BULLETIN OF The Vancouver Medical Association EDITOR dr. j. h. macdermot EDITORIAL BOARD DR. D. E. H. CLEVELAND DR. J. H. B. GRANT DR. H. A. DesBRISAY DR. J. L. McMILLAN Publisher and Advertising Manager W\ E. G. MACDONALD VOLUME XXIX. JULY, 1953 NUMBER 10 De. E. C. McCoy Past President Dr. F. S. Hobbs Hon. Secretary OFFICERS 1953-54 Db. D. S. Munboe Db. J. H. Black President Vice-President Db. Geobge Langley Hon. Treasurer Additional Members of Executive: Db. R. A. Gilchbist Db. A. F. Habdyment TRUSTEES Db. G. H. Clement Db. Mttreay Blair Db. W. J. Doebance Auditors: R. H. N. Whiting, Chartered Accountant SECTIONS Eye, Ear, Nose and Throat Db. W. M. G. Wilson Chairman Db. W. Ronald Taylob Secretary Db. J. H. B. Gbant. Paediatric Chairman De. A. F. Habdyment Secretary Orthopaedic and Traumatic Surgery Db. W. H. Fahbni Chairman Db. J. W. Spabkes Secretary Neurology and Psychiatry Db. A. J. Wabeen Chairman Db. T. G. B. Caunt Radiology Db. W. L. Sloan Chairman De. L. W. B. Caed -Secretary .Secretary STANDING COMMITTEES Library Db. D. W. Moffat, Chairman; Db. R. J. Cowan, Secretary; Db. W. F. Bie; De. C. E. G. Gould ; De. W. C. Gibson ; Db. M. D. Young. Summer School Db. S. L. Williams, Chairman; Db. J. A. Elliot, Secretary; Db. J. A. Ibvine ; Db. E. A. Jones ; Db. Max Fbost ; Db. E. F. Wobd Medical Economics Dr. E. A. Jones, Chairman; Db. W. Fowlee, De. F. W.. Huelbubt, De. R. Langston, Db. Robebt Stanley, Db. F. B. Thomson, Db. W. J. Doebance Credentials Db. Henby Scott, Db. J. C. Gbimson, Db. E. C. McCoy. V.O.N. Advisory Committee Db. Isabel Day, Db. D. M. Whitelaw, Db. R. Whitman Representative to the Vancouver Board of Trade: De. J. Howaed Black Representative to the Greater Vancouver Health League: Db. W. H. Cockcboft Published monthly at Vancouver, Canada. Authorized as second class mail, Post Office Department, Ottawa, Ont. Page 427 CANADA'S FIRST AND FOREMOST PROFESSIONAL PHARMACY Itlacdo Medical-Dental Britain^ icriplions PA.J4141 ~Jrree L^itu oDeliueru and ^rree J-^rovincial [•^odtaai Page 418 BULLETIN OF i The Vancouver Medical Association EDITOR DR. J. H. MacDERMOT EDITORIAL BOARD DR. D. E. H. CLEVELAND DR. J. H. B. GRANT DR. H. A. DesBRISAY DR. J. L. McMILLAN Publisher and Advertising Manager W. E. G. MACDONALD /OLUME XXIX. JULY, 1953 NUMBER 10 OFFICERS 1953-54 Db. D. S. Munboe President Db. Geobge Langley Hon. Treasurer Db. J. H. Black Vice-President Db. E. C. McCoy Past President De. F. S. Hobbs Hon. Secretary Additional Members of Executive: Db. R. A. Gilchbist Db. A/F. Habdyment TRUSTEES Db. G. H. Clement Db. Muebay Blair Dr. W. J. Doebance Auditors: R. H. N. Whiting, Chartered Accountant SECTIONS Eye, Ear, Nose and Throat Db. W. M. G. Wilson Chairman Db. W. Ronald Taylob Secretary Db. J. H. B. Gbant Paediatric .Chairman Db. A. F. Habdyment Secretary Orthopaedic and Traumatic Surgery Db. W. H. Fahbni Chairman Db. J. W. Spaekes Secretary Neurology and Psychiatry Db. A. J. Waeben Chairman Db. T. G. B. Caunt Secretary Radiology Db. W. L. Sloan Chairman De. L. W. B. Caed Secretary STANDING COMMITTEES Library Db. D. W. Moffat, Chairman; Db. R. J. Cowan, Secretary; De. W. F. Bie; Db. C. E. G. Gould ; De. W. C. Gibson ; Db. M. D. Young. Summer School Db. S. L. Williams, Chairman; Db. J. A. Elliot, Secretary; Db. J. A. Ibvine ; Db. E. A. Jones ; Db. Max Fbost ; De. E. F. Wobd Medical Economics Db. E. A. Jones, Chairman; Db. W. Fowleb, Db. F. W.. Hublbubt, Db. R. Langston, Db. Robeet Stanley, Db. F. B. Thomson, Db. W. J. Doebance Credentials Db. Henby Scott, De. J. C. Gbimson, Db. E. C. McCoy. V.O.N. Advisory Committee Dr. Isabel Day, Db. D. M. Whitelaw, Db. R. Whitman Representative to the Vancouver Board of Trade: De. J. Howard Black Representative to the Greater Vancouver Health League: Db. W. H. Cockcboft *ubliihed monthly at Vancouver, Canada. Authorized as second class mail, Post Office Department, Ottawa, Ont. Page 427 Announcing: a New and Specific Narcotic Antagonist- potent and well-tolerated Effect of 'Nalline on respiratory depression caused by 57 milligrams of morphine.1 Nalline is a specific antidote for poisoning following accidental overdosage with morphine and its derivatives, as well as meperidine and methadone. This new product, the Merck brand of JV-Allylnormorphine, rapidly reverses respiratory depression. The respiratory minute volume promptly increases and the rate increases two- or threefold. A recent study2 of 270 parturient women indicates that Nalline may be of value in obstetrics. Onset of breathing occurred significantly sooner in infants from mothers (sedated with meperidine) who were given Nalline 10 minutes prior to delivery. Literature available Wm lEckenhoff, J. E., Elder, J. D., and King, B. D., Am. J. Med. Scs. 223:191, February 1952.2Ecken- hoff, J. E., Hoffman, G. L., and Dripps, R. D., Annual Meeting of the American Society of Anesthesiologists, Washington, D. C, Nov. 8, 1951. SUPPLIED: Solution of Nalline Hydrochloride in 2-cc. ampuls containing 10 mg. of active ingredient, 5 mg./cc. Nalline comes within the scope of the Opium and Narcotic Drug Act and regulations made thereunder. NALLINE TRADE-MARK (JV-ALLYLNORMORPHINE HYDROCHLORIDE, Merck) Research and Production for the Nation's Health ' Page 428 MERCK & CO. Limit] Manufacturing Chemists MONTREAL • TORONTO • VANCOUVER • VALLITl HOSPITAL CLINICS VANCOUVER GENERAL HOSPITAL Regular Weekly Fixtures in the Lecture Hall Monday, 8:00 a.m.—Orthopaedic Clinic. Monday, 12:15 p.m.—Surgical Clinic. Tuesday—9:00 a.m.—Obstetrics and Gynaecology Conference. Wednesday, 9:00 a.m.—Clinicopathological Conference. Thursday, 9:00 a.m.—Medical Clinic. 12:00 noon—Clinicopathological Conference on Newborns. Friday, 9:00 a.m.—Paediatric Clinic. Saturday, 9:00 a.m.—Neurosurgery Clinic. ST. PAUL'S HOSPITAL Regular Weekly Fixtures 2nd Monday of each month—2 p.m Tumour Clinic Tuesday—9-10 a.m Paediatric Conference Wednesday—9-10 a.m Medical Clinic Wednesday—11-12 a.m—. Obstetrics and Gynaecology Clinic Alternate Wednesdays—12 noon Orthopaedic Clinic Alernate Thursdays—11 a.m—£ Pathological Conference (Specimens and Discussion) Friday—8 a.m. Clinico-Pathological Conference (Alternating with Surgery) Alternate Fridays—8 a.m. Surgical Conference Friday—9 a.m Dr. Appleby's Surgery Clinic Friday—11 a.m. I Interesting Films Shown in X-ray Department SHAUGHNESSY HOSPITAL Regular Weekly Fixtures Tuesday, 8:30 a.m.—Dermatology. Monday, 11:00 a.m.—Psychiatry. Wednesday, 10:45 a.m.—r-General Medicine. Friday, 8:30 a.m.—Chest Conference. Wednesday, 12:30 p.m.—Pathology. Friday, 1:15 p.m.—Surgery. BRITISH COLUMBIA CANCER INSTITUTE 2656 Heather Street Vancouver, British Columbia SCHEDULE OF CLINICS AND MEETINGS—1953 Every Monday—9:00 a.m.-10:00 a.m Ear, Nose and Throat Clinic 11:45-12:45 p.m. Therapy Conference Every Tuesday—11:00 a.m.-12:00 p.m Clinical Meeting 12:00 noon-1:00 p.m Therapy Conference Every Wednesday—11:45 a.m.-12:45 p.m |5- Therapy Conference Every Thursday—11:45 a.m.-12:45 p.m Therapy Conference Every Friday—9:00 a.m.-10:00 a.m j Lymphoma Clinic (during February) 10:15 a.m.-ll:15 a.m. (as of March 6) \ -.Lymphoma Clinic 11:45 a.m.-12:45 p.m - Therapy Conference Page 429 (fat turn-over, literally) WYCHOL provides an important advance in lipotropic "therapy: it combines choline with crystalline inositol. The choline content of WYCHOL is more than twice that of most other choline preparations. The lipotropic activity of choline is enhanced by the action of inositol. WYCHOL is offered for use in the prevention an(J treatment of excessive fat infiltration of the liver or vascular system and the sequels . . . cirrhosis, nephrosis, atherosclerosis, diabetes, hypothyroidism, etc. WYCHOL CHOLINE AND INOSITOL WYETH SUPPLIED: Syrup WYCHOL, bottles of 16 fl. ozs. Capsules WYCHOL, bottles of 100. JWqitt*r«d Trod* Moik Page 430 * VANCOUVER HEALTH DEPARTMENT STATISTICS—APRIL, 1953 Total population (estimated) 390,325 April, 1953 Rate per Number 1000 pop. Total deaths (by occurrence) 450 13.g Deaths, residents only .419 12.9 Birth Registrations—residents and non-residents (includes late registrations) . April 1953 Male ; 5 01 Female 479 Infant Mortality—residents only Deaths under 1 year of age 980 32 30.1 Death rate per 1000 live births _ 43.9 Stillbirths (not included in above item) ; 6 CASES OF COMMUNICABLE DISEASES REPORTED IN CITY April, 1952 Cases Deaths Chicken Pox 97 — Diphtheria — — Diphtheria Carriers .