypertensive state appearing usually in the last
trimester of pregnancy and disappearing shortly after termination of pregnancy. It
may be superimposed on previously existing renal vascular damage. It is most common
in young primigravidae, although it appears in older multiparae. .The signs are an
increase of the B.P. (especially diastolic) over pre-existing levels and the appearance
of albuminuria in the last trimester. In most cases these findings are preceded by a
marked increase in weight from fluid retention.
Fluid retention and weight gain may occur with, or without, clinical oedema, the
most serious type being fluid retention in the extravascular tissue space.
Page 30 Hypertension in pre-eclampsia is judged by a different standard from that of
essential hypertension or renal disease, the diatolic pressure being the more important
index. The latter conditions may exhibit much higher B.P. levels without the same
serious import.
In the early stages of pre-eclampsia albuminuria is the only abnormal urinary
finding. Severe toxaemia is characterized by 3 to 4 plus albumin and even by
casts and red blood cells.
Early pre-eclampsia does not usually produce symptoms and must be recognized
by the presence of the signs already enumerated. The development of symptoms,
usually cerebral and visual, indicates the approach of eclampsia. Particularly is this
true of epigastric pain.
The primary objective of treatment is elimination of retained fluid and the
best criterion of response to treatment is the amount and extent of diuresis, the
hypertension and albuminuria usually diminishing in direct proportion to the degree
of diuresis.
Although mild cases provide more time for treatment and severe cases may demand
termination of pregnancy without sufficient time for treatment to produce response,
it must be emphasized that the duration of pre-eclampsia has a more important
bearing than its severity on the production of permanent renal or vascular damage
The longer arteriolar spasm is.present, the more permanent the change in the vessel
walls.
ECLAMPSIA. Since this is a preventable disease, the only successful treatment
of which is its prevention, my only reference to this subject will concern the measures
which may be employed to prevent its development. In this regard, I wish to commend
to you the programme recommended and employed by the Women's Hospital of
Sydney, Australia, and described by Hughes6.
He sets forth the following essential points: —
(1) Antenatal care must be adequate and must comply with a high standard
of efficiency demanding an exacting control of patients, almost personal in
nature.
(2) The B.P. must be properly evaluated.
(3) The weight must be carefully observed and its significance as an indication
for treatment control and closer observation must be appreciated.
(4) Previous ideas of how often a patient should be examined must be scrapped.
(5) It must be recognized that the presence of albumin in a catheter specimen
of urine is a late sign of toxaemia and that control should commence before
its appearance. _
The programme for supervision is as follows:—
(1) A rise of 5 points in the diastolic B.P. means that the patient must be
observed within 7 days, after the 20th week.
(2) If the pressure has risen within the 7 days, the patient must be seen within
at least 2 or 3 days, according to the rise, or admitted to hospital if any
other sign has also developed.
(3) Albumin in a catheter specimen means hospitalization for observation as to
its cause.
(4) A weight increase after 20 weeks, of a pound a week, must be checked
within 7 days.
(5) If the weight increase is associated with a relative rise in B.P., irrespective
of successful weight control, Jthat patient must be seen weekly.
This programme has yielded dramatic results in the prevention of eclampsia in
Australia, as I am sure it can also do in your hands in British Columbia.
Having thus attempted to summarize the present status of pregnancy toxaemia,
this seems an appropriate juncture at which to make reference to the use of the
hypotensive drugs in the hypertensive crises of pregnancy toxaemia.
Page 31 It must here be emphasized that, although these drugs are capable of lowering
the B.P. and as such constitute a valuable adjunct in therapy, they do not constitute
a specific form of therapy, nor does their use in any way alter or modify the general
principles applicable to the accepted treatment of pregnancy toxaemias.
On the other hand, one very obvious advantage in their use relates to the simple
fact that these drugs constiute a distinctly more effective and probably much safer
means of lowering Blood Pressure than the heretofore questionably effectual employment of heavy sedation with all its undesirable, if not actually dangerous, side-effects.
Knowledge as to the causes of pregnancy toxaemia and essential hypertension
is lacking and thus it is true that any treatment presently employed may be regarded
as symptomatic. Yet it is generally agreed that the fundamental abnormality, whatever
its underlying cause, is a generalized increase in peripheral vascular resistance.
Lowering the B.P. with vasodepressor drugs in these diseases must have the
effect of decreasing the peripheral resistance without lowering the cardiac output
or the blood flow to the vital organs. This has the effect, then, of reducing cardiac
work, preventing retinal and cerebral haemorrhage and shortening the damaging
effects upon arteriolar walls.
