@prefix edm: . @prefix dcterms: . @prefix dc: . @prefix skos: . edm:dataProvider "CONTENTdm"@en ; dcterms:isReferencedBy "http://resolve.library.ubc.ca/cgi-bin/catsearch?bid=1179642"@en ; dcterms:isPartOf "History of Nursing in Pacific Canada"@en ; dcterms:creator "Vancouver Medical Association"@en ; dc:date "1938-12"@en ; dcterms:issued "2015-01-29"@en, "1938-12"@en ; edm:aggregatedCHO "https://open.library.ubc.ca/collections/vma/items/1.0214410/source.json"@en ; dc:format "image/jpeg"@en ; skos:note """ u The BULLETIN of the VANCOUVER MEDICALIASSOCIATION SIr-Vol. XV. DECEMBER. 1938 No. 3 With Which Is Incorporated Transactions of the Victoria Medical Society the Vancouver General Hospital end the St Paul's Hospital In This Issue: NEWS AND NOTES PROBLEMS OF CONTRACT PRACTICE THE (ESOPHAGUS PROVINCIAL MEDICAL ASSOCIATIONS BULKETTS (With Cascara and Bile Salts) . . FOR . . Chronic Habitual Constipation BULKETTS POSSESS ENORMOUS BULK PRODUCING PROPERTIES AND BEING PROCESSED WITH CASCARA AND BILE SALTS PRODUCE BULK WITH MOTILITY. WE WILL BE PLEASED TO PROVIDE ORIGINAL CONTAINERS FOR TRIAL ON REQUEST. Western Wholesale Drug (1928) Limited 456 BROADWAY WEST VANCOUVER - BRITISH COLUMBIA (Or at all Vancouver Drug Co. Stores) THE VANCOUVER MEDICAL ASSOCIATION BULLETIN Published Monthly under the Auspices of the Vancouver Medical Association in the interests of the Medical Profession. Offices: 203 Medical-Dental Building, Georgia Street, Vancouver, B. C. Editorial Board: Dr. J. H. MacDermot Dr. M. McC. Baird Dr. D. E. H. Cleveland All communications to be addressed to the Editor at the above address. Vol. XV. DECEMBER, 1938 No. 3 OFFICERS 1938-1939 •Dr. Lavell H. Leeson Dr. A. M. Agnew President Vice-President Dr. W. T. Lockhart Hon. Treasurer Dr. G. H. Clement Past President Dr. D. F. Busteed Hon. Secretary Additional Members of Executive: Dr. J. P. Bllodeau, Dr. J. W. Arbuckle. Dr. F. Brodie TRUSTEES: Dr. J. A. Gillespie Historian: Dr. W. D. Keith Auditors: Messrs. Shaw, Salter & Plommer Dr. Neil McDougall SECTIONS Clinical Section Dr. W. W. Simpson Chairman Dr. F. Turnbull.— Secretary Eye, Ear, Nose and Throat Dr. S. G. Elliott Chairman Dr. W. M. Paton Secretary Pediatric Section Dr. G. A. Lamont Chairman Dr. J. R. Davies Secretary Cancer Section Dr. B. J. Harrison Chairman Dr. Roy Huggard Secretary STANDING COMMITTEES Library: Dr. A. W. Bagnall, Dr. H. A. Rawlings, Dr. D. E. H. Cleveland, Dr. R. Palmer, Dr. F. J. Buller, Dr. J. R Davies. Publications: Dr. J. H. MacDermot, Dr. D. E. H. Cleveland, Dr. Murray Baird. Summer School: Dr. A. B. Schinbein, Dr. A. Y. McNair, Dr. T. H. Lennie, Dr. Frank Turnbull, Dr. W. W. Simpson, Dr. Karl Haig. Credentials: Dr. A. B. Schinbein, Dr. D. M. Meekison, Dr. F. J. Buller. V. 0. N. Advisory Board: Dr. I. Day, Dr. G. A. Lamont, Dr. Keith Burwell. Metropolitan Health Board Advisory Committee: Dr. W. T. Ewing, Dr. H. A. Spohn, Dr. F. J. Buller. Greater Vancouver Health League Representatives: Dr. W. W. Simpson, Dr. W. N. Paton. Representative to B. C. Medical Association: Dr. G. H. Clement. Sickness and Benevolent Fund: The President—The Trustees. IB Protection Against Typhoid Typhoid and Typhoid-Paratyphoid Vaccines Although not epidemic in Canada, typhoid and paratyphoid infections remain a serious menace—particularly in rural and unorganized areas. This is borne out by the fact that during the years 1931-1935 there were reported, in the Dominion, 12,073 cases and 1,616 deaths due to these infections. The preventive values of typhoid vaccine and typhoid- paratyphoid vaccine have been well established by military and civil experience. In order to ensure that these values be maximum, it is essential that the vaccines be prepared in accordance with the findings of recent laboratory studies concerning strains, cultural conditions and dosage. This essential is observed in production of the vaccines which are available from, the Connaught Laboratories. Residents of areas where danger of typhoid exists and any one planning vacations or travel should have their attention directed to the protection afforded by vaccination. Information and prices relating to Typhoid Vaccine and to Typhoid-Paratyphoid Vaccine will be supplied gladly upon request. CONNAUGHT LABORATORIES UNIVERSITY OF TORONTO Toronto 5 Canada Defot for British Columbia macdonald's Prescriptions Limited MEDICAL-DENTAL BUILDING, VANCOUVER, B. C. VANCOUVER HEALTH DEPARTMENT STATISTICS, SEPTEMBER, 1938. Total Population—estimated 259,987 Japanese Population—estimated : •_ i 8^685 Chinese Population—estimated . 7 808 Hindu Population—estima ted _ '335 Number Total Deaths . 214 Japanese Deaths 6 Chinese Deaths 10 Deaths—Residents only 182 BIRTH REGISTRATIONS— Male, 197; Female, 192. 389 INFANTILE MORTALITY— Deaths under one year of age Death rate—per 1,000 births Stillbirths (not included in above) Oct., 1938 8 _ 20.6 6 Rate per 1,000 Population 9.2 8.1 15.1 8.2 17.6 Oct., 1937 10 37.0 6 CASES OF COMMUNICABLE DISEASES REPORTED IN THE CITY September, 1938 Cases Deaths Scarlet Fever 20 0 Diphtheria 2 1 Chicken Pox 19 0 Measles 1 0 Rubella . 0 0 Mumps 6 0 Whooping Cough 28 0 Typhoid Fever 1 0 Undulant Fever 0 0 Poliomyelitis 1 0 Tuberculosis 36 17 Erysipelas 1 0 Ep. Cerebrospinal Meningitis 0 0 October, 1938 Cases Deaths November 1st to 15th, 1938 Cases Deaths 22 0 27 2 3 6 19 3 0 0 20 4 0 0 0 0 0 0 0 0 0 0 0 15 0 0 16 0 29 2 2 0 14 1 0 0 16 0 0 V. D. CASES REPORTED TO PROVINCIAL BOARD OF HEALTH, DIVISION OF VENEREAL DISEASE CONTROL. Burnaby Syphilis 0 Gonorrhoea 1 West North Vancr. Hospitals, /ancr. Richmond Vancr. Clinic PrivnteDrs. 0 0 0 42 34 1 1 0 102 25 0 0 0 0 0 0 0 0 0 0 0 0 Totals 76 130 HYPERTHYROIDISM USE BIOGLAN "C" I HYPERTENSION USE BIOGLAN "H" The most effective therapy available. A Product of the Bioglan Laboratories, Hertford, England. STANLEY N. BAYNE REPRESENTATIVE 1432 MEDICAL-DENTAL BUILDING ff Ask the Doctor Who Is Using It" Phone: SEYMOUR 4239 VANCOUVER, B. C. P age 56 OBESITY contributes to many diseases. Overweight predisposes to*such serious afflictions as diabetes, hypertension, arterio-sclerosis, heart disease, disorders of the kidneys and blood vessels and lowered resistance. Efficient reduction without drastic dieting or excessive exercise can be accomplished with IODOBESIN, a potent combination of many glandular substances. IODOBESIN For sustained pluriglandular reduction Literature and samples from: ANGLO-FRENCH DRUG CO. - MONTREAL, QUE. VANCOUVER MEDICAL ASSOCIATION Founded 1898 :: Incorporated 1906. GENERAL MEETINGS will be held on the first Tuesday of the month at 8 p.m. CLINICAL MEETINGS will be held on the third Tuesday of the month at 8 p.m. Place of meeting will appear on the Agenda. General meetings will conform to the following order: 8 P.M.—Business as per Agenda. 9 p.m.—Papers of the evening. Programme of the 41st Annual Session. 1938 October 4th—GENERAL MEETING. Dr. Frank Turnbull: "Pituitary and Para-Pituitary Tumours." October 18th—CLINICAL MEETING. November 1st—GENERAL MEETING. Dr. J. Ross Davidson: "Some Aspects of Contract Practice." November 15 th—CLINICAL MEETING. December 6th—GENERAL MEETING. Dr. Karl Haig: "Diagnosis of Congenital Dislocation of the Tip and Treatment of Those Which Are Reducible." December 20th—CLINICAL MEETING. 