— — — Dysentery _- 9 — Dysentery Carriers • ; — — Erysipelas 1 — Gonorrhoea 109 — Infectious Jaundice 15 — Measles 127 Meningitis ( meningococcic ) , Mumps . , 1 Poliomyelitis Rubella Salmonellosis Salmonellosis Carriers. Scarlet Fever Syphilis Tetanus 1 294 2 11 1 37 10 Tuberculosis 3 8 Typhoid Fever '. — Typhoid Fever Carriers [ — Undulant Fever _- — Whooping Coughs ? 11 OTHER REPORTABLE DISEASES Cancer 61 1 7 April, 1953 Cases Deaths 135 — 2 134 178 123 10 2 115 11 46 1 11 62 80 52 illlamti pleasant CJjanel I FUNERAL SERVICE Kingsway at llth Ave. — Telephone EMerald 2161 Vancouver 10, B.C. flfot. pleasant Tanoertahina Co. %tb. Page 433 —FOR PROLONGED ACTION— CORTICOTROPHIN cacth) with PROTAMINE and ZINC | Corticotrophin with Protamine and Zinc, for prolonged action and in a form convenient for use, is now available from the Laboratories. The product is prepared as a milky suspension in aqueous medium and is ready for use after shaking. In clinical investigations, two injections per day have been found to replace adequately four daily injections of regular Corticotrophin (ACTH). In some cases even greater prolongation of effect may be experienced. Corticotrophin with Protamine and Zinc is prepared with ingredients whose properties are of established value in parenteral administration. The Connaught Medical Research Laboratories now provide Corticotrophin (ACTH) in three forms—a dried powder, a sterile solution, and a suspension with prolonged-action properties. HOW SUPPLIED Dry Powder —10 International Units per Vial —25 International Units per Vial Sterile Solution —10-cc. vial (20 I.U. per cc.) Prolonged-actinsr Suspension —10-cc. vial (40 T.XJ. per cc.) CONNAUGHT MEDICAL RESEARCH LABORATORIES University of Toronto Toronto, Canada Eatabliahcd1 in 1914 for Public Service through Medical Research and the development of Product! for Prevention or Treatment of Di tease. DEPOT FOR BRITISH COLUMBIA MACDONALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. Page 434 The forthcoming annual meeting of the B. C. Division of the Canadian Medical Association bids fair to be a memorable one. We are publishing the programme in this issue. A great deal of work is being done on it and from the announcements to date, it is going to be very well worth attending—in fact, nobody should miss it. A great deal of interest, and also a great deal of discussion has been aroused by the latest effort of the Public Relations Committee of the Division. We refer, of course, to the public forums that were held at the Georgia Street Auditorium lately, with the co-operation of the Vancouver Daily Province, which paid all the expenses of the undertaking, and through whose publicity efforts a great deal of public interest was awakened. We are not at all sure that the Province did not have the easiest part of the task. The amount of work done by those medical men who participated was enormous—their sacrifice of time and effort was very great. Opinions differ a great deal about this project, running all the way from enthusiastic praise to an attitude of complete hostility. Personally, we have been tremendously interested in the undertaking, and feel like congratulating its sponsors rather cordially. It is, of course, a rather radical departure from our normal behaviour as a profession but that does not necessarily condemn it. It is the first time, we believe, that anything of the kind has been undertaken—and it is perhaps still in the experimental stage, and a matter to some extent of trial and error. To judge by some of the remarks and criticisms heard, some men feel that it is infra dig: others that it is a waste of time and effort. Some feel that there was rather too much publicity given. And there is the occasional lay critic who thinks it was a stunt on the part of the profession—one kindly correspondent even suggests that it was just a commercial stunt to secure patients. One mentions this only to say that such a suggestion is beneath contempt. But certain things stand out, which we think merit our consideration and justify further effort along these or similar lines—perhaps with some modification where experience shows this to be wise. In the first place, it was an honest effort to educate and help the public. The tone of both meetings was optimism and reassurance and from our reading of the talks given, we should say that every attempt was made to allay unnecessary fear, and to introduce a note of common sense and helpfulness. In the second place, it certainly aroused public interest. The public evidently wants to know facts and the truth, given in language that they can understand, and the hundreds of questions sent in show that they do want to know these things. The audiences were friendly and eager to learn. Again, the complete coverage given by the other Vancouver newspapers, the Sun and the News-Herald, who had themselves nothing to gain by such coverage, shows what great news value such forums have, and how eager the papers are to co-operate with us in such efforts. We are told that further forums are contemplated, and it will be very interesting to watch further developments. It took considerable courage on the part of those who organized this project, to undertake a scheme so different and so full of possible difficulties. It also took, as we have said, a very great deal of hard work, and we do not imagine that those who represented us enjoyed the limelight at all—that was merely an additional burden. Whatever the outcome, and we believe it will be nothing but good, they deserve a great deal of credit for their effort. Page 435 Nineteen hundred and fifty-four will be a very important year for British Columbia, since the Annual Meeting of the Canadian Medical Association is to be held in Van-1 couver next June. Canada is a large country, and it takes a long time to cover it all,! but next year is our turn. A very good beginning has already been made—in the selection of the new President,! in the person of Dr. G. F. Strong. This appointment could not, we think, have been! bettered—and we have heard nothing but the most cordial agreement with this view.! The choice of any man as President of the C. M. A. is a signal honour—the highest! honour the profession can bestow and nobody has deserved it more thoroughly than has \ Dr. Strong, whose record of achievement in British Columbia is a long and very full one and constitutes a great contribution to the public good. It is perhaps hardly necessary to recapitulate all the things that Dr. Strong has done I in this province—but it is a pleasure that we hate to deny ourselves. For many years, he has been a leader and a source of constructive achievement. He has filled the Presi-a dencies of the B.C. and Vancouver Medical Associations, he has been President of the Community Chest of Vancouver, of the Greater Vancouver Health League—he organized the B. C. Medical Research Council, now actively at work at the Vancouver General Hospital and the Rehabilitation Centre for Paralytics and Spastic Diseases owes its existence mainly to his energy and organizing ability. His work at the B. C. Cancer Institute has been outstanding. He has been Chairman of the Medical Staff at the Vancouver General Hospital and his work as an internist and particularly as a cardiologist is too well known to need comment. He is on the teaching staff of the University—in the Medical Faculty. One wonders often how one man can do all these things, and in the doing display such energy and strong leadership. And so while we congratulate Dr. Strong on his appointment, we feel that we, as a Canadian profession, are also to be congratulated on having him as our President for the corning year. Other B. C. men, too, have been chosen to head various Sections and Societies for the coming year. In Dermatology, for instance, Dr. D. E. H. Cleveland of Vancouver has been elected President of the Canadian Dermatological Association, which will also meet here