Assali7 summarizes the situation in the following terms, which I quote: "Functionally, the disease is predominantly an acute vascular episode, and increased vascular
resistance and circulatory impairment have been found in most organs in the acute
phase of the disease. Pathologically, the various reports indicate that the most
frequent causes of death in toxaemia are cerebral haemorrhage, left heart failure and
renal failure, which usually reflect terminal stages of vasoconstriction, anoxia and
hypertension.
On autopsy, signs of ischaemia and anoxia are present in most organs and
ischaemic placental infarcts of varying degrees are almost pathognomonic of toxaemia.
Are not these common pathological and functional findings sufficient evidence toward
the damaging effects of vasoconstriction?"—the question is Assali's, not mine. It seems
reasonable to assume that the answer must be in the affirmative.
Thus it appears that generalized arteriolar vasoconstriction and increase in
peripheral resistance to blood flow are characteristic of the hypertensive states
complicating pregnancy. It has also been established that the increase in vascular
resistance is not limited to peripheral channels, but that it applies also to the
cerebral and renal circulations. An increase in the resistance of the renal vascular
bed to the flow of blood, resulting in reduction of renal blood flow and glomerular
filtration rate are factors known to exist in toxaemia and essential hypertension.
Furthermore, renal blood flow and glomerular filtration rates are decreased in
proportion to the severity of the toxaemia. As it can be shown that renal vascular
resistance is gready increased, it is deduced that it is primarily responsible for these
efforts, and it is believed that the afferent arterioles to the glomeruli are especially
involved in this vasospasm.
Cerebral vascular resistance, attributable principally to vasoconstriction, is also
greatly increased in toxaemia of pregnancy, but cerebral blood flow remains normal.
Cerebral oxygen metabolism remains normal in non-conclusive toxaemia but it is
significantly depressed during the coma of eclampsia.
According to McCall8, the following deleterious effects are caused by vasoconstriction : —
(1) Acute local tissue damage.
(2) Acute interference with visceral function.
(3) Increased peripheral vascular resistance associated with hypertension.
(4) Chronic arteriosclerotic change.
- McCall8 also points out that while hypotensive agents have been looked upon
with disfavour in the treatment of pregnancy toxaemia, widespread use has been mado
of preventing convulsions and lowering B.P. Any decrease* in the B.P. was usually
attributable to peripheral and cutaneous vasodilatation but did not ordinarily occur
Page 32 in the absence of a psychic or neurogenic cause for the vasoconstriction. He also
emphasizes that recent studies on the effects of heavy sedation on the brain show
that the agents usually employed, particularly the intravenously administered barbiturates, depress oxygen metabolism of the brain much the same as does eclampsia
itself.
The vasodepressor drugs currently advocated are mixtures of purified alkaloids
of veratrum viride, such as Deravine or Unitensen, and Apresoline. The use of the
veratrum alkaloids in combination with Apresoline has been advocated by both Assali9
and by McCalls and seems to possess certain definite advantages to which reference
will later be made.
It seems that veratrum compounds lower the B.P. without adversely affecting
the perfusion pressure to the vital organs of the body. There is a generalized
diminution in arteriolar vasoconstriction without autonomic paralysis and not from
any toxic effect on the heart. A resulting bradycardia is due to strong vagal stimulation and is rapidly overcome by atropine without affecting the hypotension. Increased
cerebrovascular resistance is diminished as the B.P. is lowered. It appears that
veratrum compounds usually increase renal vascular tone, although it appears that
there may be a later relaxation of resistance10.
Prolonged adrninistration does not result in water or salt retention nor does
it interfere with diuresis. Resistance in the peripheral vascular bed decreases without
concomitant increase in cardiac output.
Apresoline uniformly lowers renal vascular resistance and blood pressure in
cases of toxaemia and essential hypertension associated with pregnancy. Naturally
the production of hypotension and renal hyperaemia is a desirable combination of
effects in the treatment of hypertensive states complicating pregnancy. Its mode
of action is not clearly established.
If the veratrum compounds are used in combination with Apresoline, as suggested
bv Assali and Associates9 and by McCalls, the bradycardia characteristic of veratrum
and the tachycardia produced by Apresoline cancel one another and the pulse rate
remains unchanged. Other side effects of each are less pronounced, due to the
relatively smaller dose of each drug.
Assali and Associates9 recommended a dosage of Deravine 0.25 to 0.75 ml. in
combination with Apresoline 10 - 20 mgms to produce a fall in B.P. of from 35 to 40%.
This is of course administered intravenously.
McCall8 describes his recommended technique as follows: —
(1) 20 mgm. Apresoline and 5 mgm. Unitensen in 500 cc. 20% glucose. This
mixture is attached to one limb of a Y tube.
(2) Plain 20% glucose solution is attached to the other limb of the Y tube.
(3) Intravenous infusion of the vasodilator mixture is started at 20 drops /min.