1939 January 3rd—GENERAL MEETING. Dr. G. E. Kidd: "Points in Physical Anthropology." January 17th—CLINICAL MEETING. February 7th—GENERAL MEETING. Dr. Murray McC. Baird: "Some Remarks About Rheumatism." February 21st—CLINICAL MEETING. March 7th—OSLER LECTURE: Dr. J. H. MacDermot. March 21st—CLINICAL MEETING. April 4th—GENERAL MEETING. Dr. H. A. DesBrisay: Subject to be announced later. April 18th—CLINICAL MEETING. April 25 th—ANNUAL MEETING. Page 57 EDITOR'S PAGE In this issue we publish the paper read by Dr. J. Ross Davidson at the regular meeting of the Vancouver Medical Association, entitled "Problems of Contract Practice." This paper might well come into the "Medical Economics" Section of the Buletin, and it is really a contribution to our thought on this subject. Dr. Davidson speaks from an experience of contract practice: not a very long one, but long enough to impress him with the importance, not only to himself, but to the profession at large, of the problems which Contract Practice presents. He is really much more concerned with the wider application of the question than with its more personal effects; and this, of course, is what makes his paper worth while. The discussion that it evoked was noteworthy; it was free, and many took part in it, and many new angles were suggested. The fact is that contract practice is not an ideal way of practising medicine. It is sometimes the only practical method in a given area, but it is a question whether it is as universally necessary as it has been held to be. It is a "pis aller," as the French say—a compromise with circumstances. Dr. Davidson urged a better control and more careful selection of those who are to take contracts, and he also urged a more definitely unified and uniform stand by the medical profession as to terms of contracts, etc. With these suggestions, we need hardly say, we cordially agree—but there are certain lions in the path. The weaknesses of contract practice, and the failure of the medical profession to secure adequate control of the situation, so that as an organised body we can lay down minimum standards of salary, conditions of work, terms of contract and so on, are due, in a measure at least, to factors of which we may lose sight. Each year every university turns out of its medical department so many men. Their education has been a long and costly one, and it is vital for most of them that they begin earning money at the earliest possible opportunity. To start practice in a city or even a good-sized town is a slow and tedious process, and to many a practical impossibility. So to these men contract practice has a very great appeal—and the fact that they will be busy, gaining experience, and actually practising their profession, is often more important than the actual size of the salary. As in a case quoted by one of those discussing the paper, a salary of $200 a month looked like big money. This is one of the main reasons, we feel, why the men taking the contracts so often are lacking in the experience that Dr. Davidson rightly feels is necessary. There is in existence a Medical Economics Committee of the B. C. College of Physicians and Surgeons, and they are studying this whole question, and will be better prepared to offer suggestions than we can be. But we feel that no amount of discussion, no good resolutions, no far-sighted advice from older, sadder and wiser men, will be of much use till this gap between graduation and the earning of an adequate income has been in some way bridged. Again we ask ourselves: Why cannot some scheme be worked out whereby the doctor who needs practice and an income, and the poor and needy who need doctors and medical care, can be brought together on a satisfactory basis? The day must arrive sometime when the State will recognize its obligation to provide for these people on a sound economic basis: and doctors will be paid for their work. When this comes, the economic hunger for work on the part of the man beginning practice will be capable of satisfaction in the right way. He will not be compelled to grasp at any work he can get; the medical profession as an organised body will be able to regulate the filling of positions in some such way of Dr. Davidson suggests, and this will be all to the advantage of the consumer, i.e., the patients involved. Exploitation of the doctor, and inadequate care for the patient, will then be preventable. Till then, all that can be done should be done, by surveys of existing contracts, by measures calculated to aid the men who hold these, and to protect them against unfair competition, by education of the doctor, and advice by those who contemplate taking contract work. Very much can be done this way, and many of the serious evils mitigated or removed. We are grateful to Dr. Davidson for his frank and timely speech on the subject, and feel that much good will come out of the whole discussion of the subject. Page 58 NEWS and NOTES We are glad to hear that Dr. Maurice Fox, who has been in St. Paul's Hospital for nine weeks, will soon be well enough to return to his home. Latest reports concerning Dr. T. V. Curtin, who is also ill in St. Paul's Hospital, say that he is "doing fairly well." Dr. Draeseke, who was ill in hospital for some weeks, is now well enough to be back at his office. Drs. R. L. Pedlow, A. J. MacLachlan, P. McLellan, Lee Smith, F. Brodie and H. W. Riggs attended the meeting of the Pacific Coast Surgical Association in Spokane. Dr. G. E. Gillies and Dr. A. B. Schinbein have returned from New York, where they attended the Annual Meeting of the American College of Surgeons. The following were elected as members of the Vancouver Medical Association at the regular General Meeting, held on November 1st: Drs. J. Ross Davidson, A. C. Gardner Frost, A. Leigh Hunt, A. J. McDonald, S. A. McFetridge, B. B. Moscovich, E. E. Saunders, Neil A. Stewart. Drs. W. F. Drysdale and S. L. Williams of Nanaimo were elected as Associate members of the Vancouver Medical Association on November 1st. Dr. L. H. Appleby is enjoying a vacation in Southern California. News comes from Victoria of the appointment of Dr. Andrew Turnbull as Radiologist at St. Joseph's Hospital in that city. Dr. Turnbull is a graduate of the University of Manitoba Medical School. He did general practice in Athabasca, Alberta, for four years and spent three years on a Fellowship in Radiology at the Mayo Clinic. He is a Diplomate of the American College of Radiology and practised radiology in Durham, North Carolina, prior to coming to Victoria. Drs. Gordon Kenning, A. B. Nash and W. Allan Fraser attended the recent meeting of the American College of Surgeons in New York. Drs. Nsah and Fraser were initiated as Fellows of the College. Drs. G. A. McCurdy and D. B. Roxburgh, pathologists at the Royal Jubilee Hosptial and St. Joseph's Hospital, respectively, attended the meeting of the Pacific North-West Society of Pathologists, held recently in Tacoma. Dr. T. W. Walker, superintendent of the Royal Jubilee Hospital, attended a meeting of hospital superintendents, recently held at Dallas, Texas. The Board of Directors of the Jubilee Hospital were hosts to the staff of the Jubilee Hospital at a dinner held in the Union Club on Tuesday, November 15 th. Dr. H. E. Ridewood has just returned to Victoria after a five-weeks' holiday in California. Dr. C. A. Watson attended the Annual Meeting of the Defense Medical Association in Ottawa as the British Columbia representative. Major-General Sir Ernest Walker, K.C.I.E., who has retired from the office of Director-General of the Indian Medical Services and who is now living on the