in June 1954. With him will be associated Dr. D. H. Williams, as Vice-President and Dr. Ben Kanee as Secretary, both of Vancouver. Dr. H. Fidler has been named President of the Pathologists Section of the C. M. A. Dr. J. E. Harrison will head the North Pacific Obstetrical and Gynaecological Association which will hold its Annual Meeting here at the same time as the C. M. A. Altogether, Vancouver will have plenty to offer next year to the Canadian medical profession, many of whom, with their wives and ladies will be our guests. It will be our duty, and a most delightful duty, to turn in and do all we can to make the 1954 Annual Meeting of the Canadian Medical Association the best meeting it has ever held. OFFICE SPACE Doctor returning to Vancouver to open limited practice in one of the Surgical Specialties desires to share office space with another doctor in the West Broadway Granville district. Practice is entirely a hospital one so that office requirements are minimal. Replies treated confidentially and adequate references can be provided. Forward replies care of Publisher, 675 Davie Street, Vancouver 2, B.C. Page 436 Rummer Hours: Monday to Friday 9.00 a.m. Saturday 9.00 a.m. - 5.00 p.m. - 1.00 p.m. Recent Accessions: The Surgical Clinics of North America, June, 1953. Lahey Clinic. Collected Papers of the Mayo Clinic and the Mayo Foundation, 1952. Transactions of the South Eastern Section of the American Urological Association. Florida. April, 1952. The Surgery of Infancy and Childhood, by Ladd & Gross. 1st ed. 1953. A Textbook of X-Ray Diagnosis by British Authors: edited by S. Cochrane Shanks and Peter Kerley. 4 vols., 1952. Influenza and Other Virus Infections of the Respiratory Tract, by C. H. Stewart- Harris. 1952. Diseases of Children, by Garrod, Batten and Thursfield. 5 th ed., 1953. Blood Transfusion in Clinical Medicine, by P. L. Mollison. 1952. Hospice. Here at whatever hour you come, you will find light and help and human kindness. BOOK REVIEW GUY'S HOSPITAL — 1725-1948 Every Canadian doctor should know something of the great teaching hospitals of Great Britain. A glimpse is given of one of the really great hospitals of London in a short volume of 176 pages—"Guy's Hospital 1725-1948." This handsome book is copiously illustrated and is printed in large type and has recently been added to our library through the Historical and Scientific Fund. This record brings one into the atmosphere of some of the greatest minds of medicine of the mid-nineteenth century and gives one a feeling not only of humbleness but of great pride in belonging to a profession with such leadership and such traditions. Richard Bright, who established the knowledge of kidney disease; Addison, who was the first to describe pernicious anaemia, and the disease of the supra-renal gland which is known as Addison's disease, were two physicians of Guy's Hospital who, Page 437 through great industry, careful observation, and the genius for correlating their facts, have added in crystal clear English something permanent to the very structure of; medicine. Wm Hodgkin was the first to recognize and describe the disease which still bears hisj name. Strange as it may seem, Hodgkin was never on the clinical staff of Guy's Hospital, but in 1825 was appointed curator of the museum and lecturer of Morbid Anatomy. There were also great leaders in surgery from its earliest days onwards,-Sir Astley> Cooper, Cline, Hilton and in more recent times Arbuthnot Lane, to mention a few. Hilton wrote that classic, "Rest and Pain," which every student of medicine shouldj read. The all inclusive nature of this history is indicated by the special chapters dealing) with the founding and development of both the dental school and of the training school for nurses. In 1855 "Guy's Hospital Reports" mention Thomas Bell, F.R.C.S., as giving a course of lectures on Dental Surgery. Bell was a man of great learning, for he was a fellow of the Royal Society and was appointed Professor of Zoology at Kings College, London. The unfailing vigor and industry of Guy's men could not be better shown than) by the two publications connected with the hospital—Guy's Hospital Reports, a quarterly which was started in 1836, and Guy's Hospital Gazette, which began in 1873. Both) are still flourishing. Guy's Hospital suffered severe damage during the last war as the enemy dropped) 135 bombs of one kind or another on its premises. The present historical volume of Guy's Hospital has been the work of the Guy's j Hospital Gazette Committee with Hujohn Ripman the editor. This is an excellent book for any doctor's spare time reading. —William D. Keith. DOCTOR G.L.H.—IN MEMORY— He was too young, as we count passing years, Though all were filled with others' pain and care, He was well loved, which makes the worth of life— He still is being kind—somehow, somewhere! Sometimes he had to break his tragic news, Even then, with sorrowing smile, his face would light— One felt he sorrowed as one did oneself-1- And that he'd bear it for one, an he might! And so good-bye, dear friend of many years. God rest your kindly soul, in His own peace, There's many a lonely soul will miss you hear— Yet thank Him for your swift and glad release! A.H.K. We take pleasure in printing this tribute to our late colleague, Dr. G. L. Hodgins, who died recently. The author, Mrs. Robert Kidd, is the sister of Miss Firmin, whom most of us will remember as our valued Librarian for so many years at the Vancouver Medical Association Library. Page 438 Chairman's Address at the June, 1953, Meeting of Trans-Canada Medical Plans Winnipeg, Manitoba. Chairman: E. C. McCoy, M.D., Vancouver, B.C. MEMBERS OF THE COMMISSION, ADMINISTRATORS AND GUESTS: It is a pleasure to welcome you to this, the 6th meeting of T.C.M.P. Commission. It is an even greater pleasure to welcome you to this meeting in Manitoba—which really is an ideal meeting place for any organization that is Canada-wide—because Manitoba is both east and west. We in the west consider Manitoba part of the east—most easterners consider Manitoba part of the west. It is thus in a very happy position to help weld east and west together, and I believe it was very fortunate that the first chairman of the commission was Manitoba's representative, Dr. Pat McNulty, who very ably guided us through the first year of organization. It is thus most appropriate that our meeting should be held here and we hope that it will be a fruitful one. We have now come to the end of the second year since the formation of T.C.M.P. They have been two years of planning and organizing—and meetings for exchange of ideas. Two years ago we decided that we needed T.C.M.P. but hadn't too much idea of exactly what it would do—or what shape it would take. We knew only that it would help provide prepaid medical care for the people of Canada on a voluntary basis. At that time only six provinces were represented with seven plans participating. Now seven provinces are represented with nine plans participating and applications pending which will cover two more provinces—so there is a good possibility that by the end of this meeting we shall have nine provinces represented in T.C.M.P. Also we are now ready to move from the planning stage of T.C.M.P. into the actual operational stage. Within the next month we will be establishing a head office in Toronto —and we will also have a full-time executive director. Up until now he has been on a part-time basis only. We know now the shape T.C.M.P. will take—at least at the start. The head office and executive director will function as a co-ordinator between the various plans. Actual coverage of patients will remain on a local or provincial level with T.C.M.P. acting as a co-ordinator—in handling national accounts—and in collection and presenting statistics —and in gradually encouraging development of a more uniform type of coverage across Canada. In selling any product or arranging for the provision of any service, you need three basic things: (1) A demand for the product. (2) A method of handling the product—that is to arrange for production and payment. (3) A method of producing the product, or in the case of a service