(4) Blood pressures are taken every 5 min. for 2 hours, then every 15 minutes.
(5) The inflow of vasodilator infusion is regulated as necessary after each reading
to insure maintenance of B.P. at a steady level of 110-140/60-90.
(6) If systolic B.P. reaches a level below 100 mm Hg. the vasodilator infusion
is discontinued temporarily and the 20% glucose solution is substituted until
the B.P. reaches the desired level.
Urinary output increases during this therapy.
The objects of this treatment, according to the author, are as follows:
(1) To afford at least temporary relief from intense vasospasm and the damage
it inflicts.
(2) To relieve the great tension within the vascular system by lowering the B.P.
(3) To obviate the necessity of using large amounts of sedation and to eliminate
the anoxia in both mother and baby associated therewith.
(4) To insure the maintenance of normal visceral circulation and function,
through the activity of Apresoline on the kidney, combined with the overall
maintenance of homeostasis in other parts of the body with Unitension.
Page 33 (5) To gain valuable time in which to study and evaluate carefully the seriously
toxic patient under less threatening circumstances than otherwise would
be possible, while preparations are being made for the more definitive
therapy of interruption of pregnancy. pp
This plan of treatment relieves vasospasm, which is but one of the major manifestations of this disease. Iftis not specific therapy. It is of no value in patients with
mild pre-eclampsia or uncomplicated essential hypertension. It is not indicated in a
patient whose blood pressure is already falling because of severity of the disease. Its
use should be reserved for the hypertensive crises of pregnancy toxaemia.
REFERENCES
IH. Speert and Alan F. Gattmacher—J.A.M.A.  155: 712-715, June 19,  1954.
2Diddle, A. W., O'Connor, K. A., Jack R., Pearce, Q. L., Obst. & Gynec. 2:1:63-67, July, 1953.
§Jones, W. S. Amer. Jour. Obst. & Gynec. 1951: 62: 387.
4Holly, Roy G. Obst. & Gynec. 1535. 1953.
oTenney, B. New Fingland Journal of Medicine. 1953. 249:1108.
6T. Dixon Hughes. Medical Journal of Australia. 1951. 2:871.
"N. S. Assali. Obst. & Gynec. Survey. 9:6: 766-794. December 1954.
8M. L. McCall, Obt. & Gynec. 4:4 403-409. October 1954.
9 Assali, N. S. Neme, B., and Rosenkranz, J. G. Obst. & Gynec. 3:3:270. March 1954.
JORaplan, S. A. and Assali, N. S. S. G. O. 97:4:501. October 1954.
Children everywhere like it
infantol
The multi-vitamin for children
FRANK    W.    HORNER    LIMITED
Page 34 ie   mentor 5   /" aae
The Bulletin is mourning the loss of one of the most valued members of its
Editorial Board, Dr. Donald E. H. Cleveland, who died last month, after a long
illness. Don had been a member of the Board for many years, and had contributed
very gready to the work of the Bulletin, in which he always took a keen and
constructive interest. He enjoyed this work, and, we think, had a very special
affection for the Bulletin.
Don's contributions took several forms. He was a man of high literary attainments. He read widely and with impeccable taste — his was the classic type of mind —
and he kept constandy in the company of the great minds of literature. He had a
keen sense of literary values — and both in writing (of which he did a great deal)
and reading, he showed a keen appreciation of words. He was a merciless reader of
proofs, and strove constandy for perfection.
Some years ago he wrote a short, most pithy article on the writing of papers,
pointing out some simple rules for good writing. This was published in the
Bulletin, and made an excellent guide for the inexperienced.writer. He had a scorn of
cliches, and hated to see words abused, or wrongly used — and he had no hesitation
in saying what he thought. All of us on the Publications Board valued his suggestions
— and looked to him for help and guidance — and we received these in full
measure.
As a medical man, of course, Don reached great heights. In his chosen specialty
of dermatology, he rose to the very top — as was evidenced by the honours heaped
on him, not only in Canada, but also in the United States. In fact, it was while
he was giving an address in Chicago, before the Dermatological Section of the
American Medical Association, that he suffered the stroke which ultimately proved
fatal to him. His active life came to an end, as he would have no doubt wished, on
a very high note.
Don was a lover of his fellow man. He loved to be one of a crowd, to be
with other people, to take part in everything. The long list of associations and
clubs and organizations of which he was a member shows the wide range of his
interests. He was an incurable "joiner", but not for any personal gain — it was that he
just couldn't bear to see an active group of people doing something, without wanting
to get into it, and do his share — and he was no sleeping partner in any of the
organizations to which he belonged, but always a willing worker.