Island, has accepted honorary membership in the Victoria Medical Society. Page 59 Dr. D. W. MacKay of Nelson has just been elected president of the British Col Amateur Hockey Association. Hockey is a grand sport in the Kootenays. umbia Dr. W. Laishley of Nelson, the energetic secretary of the West Kootenay Medical Association, called at the office and attended the Annual Dinner of the Vancouver Medical Association. Dr. H. Cantor has left for Mayo, Yukon Territory, to relieve Dr. E. W. T. Nash during six months while Dr. Nash is absent on post-graduate study and a well-earned vacation. Dr. H. Winter is now at McBride during the absence of Dr. L. M. Greene on holiday. Dr. G. W. Meyer has taken up the practice at Telegraph Creek. Dr. Paul Ewert of Golden called at the office. He is on a month's vacation. He will visit Dr. Carl Ewert of Prince George during two weeks. Dr. W. J. Elliot is at Golden during Dr. Ewert's absence. Dr. E. K. Hough is now at Woodfibre. Dr. and Mrs. W. J. Knox of Kelowna are spending two months in the East. While in New York, Dr. Knox will attend the convention of the American College of Surgeons. Dr. O. O. Lyons of Powell River visited the office last week. Dr. Allan B. Hall of Nanaimo was in Vancouver on November 18 th and attended the Annual Dinner of the Vancouver Medical Association. He brought greetings as representative of the Upper Island Medical Association. Out-of-town members of the Board of Directors of the British Columbia Medical Association who attended the regular meeting held November 9th, following dinner at the Hotel Georgia, included Drs. Stewart A. Wallace of Kamloops, C. T. Hilton of Port Alberni, George T. Wilson and W. A. Clarke of New Westminster, A. C. Nash of West Vancouver, Gordon C. Kenning, P. A. C. Cousland and W. Allan Fraser of Victoria. The North Shore Medical Society took on this new name at its annual meeting held on November 8th, when the election of officers resulted as follows: President: Dr. A. C. Nash, West Vancouver; Vice-President: Dr. R. V. McCarley, North Vancouver; Hon. Secretary-Treasurer: Dr. D. J. Millar, North Vancouver. Dr. A. C. McCurrach is at Blue River doing the practice formerly carried on at that point on the C.N.R. by Dr. Bramley-Moore. Dr. D. J. Bell of Vancouver was honored by the residents of Vancouver Heights and Capitol Hill when about two hundred persons gathered in the Masonic Hall and a presentation was made to this beloved practitioner by the people he has served during twenty- five years. Dr. George Pringle paid eloquent tribute to Dr. Bell and was able to refer intimately to his fine service in the Yukon. Drs. H. H. Planche, C. M. Eaton and K. L. Craig were present and participated in this fine tribute to Dr. Bell on the conclusion of fifty years in Medicine. Dr. and Mrs. H. A. L. Mooney of Courtenay are being warmly congratulated on the birth of a daughter, November 14th. Page 60 LIBRARY NOTES Recent Additions to the Library Method of Anatomy, 1937. By J. C. B. Grant. Clinical Atlas of Blood Diseases. 4th ed., 1938. By A. Piney and S. Wyard. Practcial Bacteriology. 9th ed., 1938. By E. R. Stitt and P. W. Clough. Endocrine Therapy. 1938. By E. L. Sevringhaus. Injection Treatment of Varicose Veins. 1938. By H. O. McPheeters and J. K. Anderson. Textbook of Pathology. 3rd ed. By Wm. Boyd. Surgical Pathology. 4th ed. By Wm. Bflyd. Obstetrics. 7th ed., 1938. By J. K. DeLee. Electrocardiography. 2nd ed., 1938. By C. C. Maher. 1937 Year Book. Supplement to Encyclopaedia Brtiannica. Monograph on Veins, translated by K. J. Franklin. 193 8. Cancer. 1938. Published by Canadian Medical Association. From the Nicholson Fund On Thought in Medicine. By H. von Helmholtz. 1938. Horse and Buggy Doctor. By A. E. Hertzler. 1938. Life of Chevalier Jackson. An Autobiography. 1938. Items From the Journals Cold Vaccines—An evaluation based on a Controlled Study. By H. S. Diehl, A. B. Baker and D. W. Cowan. J.A.M.A., Sept. 14, 1938. Local Urinary Antiseptics. By H. W. E. Walther. J.A.M.A., October 15, 1938. Surgical Treatment of Obstructive Jaundice in Pancreatic Disease. By Sir John Fraser. Brit. Jl. Surgery, October, 1938. Present Status of Treatment in Chronic Gastritis: Gastroscopic Observations. By W. Rudolf Schindler. S.G.O., November, 1938. I The Role of Gastroscopy in the Recognition and Identification of Gastric Lesions. By A. Swalm and Lester M. Morrison. Am. Jl. Dig. Diseases, October, 1938. Development and Healing of Gastric Ulcer—A Clinical, Gastroscopic and Roentgenologic Study. By W. L. Palmer and R. Schindler. Am. Jl. Dig. Diseases, October, 1938. A bulletin, published by the Lahey Clinic, has lately been received in the Library. Dr. Lahey, in the Introduction, states this bulletin will be published at irregular intervals, and only as material deemed worth while presents itself. Surgical Clinics of North America, August, 1938. Mayo Clinic Number Diagnosis and Treatment of Vascular Disorders of the Limbs. By W. McK. Craig and B. T. Horton. Deep Infections of the Neck. By G. B. New and J. B. Eich. Management of Head Injuries. By J. Grafton Love. Complications and Sequelae of Head Injuries. By J. Grafton Love. Recent Trends in Genito-Urinary Surgery. By H. Cabot and J. L. Emmett. Treatment of Tumors of the Bladder. By H. Cabot and G. J. Thompson. Surgery of the Biliary Tract. By W. Dalters and M. W. Comfort. Page 61 V ancouver Medical Association At the regular meeting of the Association to be held on December 6th, Dr. Karl Haig will be the speaker of the evening. The title of his paper will be Diagnosis of Congenital Dislocation of the Hip, ivith treatment of those which are reducible. ANNUAL DUES Members are reminded that the nanfes of those whose dues are unpaid on December 31st will be posted in the Library on the second day of January, 1939. THE ANNUAL DINNER Prologue. As we write this, the pleasant clink of cocktail glasses, yet afar off but ever drawing nearer, begins to reach our ears, and in dreamy anticipation we distinguish the pleasant aroma of the dry Martini, or the fragrant Old-fashioned, as it tickles (at least we hope it will) our nostrils and delights our watering palate. For the Annual Dinner is in view— tonight is most emphatically the night—and away with care! and begone! dull melancholy: for Luke Sawbones is out on the tiles tonight—has forgotten vitamin "B" and tonsillectomies and intestinal flu and Brucella abortus, and is off to enjoy a few hours' surcease from the ills of others, while he accumulates a headache on his own account. And we hear that there is to be entertainment of a very refined nature—pure and wholesome—and though we cannot, by coaxing, innuendo or direct questioning, get any lead on the programme at all, yet the presonnel of the Dinner Committee is very reassuring. In view of the rather paternalistic, not to say busybody, rules on libel, as laid down by the society in which we live, move and have our being, we shall not mention any names, nor impute any motives—in fact, we will say no more. After the ball we may have a few further remarks to make. Epilogue. We were quite right—it was a good dinner. Some hundred and sixty-five men were present—and there would have been many more—but apparently all the Surgical Associations, and Medical Associations, and Staff Meetings, and special meeting of all kinds, in the Western Hemisphere, were busy on the night of the Annual Dinner of the Vancouver Medical Association, and