you need someone to produce the service. In looking at the problem of T.C.M.P. and provision of prepaid medical care, I'm sure that we are now at the stage where the demand for the service is already there. We don't have to sell the service—the people want it and are demanding it. In looking at the second point, our voluntary non-profit prepaid care plans as under .T.C.M.P. certainly give us what we believe to be the best method of handling the service. The third point is the one I wish to emphasize—that is someone to produce the service. Certainly as an organization, the Canadian Medical Association is behind these plans 100%. However, it is just as certain that all doctors are not behind them 100%, and I believe that is a point we must consider very seriously. Page 439 If a doctor is going to produce a service that is good and efficient he must like the service and to do that he must have good working conditions—he must be adequately remunerated and he must not have to spend too much time with red tape, etc. We have to spend some effort at convincing doctors that this system of providing medical care is best for them—as well as for the patients. There may be some parts of the work they may not like—certain rulings and red tape may annoy them—but they must realize that the overall system is good. We should work very closely with C.M.A. in some good public relations with the doctors of Canada in this respect. We believe it is the plan's responsibility to acquaint the doctors with the details of coverage and terms of service of the individual plans—but it certainly should be the profession's job to acquaint the doctors with a proper understanding of what are the best basic principles of prepaid medical care and why voluntary non-profit prepaid medical care is better from both doctor and patient's point of view. We can set up the best prepaid care plan in existence—but if the doctors providing? the service are not convinced of its merits they will not be behind it, and if they are not behind it the plan cannot succeed. The plan also must learn how to control its abuses and occasional dishonesty— by either patient or doctor—and it must do this in a firm and definite manner—and yet not in a way that makes a rule which penalizes all the honest participants. I believe there is considerable work that needs to be done to persuade or demonstrate to doctors that this is the best way to provide prepaid medical care—that is that it will provide more and better medical coverage—at a lessor cost—and with better working conditions than any other system will. If we believe this then we should all be behind this. If we don't believe it then we should be backing some other plan which we believe would; be better. I believe that most of the objections that we do hear are from people who| are being destructive rather than constructive. They do not know of any other method] that is better, but they dislike the little inconveniences or bits of red tape in which they may become involved and as a result they criticise the whole system without having anything better to offer. We need to work together—and iron out small inconveniences—or differences of opinion—but at all costs retain proper perspective and back the plans as a whole—j and make them work. At the last meeting—in January—we attempted to point out where T.C.M.P.; can fit into a national health insurance plan for Canada, and I believe we should attempt to retain some perspective of this in our deliberations here. Durin gthe next two days we have several important matters or problems to discuss! It is hoped that favorable consideration will be given to applications for coverage for two more provinces through T.C.M.P. and if so that would then mean that all provinces would be represented except Newfoundland, and we would be well on the way to having truly national coverage. PROGRESS REPORT In Winnipeg, Quebec Hospital Service Association and Maritime Hospital Service Association were taken into full membership in Trans-Canada Medical Plans for coverage in Quebec, Prince Edward Island and New Brunswick. This means that Trans-Canada Medical Plans now offer a truly national coverage* in Canada through its member plans. There are doctor-approved plans in every province except Newfoundland at the present time. The head office is being opened in Toronto in July and a full-time executive, Mr. C. Howard Shillington, formerly executive director of Medical Services Incorporated, Saskatoon, takes over at that time. The officers elected at the Commission meeting are as follows:^* Dr. E. C. McCoy, Vancouver, B. C, chairman. Dr. H. H. Lees, Windsor, Ontario, vice-chairman. Page 440 Dr. R. M. Parsons, Red Deer, Alberta, honorary secretary. Dr. S. A. Orchard, Saskatoon, Saskatchewan, honorary treasurer. Dr. H. E. Britton, Moncton, New Brunswick, member at large of the executive. Other members of the Commission are as follows: Dr. P. H. McNulty, Winnipeg, Manitoba. Dr. G. C. Ferguson, Port Arthur, Ontario. Dr. I. W. Bean, Regina, Saskatchewan. Dr. N. H. Gosse, Halifax, Nova Scotia. A representative from Quebec is still to be named. All in all, a very successful meeting was held in Winnipeg and it is felt that good ■progress has been made in T.C.M.P. to date, as after two years we now can supply I coverage on a national basis. PUBLIC HEALTH ASPECTS OF EPIZOOTIC RABIES By A. John Nelson, M.D., D.P.H., and I. W. Moynihan, D.V.M., M.Sc. (From the Department of Public Health and the Dominion Laboratory of Animal Pathology, University of British Columbia, Vancouver, B.C.) AETIOLOGY AND EPIDEMIOLOGY Rabies is an infective disease, caused by a neurotropic virus discovered by Pasteur | in 1881. It is transmitted to man and most warm-blooded animals through the infective saliva of biting animals (canines). In man, ninety per cent of cases originate from dogs. rXhe virus inoculum passes from the local wound via the peripheral nerves to the central Nervous system and after a variable incubation period produces an illness of sudden onset characterized by fever, nervous exaltation and violent muscular spasms. The duration tof the incubation period, which may vary from 11 days to over a year (average 42 pays is determined by the extent and location of the wound, and the quantity and ^strength of the virus introduced. Thus, bites through clothing are not as dangerous as those on bare skin. Bites about the face, head, or neck are the most serious; for, since the infection travels along the nerve routes, the period of incubation tends to be short in the case of such bites, because of their proximity to the brain. Rabies has never been prevalent in Canada. Localized outbreaks have been reported in Eastern Canada, for example, in Montreal (1927) and in Huron County, (Ontario (1940), probably due to the importation of infected animals from the Eastern United States, where the disease is endemic. The present epizootic of rabies appears to have originated when the first animal case was diagnosed at Baker Lake, N.W.T., in April, 1947. Since then, the disease has spread in a westerly, and latterly, a south-westerly (Erection, to involve adjacent provinces—thus the first case was reported in Manitoba in September of 1951, the Yukon Territory was implicated in April, 1952, the Province of Alberta in the same year, and recently the disease has- appeared in Northern British Columbia. The following animal species have been implicated in Canada to date: dog, I fox, pig, wolf, rabbit, lynx, horse, and cattle. At the time of writing, six positive identifications of rabies in the animal life of this Province have been reported. Inasmuch as epizootic rabies is a reportable disease under the Animal Contagious j Diseases Act, (1927) the responsibility for the control of rabies in animals is primarily a Federal responsibility through the Health of Animals' Division of the Federal Department of Agriculture. The appropriate measures of control, such as the establishment of a quarantined area, the destruction of susceptible wild animals within that area by ! trapping and poisoning, and the protection of susceptible domestic animals by vaccina- I tion, are properly the concern