Many will mourn Don's loss. The Cancer Institute perhaps more than any
other, will miss him — for the work he did as clinician, as well as for his work as Editor
of the Cancer Bulletin. And the hospital staff and the university, and many other
groups will miss his wisdom and his work.
And most of all, we shall miss him as a valued friend — always genial, loyal
and generous, with his ready laugh, and his unending capacity for happy talk — for
Don loved to talk — but his talk was always interesting and stimulating — and never
dull.
And most of all, his family will miss him — and here we can only tread lighdy,
and with the deepest sympathy, for Don Cleveland was a family man. To him his
home and family and friends, his library and piano, his church and his faith, were the
best things in life, and he treasured them.
And so we say good-bye to Don Cleveland, a man it was a privilege to know —
who served his country in peace an4 war, who deserved well of his city, of his
profession, and of his friends. A very simple index of the esteem in which he was
held by those who knew him best, his own professional colleagues, is to be found in
the fact that not long before his death he was chosen to receive the award given
annually by the Vancouver Medical Association to men it wishes to honour highly,
the degree of "Prince of Good Fellows", and no man deserved it more than Don
Cleveland.
Page 55 PUBLIC HEALTH AND MENTAL HEALTH NEWS
G.  F.  AMYOT, M.D., D.P.H., Jl|j
Deputy Minister of Health, Province of British Columbia
A. M. GEE, M.D.
Director, Mental Health Services, Province of British Columbia
The Crippled Children's Registry of British Columbia are much concerned
with the large number of hard of hearing or deaf children whose names appear on
their files. It is of interest that some two years ago a pilot plan was instituted
in the Hard of Hearing Clinic at the Health Centre for Children, 715 West 12th
Avenue, Vancouver. The object of this plan was to diagnose and train the older
infantjor very young child. The plan had been conceived as a result of a visit from
Dr. Edith Whetnall of London, England.  The pilot plan study is still under trial.
It is because of this study that the Crippled Children's Registry feel that the
following article from "The Lancet" might be of interest to the doctors and
nurses of British Columbia.
"TfrnTuDiroRY approach "inthe"trainingOF DEAF CHILDREN"
By D. B. Fry, Ph.D., and Edith Whetnell, F.R.C.S., Director of the
Audiology Unit, Royal National Throat, Nose and Ear Hospital, London.
The problem of the congenitally deaf child has received attention now for
very many years; yet no method of training and educating such a child has been
clearly proved to be the best. Of the two main methods available the manual method
depends on the use of signs for communication. One of its principal defects is that
a child trained in this way, and in no other, is unable to communicate with more
than a limited section — the deaf section — of the community. Because deafness
is sometimes heritable as a recessive characteristic, this segregation encourages the
propagation of deaf children — a fact commented on over and over again by those
who have seen this side of the work. The second main method is the oral method.
This has aimed at teaching the child to speak and understand speech in others
by means of lipreading. Most deaf children have some hearing — the so-called
residual hearing — and this has been used to help the child to speak. On the other
hand few workers have used it as the main method of teaching speech.
Theaural, or preferably the auditory, method, is a development of the oral
method. Its aim is to enable the deaf child to develop hearing and speech as a
hearing child would primarily through listening.
The increased use of hearing aids has stimulated a great interest in auditory
training during the last few years, and today the method is being used in audiology
centres in many parts of the world. Nevertheless it has not been universally
accepted, and there are many children in schools for the deaf who could have been
in ordinary schools, had they been given auditory training at the right age.
There appears to be really only one reason why auditory training has not been
accepted, and that is lack of understanding of the development of hearing and
speech in the young child and of what constitutes normal hearing.
The ability to recognize the meaning of sounds or of words is by far the most
important factor in normal hearing. It is called auditory discrimination and has to
be learned by the auditory centres in the cortex. A sound is not learned on
once hearing it but only through frequent repetition; memories of sounds and
associations with their meaning are acquired slowly.
Auditory discrimination is learned during the first three years of life. The
infant first learns to discriminate between sounds and then more slowly learns
to understand speech through continual listening.  The learning of the complicated
Page 56 control of the muscles of articulation follows close behind the ability to discriminate.
It is important to realize that understanding of speech always precedes the production of speech, and therefore a period of "readiness to listen" must occur during the
first year of life. As auditory discrimination develops, the child will produce sounds
similar to those he hears.
It is now accepted that the cortical centres cban learn to discriminate between
auditory stimuli readily during the first three years of life, whereas after this
period learning becomes increasingly difficult. The deaf child without training
does not receive sufficient auditory stimuli to learn to make these discriminations.
If deafness comes on suddenly, as in meningitis, the listener cannot recognize
speech, pardy because of the sudden loss of hearing for the high frequencies.
If, however, auditory training is given as soon as the child is well enough, it may
be possible to relearn the speech sounds now heard, just as one would learn a
foreign language.