there were many men who could not be present. We received telegrams from them, and that is all very well, but we lamented their absence. There were some newly vacant seats, too, which will remain vacant, and as the list of departed members was read, all present stood in reverent silcence. We shall miss them, good fellows all. But they leave a good name, and did good work. Many of them died in harness—a happy ending for any man. The new recipient of the P.G.F. degree was Charles H. Vrooman, best known as "Charlie". The secret of his selection has been well kept and Charlie was completely taken by surprise. He well deserves the honour: he has been long a devoted worker in the Association and has, too, all the other qualifications as laid down in solemn Latin in the diploma. The entertainment was well received and our congratulations are due to the Dinner Committee that worked hard and long to provide a programme, and to ensure the smooth functioning of the dinner. Our last impression of the dinner was the sight of Dr. Freeze counting huge stacks of currency all by himself in Peacock Alley. Unless we were seeing double (and we really did not have enough for that) he had most of the doctors' incomes for the current week in his possession. That's what it is to be trusted. Leaving him in this pleasant atmosphere of wealth and luxury, we hurried out to see a malade imaginaire, as our French colleagues would say, and thereby to earn a more or less honest dollar wherewith to buy a ticket for next year's dinner. Till then, au revohrl Page 62 PROBLEMS OF CONTRACT PRACTICE J. Ross Davidson, M.D. This paper is not presented as the studied opinion of any committee on Medical Economics, nor is any claim put forward that it will even contain the main problems of Contract Practice. It is my intention to mention only a few of the problems facing a medical practitioner under such a scheme, in the hope that those of you who have had no experience in this type of work will give it your careful thought, from which will arise some concrete suggestions which can be moulded into a form that will benefit the medical fraternity as a whole. Contract practice had its origin in necessity, for which reason a group of individuals or some industrial concern contracted with a medical man for certain services. These communities were usually lying in some distant part of the province not sufficiently populated to offer any inducement to a doctor to undertake private practice, tt became necessary, then, to guarantee to some medical man a certain emolument monthly in return for certain services. This form of barter between the public and the members of the medical profession is not in itself unethical, but a recognized and highly commendable form of business transaction in the economic world of today, of which we find ourselves a part, but it has, in its fundamental aspects, some features that should be controlled, and which, if left unchecked, will not only bring the profession into disrepute but seriously undermine the health of the community, whose duty it is ours to protect. In the earlier days, most contracts were entered into between a doctor and the management of some company. Before the advent of the Workmen's Compensation Act, most companies felt some moral obligation to those of their employees who were either sick or injured, and as a result often made considerable material contributions to the contract and exercised control of the hiring of medical men. As a result of economic conditions, cutthroat competition and a mass of governmental social legislation, the companies found themselves in a position whereby they had to shift the responsibility to those pedple who were recieving the benefits. This move, I might add, was also activated by the fact that the general public, the legal profession, or both, found out that medical men were fair game for malpractice suits, and the companies found themselves as co-defendants in such suits. To overcome this difficulty the various hospital and sickness societies were incorporated to handle all matters pertaining to medical care. One can readily see that out of the arrangement would come a heterogeneous variety of plans and contracts. With organized medicine, as represented by the various local and provincial associations, frowning for the large part on contract practice and refusing to recognize it as a vital part of their programme, there was no attempt made to regulate the terms of any plan, and the individual doctor concerned was left to his own resources in framing a contract for some place which, in a number of cases, he had never seen. As a result he often fell prey to those better versed than himself in the completion of business transactions, which, once entered into, proved difficult to change. Without any positive guide to the formation of contracts, and with only negative help from organized medicine, it is easy to see the utter confusion and multiplicity, of forms that made up the present- day contract practice, for there are at the present time some hundred and fifty contracts in British Columbia, not two of which bear any great similarity to each other, even in their basic principles. It is obvious that local conditions will influence each individual contract and present peculiar problems that must be handled in an individual manner, but there should be, however, some supervision of the fundamentals. What, then, are those basic principles and what do they involve? Contract Practice is defined by the Judicial Council of the American Medical Association, as applied to medicine, as: "The carrying out of an agreement between a physician, or a group of physicians, as principals or agents and a corporation, or individual, to furnish partial or full medical services to a group or class of individuals for a definite sum or for a fixed rate per capita." Such services may include medical and surgical care, obstetrics, hospitalization, drugs, specialists'* care, and the individual plan may include all or any of these features, either for employees alone or for employees and their dependents. Let us analyze for a short time each of these features:— The cardinal question in all contracts is just what constitutes "adequate medical and Page 63 surgical care." In this age of specialization it is obvious that one medical man serving a thousand people or less cannot by any stretch of the imagination give them a specialist's service in all branches of the healing art. He not only lacks the experience, but even if he had it, the necessary equipment is wanting. There is, I believe, only one contract in British Columbia that embraces a sufficient number of subscribers to employ enough doctors who can divide the work in such a manner that each may enjoy at least some specialty. Where a general practitioner's ability is to end is a moot question that I do not intend even to open for discussion, but I can assure you it is a live issue in the relationship of the two parties to a contract practice. At this point may I make a plea for those men practicing their profession in isolated districts and ask you to exercise some forbearance with them in their diagnosis and treatment. Their laboratory usually consists of an alcohol lamp and a bottle of Benedict's solution. They are their own X-ray technicians with no portable equipment, and for an anaesthetist they usually have a nurse or a lay man pouring ether, necessitating artificial