of Federal veterinarians, and medical responsibility should therefore be limited to the protection of the public within the quarantined area. Page 441 f RABIES IN ANIMALS The clinical picture of rabies is similar in different species of animals. However, certain variations are present, depending on the mode of life, temperament, and body structure of the animal. While rabies is primarily a disease of the canine species i.e., the dog, wolf, fox and coyote, all warm-blooded animals are susceptible. The habits of the dog and his species,! the unrestricted freedom which many of them enjoy, and the fact that biting constitutes •their natural mode of defence, make them pre-eminently fitted for the transmission of this disease and responsible for the rapidity with which large outbreaks cover unlimited areas. The incubation period in natural infections is extremely variable, depending for the most part on the distance between the site of infection and the central nervous system. Clinical signs of rabies in the dog vary from "furious rabies" to "dumb rabies". The former is the type where classical "mad dog" symptoms appear. In furious rabies the prodromal symptoms are vague and consist of a slight change in the behaviour. In the case of household pets, the only change may be an increased tendency to skulk, or they may become more affectionate than previously. Gradually the animal becomes irritable and excited. It will snap and bite at non-existent objects, become easily startled by sudden stimuli, and inflict extensive injury to its own body. Dyspnoea, anorexia, inequality of pupils, and a weakness of the vocal cords resulting in a characteristic voice change are present in the early stages of the disease. At the height of the irritable stage the animal becomes vicious and violent. If caged, it will make every effort to escape. If free, the animal will wander far from its home, attacking any living thing that appears in its path. During this time the animal finds it increasingly difficult to swallow food and water, hence it will avoid them. The characteristic salivation is due to deglutition difficulties. Paralysis ensues rapidly and the animal usually dies four to seven days after the onset of the disease. Death may occur during a convulsive seizure, or the animal may become completely paralyzed and die in coma. The furious form of the disease always progresses to the dumb form if the animal lives a sufficient length of time. In dumb rabies the prominent symptoms consist of drowsiness, melancholia, and a paralysis of the lower jaw, tongue, larynx, and pharynx. There is a tendency for the animal to run away and hide. Food and drink are left untouched because of the inability to swallow. In contrast to furious rabies there is no irritability or tendency to bite, unless the animal is disturbed. The paralytic symptoms gradually become more pronounced, and the animal lapses into a coma and dies two or three days after the onset of the disease. Rabid animals are relatively insensitive to pain and often mutilate themselves during an attack of furious rabies. Rabid wolves and foxes frequently invade farms and attack man and domestic animals in the daytime. Wild animals with dumb rabies avoid company, seeking death in seclusion. When infection takes place in the cat, the disease progresses very rapidly, terminating fatally within a few days after the commencement of symptoms. The animal is extremely restless and excitable, moves about persistently in an erratic manner, and seldom remains at ease. The eyes assume an unusual brilliancy, the pupils are dilated, resulting in a wild frightened expression. Great thirst is apparent, but there is no desire for food. The animal may show a tendency, however, to pick up and swallow stones, sticks and other foreign bodies. The voice rapidly changes to a loud harsh tone. Saliva flows profusely, which with persistent licking soon moistens the coat of the animals, and adds to its dejected appearance. Any noise or excitement may be followed by paroxysms; these may occur frequently, and during them the animal jumps about furiously and will attack a dog, or other animal or man. Page 442 DIAGNOSIS OF ANIMAL RABIES Any wild animal which is suspected of rabies, or any domestic dog which develops rabid manifestations during the observation period prescribed below, should be immediately killed by a shot through the chest. The soft tissues of the neck, and cervical vertebral column are severed, and the complete head and intact skull of the animal should be wrapped in waxed paper, and packed in ice and sawdust within a tin box or some such suitable container. The specimen should then be forwarded, with a detailed history of events preceding the death of the animal, to the Laboratory of Animal Pathology, University of British Columbia, Vancouver 8, B.C., for pathological examination of the brain, and mouse inoculation tests. The typical pathological lesion of rabies in the central nervous system in all animals is the so-called "Negri body". This pathological aggregation is from 0.5 to 18.0 microns in length, occurring in the cytoplasm of nerve cells. The bodies are most numerous within the large motor nerve cells situated near the periphery of the hippocampus convolution (Amnion's horn) and consist of hyaline-like cytoplasm containing one or more chromatin granules. Throughout the central nervous system of infected animals, there appear multiple foci of invasion which appear as disseminated areas throughout the midbrain and cord, as well as in typical areas of perivascular infiltration. Accurate microscopic diagnosis must be made by the use of special staining techniques. RABIES IN MAN By no means all patients bitten by rabid animals die, but once clinical manifestations appear the disease invariably ends fatally, since no specific treatment is known. The protection of the human subject is therefore entirely dependent upon the application of preventive measures during the relatively long incubation period. PREVENTIVE MEASURES (1) A suspected dog should be chained up, muzzled, and kept under the observation of a veterinarian. Should the animal be alive at the end of ten days, it is proof that the bitten person has not been infected. In the case of a wild animal whidh is suspected of rabies, or a dog which develops rabid manifestations while tinder observation, proceed as outlined above for diagnosis of animal rabies. (2) Treatment of animal bites. Formerly, cauterization with fuming nitric acid, was recommended, a procedure accompanied by considerable tissue damage. Recent experimental work (Shaughnessy and Zichis, 1943) suggests that preferably a recent puncture wound, or one that is otherwise inaccessible, should be enlarged and irrigated to its depth with a twenty per cent aqueous solution of soft soap introduced under pressure from a 20 or 50 cc. syringe. Then, after debridement, the wound should be sutured. (3) Anti-rabies vaccination. Owing to the long incubation period it is feasible to attempt to immunize patients. The modified Semple vaccine, as prepared by Connaught Medical Research Laboratories, consists of a four per cent suspension of "fixed" rabies virus prepared from the brains of rabbits and inactivated by irradiation with ultraviolet light. The vaccine contains merthiolate 1:10,000 as a preservative, and is put up in the form of courses, each containing fourteen 2 cc. ampoule doses. The volume and strength of the vaccine is the same in each ampoule. Full instructions for the administration of the vaccine by subcutaneous injection over the abdomen, are enclosed with each packaged course. Owing to the small but definite danger of neuro-paralytic accidents following anti-rabies vaccination of human subjects, the vaccine is not recommended for an immunization program of the general public within an area quarantined for rabies. Page 443 Patients for vaccination should be selected only if they fall into the following categories: (a) Persons bitten by animals which have been proved rabid either by clinical symptoms or by microscopic examination of the brain. (b) Persons whose hands or face have been contaminated with saliva of a rabid