It is well known that an elderly person with perceptive deafness is one of the
more difficult patients to help, but in this type of patient, as in many others, the
disability is overcome by the use of a suitable hearing aid. The degree of deafness
which most adults have before seeking a hearing aid is such that if it were present at
birth it would have prevented them from learning speech without special help.
It is seen that a very severe degree of deafness need not prevent the child
from learning, provided that the deafness is detected early enough and that during
the period of readiness for speech there is a continual repetition of sounds within
the child's range of hearing . . . Thus it is evident that it is the learning period of
speech that is so important. It appears remarkable that it should be possible for
these children to learn speech when so much of the speech-frequency range is
missing. The explanation is that the young child can learn to discriminate between
almost any sounds, provided they are presented often enough.
The right time to start training the deaf child is during the first year of life.
The mother should be taught how to do this, for she can give the individual and
constant attention which every person who speaks has had. There is no short
cut which will eliminate the need for repetition of sounds, if the auditory areas of the
cortex are to learn. The child trained at this early age can develop speech
^during the normal physiological period.
The child, should have an individual hearing aid, which must be small and
easily worn. He must always wear the aid so that he may hear sounds continually.
The difference in response bv the young and by the older child to the use of a
hearing aid is remarkable. The young child likes his aid, wears it all the time,
and is unset without it. The older child is upset with it and will always be finding
excuses for not wearing it. He is past the age when discrimination can be learned,
and all sounds to him are noises. In addition he is a fixed visualiser. The child
with an acquired deafness of severe degree will learn to lip-read to help his remaining hearing; but once the congenitally deaf child whose hearing is untrained has been
taught only to lipread, he seems incapable of adding the ability to listen.
Few children are so deaf that they cannot hear sounds at all; most have some
hearing, though sounds loud enough to be heard by them occur so rarely that
they do not acquire meaning. Children with a litde hearing may have learned to
discriminate between noises but not between speech sounds. Sounds which have
been learned become familiar and are then easy sounds, which can be heard and
understood at greater distances than new and difficult sounds could. It is impossible
to test a child's hearing accurately until the residual hearing has been trained. The
intelligent child will make full use of a few clues which would be of less value
to the less intelligent.
The child who at the age of 4 to *Wi can discriminate vowels at the meatus
when first tested, and whose speech consists of a few unintelligible words, can be
Page 57 enabled by auditory training with a hearing aid to make good his deficiency in
auditory discrimination and to be educated in an ordinary school.
We can now select these children at an earlier age — 2 or 3 years — and
have shown that where a child hears (though he does not understand) the voice
at 1 or 2 feet, and hears a drum at 10-15 feet, he has enough hearing to enable
him to learn speech through hearing, and when trained to go to an ordinary
school.
Even when there is no response at the first examination, all children should
be given the opportunity of receiving auditory training with a hearing aid. In some
cases they will be found after several months to have an appreciable amount of hearing
Although the results are quite good at 2 or 3 years, the ideal is to start as
soon as possible after the birth of the child, so that the listening opportunities can
approximate as nearly as possible to those of the child with normal hearing. The
earliest age at which we have given a hearing aid to a child is 10 months, and
there are several others who received their aids when not very much older than this.
Most of these children are developing normally.
Auditory training, then, should be given to every congenitally deaf child if
he is to have the best chance of developing normal speech and of establishing
comparatively normal social relationships. The method should be applied as
widely as possible until such time as deafness in these young children can be
prevented altogether.
R.C.A.F. AIR EVACUATION
In recent months certain difficulties have arisen relative to air evacuation by
the R.C.A.F. within this province.
The following is a copy of previous instructions that have been published in
the Bulletin and are brought to the attention of all doctors and hospitals:
Vancouver, B.C., February 23, 1955.
Vancouver Medical Association,
1807 West 10th Ave.,
Vancouver, B.C.
Gendemen:
It has recently been agreed between the R.C.A.F. and Department of Health
of British Columbia that; when such a position exists, request for R.C.A.F.
transportation shall be made through the local Medical Health Officer.
Where no Medical Health Officer is established request will continue to
be received at the 5 Air Div. Headquarters Rescue Co-ordination Centre, Telephone
CEdar 9111, Local 132 or 137.
An extract of the regulation governing R.C.A.F. Transportation of patient is
as below.
ft/        EMERGENCY EVACUATION OF PERSONNEL "«
It is not R.C.A.F. policy to operate an air ambulance service. Mercy flights
for evacuation of those seriously ill or injured are normally to be conducted only
at the request of other government services or departments and then only in areas
where no sufficiendy rapid alternate form of transportation is available, no commercial air operator is equipped or willing to handle the flight, and no adequate
medical care is available.