respiration at least twice during the course of a simple appendectomy. I think that in these contracts, all that can be expected is the service of a medical man with average training. In this regard, if it is to be the policy of the Medical Association to protect the medical man by defining the terms he is to expect under such a contract, then I feel it should likewise be their duty to protect the public he is to serve by stipulating that any man undertaking such a contract should have certain requirements of training. To demand from society a salary that we consider fitting for a medical man and then fill the position with a recent graduate having no postgraduate training is to my mind neither protecting the public nor the medical profession. That man is often placed where there are no consultants and he can get no assistance. The impression he leaves with his patients will be the impression that that community will have of the medical profession as a whole. There is no place in the practice of medicine for "the public be damned" attitude, and I can assure you that one has only to live in one of these communities to realize that hospital and medical attention is the dominant factor of their existence. Hospitalization is always a bone of contention in all contract practice, and I feel that no medical man should associate himself with any guarantee to provide such for any patients under his contract. He is courting financial disaster to undertake such an agreement, for all of you are aware of the ever-changing demands of modern hospitalization and equipment. The old axiom of a man not being able to serve two masters is still true, and, after all, running a hospital for financial gain is not one phase of the healing art. The ever-prevailing chance of an epidemic hangs over his head to ruin him, and in the majority of these places there is a large proportion of the population living in bunk houses who require hospitalization for conditions which in larger centres would not be considered as such. This type of man demands hospitalization if he is under contract, because he probably not only finds it inconvenient to carry out treatment in his bunk, but while in the hospital he is saving his board bill. There is in addition considerable responsibility resting on the shoulders of any docotr who has refused to hospitalize a simple influenza case when this is demanded, when the patient later develops broncho-pneumonia and dies. The harmonious relationship between patient and physician is, as wou are all aware, one that is subject to considerable variations. An even more dangerous tension exists under Contract Practice when the doctor is financially interested in providing the service of hospitalization. The question of supplying drugs is perhaps the most controversial point that will crop up in the creation of any contract, and it will in all probability be the one stumbling block of an otherwise smooth relationship. Some contracts call for free medicines, some for medicines to a limited degree, while others will require patients to pay some part of the cost. Perhaps the clause which will give the greatest difficulty is the system under which free drugs are limited. In other words, the contract will read that drugs are limited to those in the British Pharmacopceie, or it may be drugs exclusive of biologicals. The most vicious clause of them all is one that reads: "Drugs as prescribed by the local doctor." The pitfalls of such a system are obvious. Anything that is free is gathered in large quantities and stored away in some cupboard against any and every possible emergency. Under a contract that supplies free medicines yet allows a fee charge against dependents, any too close enquiry into the reason for such drugs will cause only the feeling that the doctor is seeking a consultation for a fee. I might mention just a few of these—something for a burn; Page 64 something for my son's tummy ache (it cannot be appendicitis); something for a cut that is infected. Each in itself may be trivial but has possibilities of serious consequences. Recent years have seen such advances in endocrine and biological therapy that they now form a great part of the general practitioner's armamentarium, but the cost of these products is still almost prohibitive, especially so under contracts drawn up before their advent. To prescribe these products is courting bankruptcy, yet it is the patients' right that they should receive any benefit of recent therapeutic advances. There is nothing to be gained by arguing with a patient that the only drug that will cure him is not in the B. P. or is a biological product, hence he will have to pay for it. They are only aware of the fact that they have so much money deducted from their pay cheques for sickness and drugs, and if the doctor prescribes it, it must be a drug. Those fortunate individuals who could afford a trip to town for a specialist check-up would return and present a prescription bearing the latest in trade names. Not only would the local doctor not carry it but would not even know what it was. These people will not even tolerate a change in the vehicle of a prescription for triple bromide that they have paid twenty-five dollars to get, and the poor local doctor is in wrong again. "He is obstructing the march of progress, not keeping up with the times, and it is time he was fired." Making a patient pay for a portion of all drugs has its beneficial side, but unless the community is big enough to support a druggist, is also has its drawbacks. It puts the local doctor in the business of bookkeeping, and it is almost impossible for him to figure out the cost of individual prescriptions, especially if he is busy practicing medicine. The question of obstetrics is relatively a simple one. If the contract calls for service to dependents as well as employees, then the inclusion of midwifery should be part of the service. To the lay mind there is no logical reason why it should not be classed as a sickness, and its exemption only leads to dissatisfaction. Mention of exemptions brings to mind the one great contentious point of Contract Practice. In practically every contract there is a clause which states that free service will not be given to pre-existing diseases. In most large industrial plants each employee is examined prior to being taken on the payroll and a record kept of that examination. It is surprising the number of prospective employees that have some physical defect, which does not at all impair their ability to work and in the majority of cases has caused the applicant no discomfort or symptoms. Yet if the doctor is to protect the company or association against future medical and hospital expenses, these must be excluded. Such cases include chronic infected tonsils, sinusitis, chronic ears, bronchitis, hernia, enlarged inguinal rings giving an impulse on coughing, varicose veins, haemorrhoids, fallen arches, presence of cardiac murmurs with or without some degree of hypertension. Each of these cases represents a potential patient with resultant expenditure of drugs, hospitalization and doctor' services. If one is to accept these cases as employees and they report sick two years later, it is difficult to convince them that they should pay for any service rendered, for they feel that having contributed for two years they are entitled to free medical care. What are you going to do with these cases that deny at the time