animal without being bitten. This is because of the possible presence of cracks, hang-nails or other small open wounds. (c) Persons bitten by stray dogs, when it proves impossible to locate the dog for observation and diagnosis. (d) Persons bitten by an animal whose behaviour or symptomatology was sus- j picious, pending laboratory examination of the brain of the biting animal. Inasmuch as the immunity conferred by vaccination lasts a varying period of time, and gradually wears off, prohylactic treatment should, therefore, be repeated in persons bitten a second time. The Health Branch of the B.C. Department of Health and Welfare is prepared to supply anti-rabies vaccine for the prophylactic treatment of patients falling within the above-mentioned categories. All requests for vaccine should be directed 1 in the first instance to the local Medical Health Officer. RECENT DEVELOPMENTS Current research, mainly by Koprowski and Cox of the Lederle Laboratories at Pearl River, N.Y., is proceeding along two lines: (1) Clinical evaluation of combined passive-active immunization, the patient being given a horse or rabbit serum concentrate immediately after exposure to confer a temporary passive immunity, followed a few days later by vaccine treatment. The passive immunity so conferred would suffice to carry the patient through the greater part of the observation period prescribed for a suspect animal, while the course of vaccine therapy could be shortened considerably, thus decreasing the risk of neuroparalytic accidents. (2) The Flury strain of rabies virus has recently been attenuated by passage in chick-embryos. Its use in the avianized rabies vaccine for the immunization of dogs suggests that it may confer a more durable immunity than that conferred by vaccines containing inactivated virus. It is understood that this avianized anti-rabies vaccine has passed preliminary clinical trials in the human subject and that field trials are to be undertaken in the near future. REFERENCES Shaughnessy, H. J., and Zichis, J. Prevention of experimental rabies. J.A.M.A., 123: 528, 1943. Koprowski, H., and Cox, H. R. Recent developments in the prophylaxis of rabies. Am. J. Pub. Health, 41: 1483, 1951. OFFICE SPACE Doctor's office conveniently located. Approximately 1,050 sq. ft. Available October. For particulars phone KErrisdale 0484-L evenings. CEdar 5814 mornings Page 444 THE DIAGNOSIS OF APPENDICITIS W. E. Austin, M.D., F.R.C.S. (Edin.), (C), F.A.C.S. The mortality rate from appendicitis has fallen sharply in the last 20 years. Slattery1 of New York recently analyzed 942 cases of acute appendicitis treated between 1928 and 1947 inclusive and found an over-all mortality rate of 4.1%. The first 5 years had a rate of 6.3% and last 8 years only 1.5%. During this time the mortality rate for unruptured acute appendicitis dropped from .6% to 0.4%. That of ruptured appendix in any form is still nine times greater despite antibiotics, gastric suction and intravenous feeding. Therefore one of the aims of this paper is to improve our diagnosis so as to reduce still further this more lethal group. The second object of the presentation is to point out that appendicitis is still too often misdiagnosed. A recent survey of 3 5 0 cases diagnosed as acute appendicitis in the Vancouver General Hospital, January to June 1950 shows that 64% only were actually found to be acute by the pathologist. Another 4.6% showed some chronic changes. The remaining 31% (109 cases) were quite normal. Of this latter number the symptoms were due to other disease in 30 cases (9%). Joffe and Wells2 report 27.5% of normal appendices in 1000 cases examined and suggest that in a good surgical practice not more than 15—20% should be normal. There is, therefore, room for improvement both in diagnosing acute appendicitis early when we see it, and in avoiding the diagnosis when it is not there. There is a tendency to think at times that the removal of a normal appendix is not of great moment, and indeed the risk is estimated at one thirteenth that of a ruptured appendix. However, as honest clinicians we must feel chagrinned and defeated when our diagnosis is proven wrong. Factors which influence mortality are the taking of: 1. Purgatives. 2. Delay in seeking advice by the patient. 3. Delay in early diagnosis by practitioner. Consideration of the subject suggests a division into acute and chronic appendicitis. In the old days when pathologists were more generous chronic productive appendicitis was a common lesion. Now when they bluntly report that the organ so carefully removed is a "vermiform appendix" one may be pardoned for blushing occasionally. It is not my intention to pursue the differential diagnosis of chronic appendicitis except to say that it is probably rare. An appendix with a foreign body or a definite fecolith or pin or round worms in it might qualify, but when faced with such a diagnosis one had better consider carefully such things as mesenteric lymphadenitis, urinary tract disease or stone, regional ileitis, or that happy hunting ground, the female pelvis. A recent urologic survey showed that 25-30% of cases had had the appendix erroneously removed. The diagnosis of acute appendicitis may be ridiculously easy in the typical case but there are so many bizarre pictures that even the most experienced may be confused. The abdomen that is opened for a suspected perforated ulcer and reveals an acutely inflammed highly situated appendix is not uncommon. The varied locations of the appendix from below the liver to the pelvis and all the areas between, both intraperitoneal and retrocaecal contribute not a little to the difficulties. A simple classification of acute appendicitis is the following: 1. Acute imperforated— a. Acute catarrhal, or cellulitis or the appendix. b. Acute obstructive. 2. Perforated— a. Abscess. b. General peritonitis. Page 445 The typical case of acute appendicitis is in a person under 40, more commonly male, who exhibits intermittent crampy abdominal pains in the epigastric or umbilical regions, associated soon after with anorexia, nausea and vomiting. (Thorek states that if the appetite is not affected doubt the diagnosis). After a varying period the pain shifts to the lower right quadrant. If the lesion is obstructive the pains will be frequent and severe and vomiting probably a marked feature. Time is not the important element which decides the pathology but rather it is the degree of obstruction. An obstructed appendix may perforate in a few hours while the catarrhal type may be unruptured after several days. Constipation is usual in this condition. Only in pelvic appendicitis or when peritonitis is present is diarrhoea at all likely. The history of a previous similar attack is suggestive. On examination the temperature is usually not raised more than 1° or 2°, and the pulse is often normal or only moderately increased. The tongue is usually furred and the breath heavy. The legs may be drawn up as the patient lies on his back or his side. There is localized tenderness at McBurney's point accompanied by involuntary muscle spasm. Rectal examination may reveal increased tenderness high on the right. The white blood count will range from 10,000-15,000 with increased polymorphs and staff cells. The urinalysis is negative and examination of the other systems is normal. If the patient is asked to sit up, he does so with care and if he walks he often bends forward with his hand over his right lower abdomen. The typical case of acute appendicitis may thus often be diagnosed from the history shown—crampy abdominal pains, a "bellyache", beginning in the mid-abdomen and shifting to the lower right quadrant and associated with nausea and vomiting is appendicitis until proven otherwise. When local tenderness and muscle guarding are present the evidence is strong. Why then do we misdiagnose so many cases, even allowing for the percentage of cases with unusual and complicating manifestations? The answer probably lies in an inadequate history and examination. Five minutes spent in getting an account of the sequence of events and the present complaints, a questioning regarding the other systems and of any past or recent illnesses or operations, would prevent many errors. Another five minutes examining the patient would eliminate many more. Checking his temperature and pulse, looking at his throat and tongue, examining his chest and doing a rectal are just as important and revealing as putting a hand on his abdomen. In a female the presence of vaginal discharge or bleeding should always be looked for despite a negative history. A urinalysis, a catheter specimen if necessary, is a must if one is to avoid operation on urologic cases and the occasional diabetic. The W.B.C. and differential are good aids to diagnosis, the latter being particularly valuable from a prognostic point of view. However, if the blood picture doesn't seem to fit in with the clinical diagnosis it may at times have to be disregarded. Even at that it should cause us to give pause for a moment's reflection and a restatement of the case. If the history and findings are not conclusive then there are a few well known tests which may aid in a decision: 1. Observe the chest and abdomen during the inspiration. Both ordinarily come out together. If the abdomen remains still or goes in, it is suggestive of peritoneal irritation. 