The fact that those requiring emergency transportation are unable or unwilling
to pay charges levied by commercial firms cannot be allowed to influence general
R.C.A.F. policy. Requests for emergency flights where adequate alternate means
of transportation are available are to be refused with an explanation of R.C.A.F.
policy if necessary, and that applicant referred to a commercial operator.
Page 58 Where a request has been made and accepted the patient should be kept
under cover awaiting arrival of the aircraft and not held in the open at the
airport.
Yours truly,
G. C. Bending,
Squadron Leader, for Group Commander,
5 Air Division Headquarters,
4050 W. 4th Avenue,
VANCOUVER 8, B.C.
STAFF  NOTES
Dr. A. J. Nelson, formerly Consultant in Epidemiology to the Health Branch,
Department of Health and Welfare, has resigned to assume the position of
Assistant Dean and Associate Professor, Department of Public Health, Faculty of
Medicine, University of British Columbia, effective October 1, 1955.
Dr. W. S. Maddin has resigned as Director of the Division of Venereal
Disease Control and has been appointed as Consultant Syphilologist to the Division.
Dr. A. A. Larsen, formerly Director of the North Fraser Health Unit at
Mission City, has been appointed as Director of the Division of Venereal Disease
Control and Consultant Epidemiologist, effective October 1, 1955.
MEDICAL VACANCIES
The Medical Clinic at Powell River requires applications from graduates for immediate occupancy of one or two vacancies. The salary
offered is approximately that outlined in the Report on Medical Salaries, issued by the B.C. Medical Association in 1953. A position is also
vacant for a practitioner certified in Pediatrics at a higher rate of pay,
commensurate with that outlined in the same Report. Address all
communications to the Chairman of the Medical Clinic, Powell River,
British Columbia.
||for rent
Doctor's
modern office, good residential area.
25th Ave.
at Macdonald
St.   Immediate possession.
Montrea
1 Trust Company
MArine 0567
466 Howe
St.
Page 59 n
ewA an
d Iloted
Dr. Ian D. Findlay is doing post graduate work in Scodand.
Dr. J. P. Fleming is now practising in Whalley.
Dr. R. C. Foulkes is stationed with the RCAF in Fort Nelson.
Dr. J. D. Hamilton is practising in West Vancouver.
Dr. R. W. Lamont Havers is now in New York.
Dr. Bruno Lindner is now in Tahsis.
Dr. Carl McKinnon is doing P.G. work in physical medicine in Toronto.
Dr. N. Schmitt is now at Prince Rupert.
Dr. E. N. Brockway is specialising in orthopedics in Trail.
Dr. R. D. Smylie is now practising in South Burnaby.
Dr. G. A. Vanner is practising in Bella Coola and Dr. Joseph Pawlowski is at
Departure Bay.
Dr. H. H. Cuylits is now with the Metropolitan Health in Vancouver.
Dr. Q. D. Jacks is specialising in ear, nose and throat in Vancouver.
Dr. M. F. Angus is at the Montreal General Hospital in Surgery.
Dr. C. A. Forssander is at the Montreal General Hospital.
Dr. J. R. Hemstock is now on Resident staff, Queen Mary's Veteran's Hospital,
Montreal.
Dr. Fred Harder is now practising with Dr. Roy McNeil of New Westminster.
At the Annual Meeting of the Victoria Medical Society held on October 11th,
1955, the following officers were elected: President, Dr. W. A. Trenholm; Vice-President, Dr. G. F. Homer; Honorary Secretary, Dr. J. Boyd Roberts; Honorary Treasurer,
Dr. James W. Anderson. Library Committee, Drs. H. H. Murphy, Jack Anderson
and P. M. Ransford.
Births — Born to Dr. and Mrs. Whitehead, a son.
Dr. George W. Hall, resident of Victoria since 1905 and former president
of the B.C. College of Physicians and Surgeons and the B.C. Medical Association,
died in St. Joseph's Hospital October 1st, after a lengthy illness. He was 73 years of
age.
Following his graduation from Trinity College in Toronto, he came to
Victoria to open a practice with his uncle, the late Dr. Frank Hall. He retired
three years ago.
The younger doctor went overseas with the 16th Battalion during the First World
war, rising to the rank of lieutenant-colonel and winning the Distinguished Service
Order on the field.   He was also with the army hospital service.
Dr. Hall was an Honorary Member of the staffs of Royal Jubilee and St.
Joseph's hospitals and a consultant at the Wilkinson Road Mental Hospital. He
was recognized as an authority on medicine and surgery. Survivors are his widow,
Elsa, at home, 1720 Rockland, and one brother, Magistrate H. C. Hall.