of examination any gastric symptoms, yet when they appear with symptoms of peptic ulcer will, on questioning, admit attacks dating back several years prior to employment? It is easily said that you should force them to pay for treatment, but remember that after all these men are members of an association that is paying your salary and it is very easy to start a whispering campaign against the doctor that gathers momentum until the original cause of the dissension has been lost sight of in the gross charges that follow. It is perhaps often better to handle these cases without comment when first seen. There is no denying the fact that the general public today is specialist-conscious and small isolated communities are no exception. A specialist, in their case, is any medical man outside their own community who puts on a different type of splint or uses heat where the local doctor prescribes cold. Human nature being what it is, you will always find a certain percentage of people without confidence in the medical man to whom they are forced to go by virtue of a contract. They are the ones who on the slightest provocation demand the service of one whom they choose to call a specialist. In drawing up all contracts the need in certain cases of a specialist is foreseen and the provision is written into the contract to cover such cases in somewhat the following manner: "The doctor or society (as the case might be) agrees to furnish the services of a specialist where required." All of you can at Page 65 once see the difficulties that arise from this clause. Where cost of transportation, hospitalization and specialist fees are guaranteed the situation is aggravated. Even Workmen's Compensation Board cases come under this provision when working under what is termed the Approved Plan. For those of you not familiar with this scheme I will merely say in passing that the Workmen's Compensation Board allows certain companies or societies that have their own hospitals and doctors to forego any payment for medical service to the Board and they in turn do not have to pay either the doctor's fees or hospitalization. Thus any case sent out for a specialist's care is a direct charge against the society at the local community. A conservative estimate, I believe, would be that every case sent to one of the large centres for a specialist's care costs the local society an average of over two hundred dollars. There are always a few people who desire the service of certain medical men who enjoy the public favor at the time and this desire becomes acute if they themselves do not have to pay for it. The trip to Vancouver at no added cost is also an inducement, and these people, immediately on getting hurt or becoming ill, demand through themselves or friends that they be sent to a specialist. At this point the local doctor is literally "on the spot." If he insists that the patient does not need a specialist and any complications arise, he was wrong. If the patient gets better he is annoyed at the doctor for not giving him the benefit of a holiday for which he would not have to pay. In either case the doctor's lot is not a happy one. Here, I may honestly say, I have slightly exaggerated the conditions, and it is only rarely that one is faced with such a problem, yet it does arise, and when it does, disturbs the relationship that should exist between the doctor and his patient. Insert into any contract the stipulation that all or part of specialist fees must be borne by the patient and a great deal of this unpleasantness will disappear. The free transportation feature, at least, should never be included, for this item alone, if made a responsibility of the patient, will act as a deterrent to a great many of the specialist-minded people. I realize that in addressing these remarks to the medical men of Vancouver I am treading on dangerous ground when I offer as one of the problems of Contract Practice the relationship between yourselves and those medical men in general practice in remote places. It is obvious that a certain number of patients will be referred or come down to the large centres of their own free will to consult you regarding conditions that have baffled the local doctor or under whom treatment has been unsatisfactory. I ask you to remember that it lies in your power to make or break the reputation and even the livelihood of the doctor in that community from whence the patient comes. Merely by suggestion alone, you can give that patient an idea that he possibly exaggerates, and which by the time it is retold with embellishments of his own imagination, will be sufficient to prove to the populace at home that the doctor is incompetent. Try and place yourself in the position of one of these men who is working seven days a week, with no afternoon off for golf, seeing thirty or more patients a day, of all kinds, and with very little in his laboratory as an aid to diagnosis, and ask yourself if you could have done any better. It is perhaps easy to criticize the position of a fractured femur after you have had the opinion of an X-ray specialist, but could the fracture under your hands have been any better with adhesive for traction and no check-up by X-ray possible? I am sure that when any false impressions are left with patients who have consulted you, it is not with any intent to harm but a result of thoughtlessness, yet it is difficult for the small-town doctor to view them with equanimity when, by the next boat after his patient returns, he receives a letter from the parent Medical Association asking him to sign a form committing him to abide by any arrangements that a committee will make on his behalf, when he might find on that committee the names of one or two men who have by their actions already jeopardized his standing in that community. Was it not Iago in Othello who said: "Who steals my purse steals trash, 'tis something, nothing, 'Twas mine, 'tis his, and has been slave to thousands, But he that filches from me my good name Robs me of that which naught enriches — short-cut to Vernon and on to Kelowna. Doctors (Mc) Baird and (Mc) Thomas (Doctors Huggard and Thomas had lost their Irish and Welsh character and had fallen under the influence of the Scot) had Dr. (Mc)Huggard's toothbrush with them. They took the other route via Chase and Salmon Arm, Enderby and Armstrong—no dust and all the beauty of that road. At Chase they stopped to visit Dr. and Mrs. Scatchard and, as anticipated, Dr. Baird, too, was captured by the charm of England at Chase and a visit with a doctor who had received a degree in 1882 at the Rotunda, and to meet Mrs. Scatchard. It is only a year since these dear people celebrated their fifty years of marriage. Enough for now. If you have never visited the Scatchards at Chase, you should. Kelowna was reached late that night and Dr. Huggard was sitting up sleepily and impatiently awaiting the arrival of his sleeping suit. Doctors Eddie Lyon and Leonard Panton were talking about Toronto. The next day, October 3rd, saw the arrival of doctors and wives from Revelstoke, Princeton, Oliver, Summerland, Vernon, Armstrong, Enderby, Kamloops, and the Annual Meeting of the No. 4 District Medical Association began. It is not important that the entertainment began at the canning plant and led the party on to the "Calona" Winery. The samples were good and one can get a real kick out of Kelowna. (Inserted without prejudice to the Liquor Control