2. Have the patient distend his abdomen. If this causes further pain it also suggests peritoneal irritation and the patient can often tell you where it hurts. 3. The test for rebound tenderness if positive is a fairly reliable indication of peritonism. 4. The test for epicritic hyperaesthesia by pin prick or by plucking the skin with two fingers (Ligat's Test) over Sherren's triangle may be helpful as long as the appendix is not ruptured, (positive in 86%). 5. Rovsing's sign is obtained when pressure over the left colon produces pain in the lower right quadrant by increasing the intraluminal pressure. Page 446 6. The flank should be examined for rigidity in suspected cases of retrocaecal appendix when there are few abdominal signs. 7. Baldwin's test, also for retrocaecal appendix, is present when pressure is made over the painful area in the loin and the patient told to raise his right leg with the knee stiff, at which he cries out with pain or drops his leg. 8. The obturator test is applied by flexing the right thigh with the knee at a right angle and then medially rotating the thigh. This puts the obturator internus on stretch. If a pelvic appendix is present this may cause abdominal pain in the hypogastrium. 9. The psoas test is performed with the patient on his left side when the right thigh is hyperextended and abducted. If an inflamed appendix is in contact with the muscle, the manoeuver is painful. From the typical case there may be many variations. The temperature or pulse or both may be normal. There may be very little tenderness or rigidity when the appendix is in a posterior position. There may be no vomiting. The patient may have forgotten or fail to tell you that the original pain was mid-line. There may be no [appreciable rectal tenderness. There may be a few pus and red cells in the urine when an acute appendix lies against ureter or bladder. There is a non-localizing form of appendicitis which in the early (3) stages, especially the first 8 hours, will exhibit few signs of its presence. It has been suggested that the diagnosis may be made by a history of: 1. Mid-line pain which persists for 8 or more hours. 2. Anorexia. 3. A downward urge to defecate. The pain persists despite bowel movement and even despite diarrhoea. Three questions may help in this connection: 1. At the onset of the attack did you have a sensation of gas stoppage in your bowels? 2. Did you feel if you could pass gas that you would be relieved? 3. Were you relieved when you were able to pass gas through the rectum? If you happen to see the patient in the so-called "stage of illusion", just after the appendix has ruptured, he may state that he no longer has pain, there may be little tenderness or rigidity, and only a rising pulse and fever may explain his position. If a tender mass is palpable it may be an abscess but it may also be an appendix wrapped in omentum and safely removable. This is one of the arguments in favor of exploration of an abscess. If diarrhoea and mucus are present a pelvic abscess is almost certain. When general peritonitis is present the pulse and temperature will be elevated, the patient will look ill, hollow-eyed and anxious. The abdomen will move little and will have widespread rigidity and peritonism. This is the state to be avoided for even with antibiotics the mortality is many times that of the risk of a simple appendectomy. Before we consider the differential diagnosis there are a few special considerations— In children—8.6% of acute appendices are in children under 10 years. Acute appendicitis is rare under 2 years of age. It is more common in the late winter and early spring months. The history of a purgation is more serious and the condition runs Page 447 "a more rapid and deadlier course" (Ladd and Gross4) and general peritonitis is more often present. The shorter omentum, the higher position of caecum and appendix, and the wider calibre of the appendix are factors favouring wider spread of the disease. Vomiting is practically always present. Appendicitis may occur during an upper respiratory infection or an acute exanthem, particularly measles. Careful inspection and gentle palpation are essential. In the aged—acute appendicitis is less common than— 1. Acute obstruction due to hernia or other causes. 2. Acute cholecystitis, and 3. Diverticulitis, but occurs in about 10% of acute abdomens. The reaction in* these old people is below normal and yet the disease often runs a fulminating course. Of 17 cases over the age of 65 reported by Beck5 all had either a gangrenous appendix j or an actual performation. A low grade fever, a pain which is often minimized by patient and relatives alike and a little tenderness, may suggest a lesion much less acute j than it really is. In the pregnant woman—the symptoms are those of ordinary acute appendicitis butj because of the pains which accompany pregnancy and because of the vomiting which may also be a feature of that condition the possibility of appendicitis may not even be considered. With advancing pregnancy the situation of the appendix rises so that at 5 months it is on the level with the umbilicus and in the last trimester it is higher. In acute appendicitis the point of maximum tenderness will be at the corresponding higher level. A moderate leucocytosis may not be of much help because there is a leucocytosis of pregnancy. Because of these features diagnosis is often late and gangrene and perforation are 3 to 5 times more common. The mortality of peritonitis cases is given as high as 30%. The dangers of abortion increases sharply from 11.4% in ordinary acute; appendicitis to 72% in cases with peritonitis. Delay in diagnosis is the main factor responsble. If appendicitis is suspected and a catheter specimen of urine is negative operation should be carried out without delay. During menstruation appendicitis may occur and not be considered because dys- menorrhoea is often present. A recent editorial stressed this strongly. The differential diagnosis of appendicitis is legion but a few of the more common ones may be briefly mentioned. 1. Pyelitis—dysuria, frequency, chills, tenderness over the kidney, pus in the urine. 2. Pneumonia—signs of respiratory embarrassment, use of the alae nasi, cough, increased respirations. Absence of deep abdominal tenderness. Rigidity which may disappear if the chest is splinted. Fever higher, leucocytosis higher. Chest film—especially necessary in children. 3. Salpingitis—often with or just after a period. Pains low, bilateral, usually backache. Vaginal discharge. High leucocytosis. Tender masses in fornices. 4. Ruptured Tubal Pregnancy—period missed or just due. Sudden pain and fainting. Low crampy menstrual-like pain. Pallor, sub-normal temperature. Boggy mass in pouch of Douglas. Spotty bleeding and intermittent pains in subacute attacks. Ruptured Graafian follicle—onset half way between periods. Pain low. fever. Peritonism present from blood. No Page 448 6. Mesenteric lymphadenitis—in children and young adults. May have pain, fever, vomiting, tenderness and elevated W.B.C. Usually appears less ill than signs suggest. When less acute, local abdominal tenderness and rigidity are less than they would be in appendicitis. 