Page 60 CANADIAN  MEDICAL ASSOCIATION
BRITISH COLUMBIA DIVISION
PROCEEDINGS
OF
THE ANNUAL GENERAL MEETING
October 5, 195 5
AND
THE GENERAL ASSEMBLY
October 4, 195 5
Hotel Vancouver, Vancouver, B.C.
Page 61 PROCEEDINGS
of  the
1955    ANNUAL    MEETING
Canadian Medical Association — B.C. Division
OCTOBER 5th - 8 P.M.
BANQUET ROOM - HOTEL VANCOUVER
1. Call to Order — Chairman, Dr. Frank Turnbull, President.
2. Financial Statement and Appointment of Auditors.
The financial statement for the year ending December 31, 1954, Was presented
to the General Assembly in February and published in the February 1955 Bulletin.
A statement for the first six months of 1955 was presented by the Honorary
Secretary-Treasurer, Dr. R. A. Palmer, for information.
FINANCIAL STATEMENT—1955
First Quarter
Second Quarter
Jan. 1 - Mar. 31
Apr. 1 - June 30
RECEIPTS:
Membership  Dues
33,980.00
2,780.00
Founders' Fund — conrtibutions
365.00
750.00
— interest, Bar
ik & Bond
-  -
314.80
CM.A. — Refund re Secretaries
'■>, Conference
- -
311.81
Overpayment to C.M.A. — Mem
ibership Dues
20.00
- -
Interest — Bank and Bond
- _
194.85
Commercial  Exhibits — Annual
Meeting
- -
2,882.00
$34,365.00
$7,233.46
DISBURSEMENTS:
Travelling Expenses
Board of Directors
235.15
91.85
Canadian Medical Association
375.90
- -
District Tour
305.25
227.35
Economics
172.25
- -
Executive Secretary
97.13
1,185.68
640.34
959.54
Committee  Expenses:
Public  Relations
1,207.13
1,101.45
Board of Directors
3.25
3,00
Reference
-
1,210.38
270.62
181.00
1,285.45
General Assembly Expenses
- -
Vancouver Medical Association 1
3ulletin
150.00
150.00
Administrative & General Expenses:
Salaries—Executive Secretary
3,000.00
3,000.00
—Office  Staff
1,770.00
1,770.00
Audit  Fees
250.00
- -
Bank Charges
9.80
3.25
Gazette-Printing   &   Postage
125.77
153.77
Medical Services Association
6.52
4.89
Miscellaneous Expenses
33.25
20.00
>t
Postage
240.97
298.93
Petty   Cash   (indnease)
5.00
—      -»
Rent  —  Office
390.00
390.00
Telephone & Telegraph
74.42
75.90
Unemployment Insurance
19.50
19.50
Office  Supplies
806.53
6,731.76
797.47
6,533.71
9,548.44
8,928.70
Page 62 Investments:
Savings Account 8,027.67
Founders' Fund Account 2,006.92
Excess of Receipts over Disbursements
Excess of Disbursements over Receipts
CASH BALANCE:
Cash in Bank as at overdraft
General  Account 1,283.98
Savings Account
Founders' Fund Account
1,283.98
10,034.59
19,583.03
14,781.97
1,695.24
$34,365.00
$7,233.46
Dec. 31, 1954
Mar.31,  1955
8,999.52
2,064.13
20,167.58
3,971.85
422.21
11,063.65
1,283.98
24,561.64
Add — Increase for the period
Cash in  Bank as at
General Account
Savings Account
Founders'   Fund Account
BUDGET
REVENUE:
Membership — 1,280
In'erest — Saving and Bond (18x30.25)
C.M.A. Grant — P.G. Medical Education
9,779.67  (Deduct-decrease
14,781.97  (for the period 1,695.24
$24,561.64
Mar. 31, 1955
20,1667.58
3,971.85
422.21
$24,561.64
— 1956
$22,866.40
June 30, 1955
17,212.69
4,166.70
1,487.01
$22,866.40
$38,400.00
550.00
1,000.00
$39,950.00
EXPENDITURES:
Administration and General:
Salaries: Executive Secretary
Office Staff
Rent
Postage, Telephone and Telegraph
Office Supplies and Misc. Expense
Travelling Expenses:
Executive — Auto
District Tour
Board of Directors
Economics Committee
Vancouver Medical Association
Audit
Committee Expenses:
Reference Committee
Public Relations
Annual Meeting
Depreciation
Surplus
Bulletin
$13,500.00
7,260.00
1,560.00
1,500.00
4,000.00
800.00
900.00
800.00
500.00
400.00
2,700.00
27,820.00
3,000.00
600.00
250.00
3,100.00
1,000.00
500.00
3,680.00
$39,950.00
MOTION — THAT Buttar & Chiene be appointed auditors of the Association
for the coming year. Carried.