Board). There was much visiting and fraternizing at luncheon at the Royal Anne Hotel, which housed the visitors and the meeting. The arrangements were planned by Dr. and Mrs. J. S. Henderson and Dr. Reba E. Willits, the secretary. The whole party prepared for the dinner in the lounge and repaired to the banquet hall, where covers were laid for fifty-seven. The ladies attended the dinner and thus a group of twenty-eight doctors produced a large gathering. A charming feature of the dinner was the delightful address of Dr. G. A. Ootmar, who came to the district about twenty years ago, as he thanked the doctors for the kindly reception accorded Mrs. Ootmar and himself on their arrival from Europe and during these many years. Dr. Huggard left that night for Penticton in company with Doctors McGregor and Borden. He was able to help with an operation on Tuesday morning and when Doctors JBaird and Thomas arrived he addressed a largely attended public luncheon and assisted the local doctors in the organization of Penticton Unit of the Canadian Society for the Control of Cancer. Luncheon over and a puncture repaired, the party of three filled up with gas and set out for Grand Forks via Oliver, Rock Creek and Greenwood. At Grand Forks, which was much interested in mining and a dinner to the Honourable Mr. Asselstine, Minister of Mines, Dr. Windsor Truax and Dr. C. M. Kingston visited the party in the Annex (with the red door) of the hotel. Safely out of Grand Forks on the morning of the 5 th of October, the heavy rains made the Washington roads more passable, so the approach to Rossland and Trail was made by the American route. The Annual Meeting of the West Kootenay Medical Association and Doctors Basted and Laishley awaited the arrival of the party. On October 6th the party reached Nelson via Castlegar in time for a large lay-medical luncheon arranged by the doctors in support of their cancer membership effort. Doctors Huggard, Baird and Thomas were through in time for the ferry to reach Creston for dinner with Doctors Vernon Murray and D. A. Campbell, and then on to the church, where Dr. Huggard addressed a large lay audience, and then on to Cranbrook by midnight. Dr. Thomas had some trouble at this point in that the two lecturers were tired. However, he gave ear to their protests. As they had two papers each to present at the Annual Meeting of the East Kootenay Medical Association on the following day, October 7th, they were allowed to sleep in, while Dr. Thomas met the early train and Dr. J. Bain Thorn, the member of the Council for that district. Together they drove to Kimberley to visit T)r. D. W. Davis and Dr. J. F. Haszard. Dr. Huckvale was away on vacation. The same happy atmosphere which welcomed the team at Chilliwack, Kelowna and Trail was found at Cranbrook. There was frost in the air but there were warm hearts to meet and greet the visitors. (Continued on page 80) Page 74 Victoria Medical Society Officers, 1938-39. President , Dr. P. A. C. Cousland Vice-President Dr. W. Allan Fraser Hon. Secretary—. Dr. W. H. Moore Hon. Treasurer Dr. C. A. Watson On November 7th, His Honor Lieutenant-Governor E. W. Hamber officiated at the opening the new X-Ray Department of St. Joseph's Hospital, Victoria. St. Joseph's Hospital has recently replaced its x-ray equipment with new x-ray apparatus, the major part of which was made in Canada by the Ferranti Electric Company of Toronto. This new apparatus includes a 400,000-volt x-ray therapy equipment and is the fifth supravoltage installation in Canada. There is also a three-phase transformer for diagnostic work which is the first of its kind in Canada. The equipment includes numerous modern improvements, making the department one of the most thoroughly equipped in Canada. CLINICAL CONFERENCE A Clinical Conference was held at the Royal Jubilee Hospital on Friday, November 4th, 1938, at 12 noon, under the chairmanship of Dr. H. H. Murphy. Dr. R. Scott-Moncrieff was introduced to the meeting and presented a paper on The Oesophagus. On opening the subject, Dr. Scott-Moncrieff stated that the time being brief he could only hit the high spots of his address on the oesophagus. "Since the cesophagoscope plays such an essential part in the diagnosis and treatment of the vast majority of diseases of the oesophagus, I am going to begin by reading the opening paragraphs on the section of cesophagoscopy in Recent Advances in Laryngology and Ootology, Stevenson, 1935. It is typical of the opening paragraphs of all such works." ff fOesophagoscopy: As in the case of bronchoscopy, cesophagoscopy has today advanced far beyond the mere passage of an cesophagoscope to remove an impacted foreign body, though not all hospitals have yet attained the range of Chevalier Jackson's clinic, where every patient complaining of persistent abnormal sensation or disturbance of function of the oesophagus has an cesophagoscope passed as a routine, and not all physicians and general practitioners have yet realized that cesophagoscopy can be a painless proceduare, safe in the hands of an expert and capable of yielding valuable information in many obscure cases. Dysphagia may be due not only to a foreign body in the pharynx, oesophagus, larynx, or trachea, but also to benign or malignant neoplasm or abcess in these regions; to spasmodic, cicatrical or other strictures; to tuberculosis, syphilis, or diphetheria; to oesophagitis, ulceration or erosion; to varicosity or diverticulum of the oesophagus, or aneurysm, to aero- phagia or hysteria, or to other minor causes. In the past the diagnosis of hysteria has in many cases prevented the recognition of serious disease of the oesophagus in its early stages, and organic disease cannot-be excluded without cesophagoscopy—nearly every patient with post-cricoid carcinoma has had symptoms of swallowing neurosis dating back many years and has been called a case of globus hystericus. As the function of deglutination can best be studied by observing the swallowing of a barium or other opaque mixture with the fluoroscope, Chevalier Jackson advises that cesophagoscopy for general physical examination (including the mouth, pharynx and larynx) and the Wasserman test should be further routine preliminaries. " 'Mosher has recently made an important statement about the alleged dangers of cesophagoscopy. For years he has maintained that every examination of the oesophagus, even the simple passage of a bougie, is a possible tragedy, and he has had a few tragedies with both procedures. He states that the general impression among the medical staff of his Page 75 hospital is that cesophagoscopy is too dangerous a procedure, and they do not feel safe in referring cases for oesophageal examination. Those of them, however, who are doing oesophageal work have known all along that the percentage of tragedies is low. During the past twelve years there have been 938 oesophageal examinations with the cesophagoscope. There were nineteen mortalities associated with this examination, and probably due to it. This makes a mortality rate of a little over 1.50 per cent. The cases of stricture of the oesophagus numbered 294, with six mortalities reported in this group. Webs of the oesophagus numbered 79, with one mortality; carcinoma of the oesophagus numbered 247, with nine mortalities; foreign bodies of the oesophagus including all kinds, simple and the most difficult, numbered 285, with two mortalities; cases of cardiospasm numbered 33, with one mortality. 