7. Meckel's diverticulitis—Not common. Tenderness more subumbilical. May bleed. 8. Terminal ileitis—Acute, usually diagnosed as appendicitis. May be palpable swelling. May have diarrhoea. 9. Primary peritonitis in children—after upper respiratory infection, prostration. High fever. W.B.C. 30,000-50,000, due to streptococcus or pneumococcus. 10. Renal colic—Pain in loin referred to genitals. Worse on jolting movements. Blood in urine. Other conditions which are mistaken for appendicitis are: lead poisoning, diabetic coma, Herpes Zoster, epididymitis, torsion of the testicle, intussusception in children acute enteritis in children, acute cholecystitis, acute pancreatitis, perforated ulcer, perorated diverticultis, torsion of ovarian cyst. In conclusion, may I again reiterate that most cases of acute appendicitis can be diagnosed by an adequate history and examination. There is nothing so satisfying as a substantiated diagnosis and the sense of achievement that goes with it, and nothing so humiliating and so unfair to the patient, as a wrong diagnosis made because of an inadequate investigation. REFERENCES 1. Slattery, L. R. et al; Acute appendicitis, evaluation of factors contributing to decrease in mortality in Municipal Hospital over 20 year period. Arch, of Surg.; Vol. 60, P. 31-41, Jan. '50. 2. Joflfe, H. H. and "Wells, A. H.; Normal appendices in 1000 appendectomies. Minn. Med.; Vol. 29, P. 1019-1021, Oct. '46. 3. Keyes, E. L.; A new method for the early diagnosis of acute appendicitis in the absence of localization. Surg. Clin, of N. A. ; P. 1447-1456, Oct. '50. 4. Ladd, W. E. and Gross, R. E.; Abdominal surgery in infancy and childhood. P. 201, W". B. Saunders Co. 5. Beck, W. C; Acute abdominal disease in the aged. Surg. Clin, of N. A.; V. 28, P. 1361-69, Oct. '48. IMPORTANT ANNOUNCEMENT 200 .. . PRIZE Donated by British Columbia Surgical Society—for the Best Paper of the year on a Surgical, Medical, or Scientific subject. Limited to Students or Graduates under 30 years of age. For Details, Write DR. S. A. McFETRIDGE Sec reta ry-Treasu rer 718 Granville Street, Vancouver, B.C. FOR SALE X-Ray Portable on stand, in excellent condition. Fuloroscope, developing tank, etc. M DR. J. H. MacDERMOT CEdar 4214 1701 West Broadway Page 449 o I—I t/j pi O H 1—4 y o en I HH Q (4 S 2 Q 2 ►* u Si CO X P^ g V pi a, 4> CO Q u co o> £ s m V CO CO 1 c ro TJ £ « **2 | >. -Q TJ TJ 4- c O o 1- 4- (0 • [» * c OF O 3 0) U c CD TJ LU ll a> c o 4- (TS i_ 4- (/> CJ) V _ 4- .5 x u > 10 CL c < 0) XI o o o u CD ro c 4- i_ 0) __ TO CU a CO tj CD u 4- x X —> CO _i \1 E 4- ro V h- ro o £ o c u _Q) LU TJ C c cu 4- c 1 0 CO 1 c ' 1 c_ ^ 1. 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CU a. o 4- a cu a. cu 4— 3 U < O i- cu i: P'o 3 U) - CO TJ U ^ °l to ii ^_ • !2 o ^ to +. t." 4- C I .° ro ll. c cu — »-S o S 8' S1 i- ro u X u co cu a x LU TJ cu ro o w c 0 <0 X u c z E _ o c 0 v X o cl 3 ro 3 C C < E a o rt CO 'to 10 fl) O 4» TJ c C C CJ) -— 3 O L_ ro b o 1- 4— to — ro C ro ro O g o «j 4- * CO 4~ c CD 4- c r U) j_ 3 CO E CD i_ CD *4- >4- Q o 4- c CD £ cu CJ) ro X o £ CD CD X O CC CD -_ (J 3 O CO TJ TJ 3 CO o 10 CU CJ) ro cu ro co of a. J1 CO J. o o , CU ro c ro cc ~* LU c_ 1- © X ro CO ro c __ i_ _ V. __ in h- 4— Q L_ Q Q Q o o cm u i_ • CD cu c c > 3 O u Q _ ro __ > ro 3 C "cu 4- _ o < I cu CO ro — cu _i < cu Q I cc m cu c Q cu 13 o CQ E 1 a < o ^ CO U in* o o CM CO — X CQ E "5 U co CO Ifrtttsijr Columbia Htutatnn Canadian Mvftxtal JVsBnriatian 1807 West 10th Ave., Vancouver, B.C. Dr. G. Gordon Ferguson, Exec. Secy OFFICERS-1952-1953 President—Dr. J. A. Ganshorn Vancouver President-elect—Dr. R. G. Large Prince Rupert Vice-President and Chairman of General Assembly—Dr. F. A. Turnbull Vancouver Hon. Secretary-Treasurer—Dr. W. R. Brewster ; New Westminster Members of the Victoria ' Dr. G. Chisholm Dr. E. VV. Boak Nanaimo Dr. C. C. Browne Prince Rupert and Cariboo Dr. R. G. Large New Westminster Dr. J. A. Sinclair Dr." VV. R. Brewster Yale Dr. A. S. Underhill Dr. C. J. M. Willoughby Board of Directors Vancouver Dr. F. A. Turnbull Dr. A. VV. Bagnail Dr. F. P. Patterson Dr. P. O. Lehmann Dr. G. C. Johnston Dr. Ross Robertson Dr. R. A. Gilchrist Dr. J. Ross Davidson Dr. R. A. Palmer Kootenay Dr. J. McMurchy Standing Committees Constitution and By-Laws Finance Legislation Medical Economics Medical Education Nominations— Programme and Arrangements Public Health__ Chairmen Dr. R. A. Stanley, Vancouver Dr. W. R. Brewster, New Westminster .Dr. J. C. Thomas, Vancouver Dr. P. O. Lehman, Vancouver Dr. T. R. Sarjeant, "Vancouver Dr. J. A. Ganshorn, Vancouver Dr. Harold Taylor, Vancouver Dr. G. F. Kincade, Vancouver Special Committees Arthritis and Rheumatism- Cancer Civil Defence Hospital Service Industrial Medicine- Maternal Welfare -Dr. F. W. Hurlburt, Vancouver j Dr. Roger Wilson, Vancouver Dr. John Sturdy, Vancouver Dr. J. C. Moscovich, Vancouver Dr. J. S. Daly, Trail Dr. A. M. Agnew, Vancouver Membership Dr. E. C. McCoy, Vancouver Pharmacy Dr. D. M. Whitelaw, Vancouver. Public Relations Dr. G. C. Johnston, Vancouver PUBLIC MEDICAL FORUMS The recent spread of medical forums for the public apparently began in Florida. The reception was so enthusiastic that it has spread to other parts of the States. I understand that in Atlanta the tremendous response has encouraged them to put it on television in the near future. In spite of these reports of the great success of these forums there was considerable trepidation on the part of the Public Relations Committee about starting them in Vancouver when the Vancouver Province approached the B. C. Medical Association in this regard. It was felt by the executive and the chairman of the Public Relations Committee that they should inflict the responsibility for the first two on the Page 452 members of the Public Relations Committee. The above mentioned trepidations of that committee were felt a hundredfold by the two moderators, more espcially when the terriffic publicity appeared in the press. The doctors whose pictures were so prominently ipsplayed are tending to slink around town with their coat collars up so that no one will recognize them. However, the executive and the rest of the committee, back them up completely so that the groups chosen appeared on the two respective forums even though their knees were knocking. As far as the public were concerned, we were assured by the response and by the newspapers that the forums were a terrific success. They are apparently having considerable effect along the lines which we desired. The expression was used by one person that ftThe doctors are again becoming part of the community." The whole subject of these were discussed again at the last meeting of the Public Relations Committee and it was felt that they should be continued in the fall. The present plan is to hold them monthly, beginning in September. It will, of course, be an entirely new moderator and panel for each forum so that the names of those appearing will tend to be forgotten, and the public will remember only that it was doctors representing the B. C. Medical Association. We certainly appreciate the co-operation and sponsorship of the Vancouver Province which made these forums possible with no cost to our Association. F.L.S. M-S-A COVER FOR EMPLOYEES IN DOCTORS' OFFICES That employees in offices of the doctors in active private practice may have coverage under M-S-A, it is proposed to enter into a trustee-type plan with M-S-A. This provides that the doctors enter into an agreement amongst themselves and appoint a trusee who will do for them collectively those things that an employer normally does when entering into a contract with M-S-A. This type of plan is necessary because few offices have sufficient numbers of employees to qualify for a group contract of their own. Full details together with a timetable for organization of the various areas will be mailed to each doctor's office. 4?o* Ijousi 9n