Page 63 3.    Report of Chairman of General Assembly
In reporting the activities of the General Assembly for the past year only
slight reference can be made to the most important phases of its business.
One cannot help but be impressed with our Financial Report, particularly
since our Honorary Secretary-Treasurer is planning a budget in the neighbourhood of $40,000.00. This gives one some idea of the growth and strength of our
organization.
Another noteworthy report is that on Group Insurance Policies. Reports were
made on four such group policies and all of them appear to be flourishing. This
gives one some idea of the tremendous change which has occurred in four short
years and emphasizes the virility of our Association.
In reference to the committee reports one notices that there are no less than
sixteen great committees. The Public Relations Committee's work was reported
by Dr. Bagnall and he stated that there were over one hundred doctors involved
in its activities during the past year. There is the Committee on Medical Economics
and its various sub committees, which always reports a vast amount of work and
when one reads the report of the Committee on Public Health, on the Foetus and
Newborn, only to mention a few, one gets some idea of the tremendous work and
intelligence and long hours which have been spent by a great number of our
doctors on behalf of this Association.
On the political scene our successes are not as bright. Our chief concern
has been to achieve satisfactory liaison with the Government. We have tried
diligently to do this for the last four years. From time to time the goal seems to
be within our grasp but then it proves to be a mirage, which shimmers and
rapidly fades into a haze of political nonsense. New tactics and a new approach
have to be developed after each failure. Why this should be we do not
understand, since our only objective is to help those who appear to be beyond
their depth, to protect the public and to raise the general standard of medical
care.   Nevertheless, we must persist in our objective.
Another perennial problem is our own internal economics. This year there
have been two meetings of the General Assembly and many hours of debate have
been held on this subject. Economics is a personal matter and affects each of our
members very intimately. Nevertheless, the discussions have been restrained,
reasonable and very much to the point. Perhaps our evolution has been too rapid.
We are used to a free economy, in which the financial arrangement between* the
doctor and his patient is a very simple matter. Suddenly, we have been thrown
into a rigid pre-paid financial structure, which involves a third person armed with facts
and figures which are foreign to us. So far, we have attempted to solve problems
about the periphery as they arise but the basic fault has escaped us. This year we
came to a decision on the Internists' problem but no one is particularly happy
about it. We also made a decision on the Surgical Fees structure but no one would
suggest that this is a panacea. No doubt these were courageous decisions but we must
go further. Our objective must be to remove all sources of friction between the
General Practitioners and the Specialist, between the Physician and Surgeon and
between the employed and the self-employed doctor. One feels optimistic that all
this will be achieved in the not too distant future.
Gordon C. Johnston, M.D.,
Chairman General Assembly. -*
Amendments to Constitution and By-laws — Dr. H. Carson Graham
Each of the following amendments was moved, seconded and agreed.
1. That By-Law No. IV Sec. 1 be amended by deletion of the word "New"
in line ten so that this line will now read "District No. 5 shall comprise
the County of Westminster." 2. That By-Law No. V Sec. 2 be amended bv the addition of the words "And
Immediate Past President" after the word President.
3. That By-Law No. VII Sec. 2, sub sec. 3 para, (d) be amended by the
deletion of all words after the word "Association".
4. That By-Law No. VII Sec. 2, subsec. 4- para (a) be amended by the
deletion of the last sentence.
5. That By-Law No. VII Sec. 2, subsec. 4 para (c) be amended to read:
The Secretary shall keep the records of the Committee and perform
such other duties as may be required of him by the Committee or the
Board of Directors and shall keep accurate record of any expenditure
incurred on behalf of the Committee and shall submit accounts for payment
to the Honorary Secretary-Treasurer of the Association.
6. That By-Law No. VII Sec. 2, subsec. 7, be amended by rewording as
follows "In the event of a tie the Chairman may cast a second ballot."
7. That By-Law No. VII, Sec. 2 be amended by the deletion of Subsections
11,  12,  13 and 14.
8. That By-Law No. XIV be amended by adding a new section to be called
Section 4 and to read as follows:—
The representative to the Canadian Medical Association Executive, when
first appointed by the General Assembly, must be an Officer of the Association, He may subsequendy be reappointed annually by the General
Assembly, but not for more than five years consecutivelv.
5.    Report of the President — Dr. Frank Turnbull
It is my pleasure now, as retiring President, to report to you about my year
in office. It has been an interesting, stimulating and rewarding experience. In
retrospect, the highlights are twofold. On the one hand; the successive meetings
with representatives of Governmnt in Victoria — sombre and serious occasions
as a rule, illuminating in the behind-the-scenes glimpses of Government in action,
often frustrating, occasionally rewarding when one sensed a respect by Government
for the