'Oesophagoscops is contraindicated (except for urgent reasons, such as an impacted foreign body) in the presence of aneurysm, advanced organic disease, extensive varicosities of the oesophagus, and in acute necrotic oesophagitis and acute oesophagitis with sloughing from swallowing caustics—in the last it should be deferred until the healing process is well advanced.' "Because the hypopharynx is the funnel-shaped entrance to the oesophagus proper, it should be briefly dealt with first. Anteriorly the hypopharynx is bounded by the posterior wall of the larynx, in the upper part of which lie the arytenoids. Thus many conditions which are primarily laryngeal spread posteriorly to the hypopharynx. The two which immediately spring to mind are tuberculosis and malignant growths. "From the diagnostic point of view the following conditions of the hypopharynx must be considered. They are the same as in the case of the oesophagus: 1. Dilation. 2. Diverticulum. 3. Stenosis — congenital, spasmodic, inflammatory (acute and cronic), cicatricial or stenosis from compression. 4. Abscess. 5. Tuberculosis. 6. Syphilis. 7. 'Non-specific' inflammation. 8. Ulceration or erosion. 9. Neoplasm—benign or malignant. 10. Paralysis—functional or organic. 11. Foreign body, etc., etc. "The symptoms, except in severe traumatic or acute conditions, are in the early stages of hypopharyngeal disease generally slight, vague and poorly localized sensations, either spontaneous or on swallowing, and it is due to this very fact of the patient's inability accurately to place and describe his symptoms that the diagnosis of globus hystericus is so often forced upon him. This symptom, when it occurs in hysterical patients, is due to spasmodic contraction of the inferior constructor muscle in part or whole. But, as Chevalier Jackson so well puts it, globus hystericus is more often cancerous than hysterical. "In the later stages of most diseases of this region the symptoms are mainly referable to the act of swallowing, there being either pain or difficulty in swallowing, or both. There may also be spontaneous pain, either local or, as is often the case, referred to the ear. There may often be local tenderness, but this generally located in the regional lymph glands. "While on the subject of referred otalgia, I should like to remind you of that well- known saying to the effect that, in an apparently healthy male, with a hoarse voice and a wad of absorbent cotton in one ear an immediate diagnosis of carcinoma of the larynx is very often correct. "Inflammation, ulceration, erosion and stricture of the hypopharynx are usually secondary to trauma, such as foreign body, instrumentation -or the swallowing of some caustic substance such as lye or acid. "Traumatic perforation as from the blind passage of a bougie is generally followed by cervical emphysema and cellulitis, which very apt to spread downwards to the mediastinum and a fatal ending. "Abscess is usually the result of a retropharyngeal abscess, which has worked down from above. Its chief causes are adenoid or tonsillar infection, disease of one or more vertebrae (as for instance in cervical Pott's disease), suppurative adenitis, foreign body or perforation. "In children the finger will give the diagnosis, but it should be remembered that this procedure is not without risk, especially in the very young. Page 76 "Paralysis of the hypopharynx is paralysis of the interior constrictor in part or whole. The patient being unable to swallow will rapidly die of thirst if not fed by artificial means. Gravity has almost no effect on the descent of either liquids or solids from mouth to stomach. "Diverticulum of the hypopharynx affects the oesophagus more than the hypopharynx and so will be mentioned later in this connection. "Inferential methods of diagnosing hypopharyngeal disease cannot be relied upon. It is upon objective methods that diagnosis should depend. These are: 1. Palpatation of the lower part of the neck, particularly deep under the sternomas- toids. 2. X-ray, first without and then with an opaque mixture. 3. Direct inspection. The mirror will.seldom suffice, and for absolute certainty the area must be examined by direct inspection through a laryngoscope or oesophageal spatula. 4. A biopsy, when necessary, can be taken with great ease and certainty when done thus under direct vision. "As regard the oesophagus proper, a few anatomical and physiological facts should be mentioned. "The oesophagus, like the gut, has two muscular coats, an outer longitudinal and an inner circular. The latter is a continuation downwards of the inferior constrictor, while the longitudinal fibres are attached to the back of the cricoid cartilage, which lies wholly in front of the oesophagus. The muscle spreads down and round the sides of this organ from its attachment. In reaching the posterior oesophageal wall a V-shaped space, about one inch long, is left at its upper and posterior extremity where the circular fibres lack the support of the longitudinal. This the weak spot of the oesophagus where herniation may take place in the formation of a diverticulum. Between the muscle layers lie the plexuses of Meisner and Auerbach, the latter supplying vagal control. "Within the muscular tunnel is the glandular layer with its covering of pavement epithelium. "The total thickness of the wall measures no more than 3-4 mm. This must be kept constantly in mind by anyone who passes an cesophagoscope, and as bacteria are always present, surgical procedures are associated with the risk of infection. 'The anterior wall of the oesophagus is, in part of its length, shared with the trachea. It is in this party wall that are situated the lymphatics draining the posterior portion of the larynx, and it is largely by this route that posteriorly situated malignancies of the larynx early spread to the mediastinum. "The average length of the oesophagus at different age periods is shown in the table (B. and E., p. 68). These are not hard and fast measurements, they are averages. It is not uncommon to find in a long-trunked adult that the cardia is 45 cms. or more from the incisors. In one patient with whom I had dealings the 60 cm. cesophagoscope was necessary to look beyond the hiatus. "Note the anatomical constrictions. Four can be demonstrated with the cesophagoscope. A fifth is often demonstrated by foreign bodies but not easily by cesophagoscopy. This is the point at which occurs the narrowing at the upper opening of the thorax, and seems to be due to the crowding into a narrow, circumscribed space of the many organs, which here enter and leave the thoracic cage. It is, however, a fact that foreign bodies will stick here more often than anywhere else in the oesophagus. "The cricopharyngeal pinch-cock, as Jackson terms it, is produced by the tonic contraction of the orbicular band of fibres at the lower end of the inferior constrctor. In the normal oesophagus it is at this point that the greatest difficulty is experienced in passing an cesophagoscope from pharynx to stomach. In health it relaxes only on the approach of a bolus of food—its momentary relaxation being timed to coincide with the contraction of the inferior constrictor above. Saliva in small amounts will pass this point, but a slight excess necessitates the act of deglutition. "The cricopharyngeus is attached to the flat posterior surface of the cricoid cartilage and closes the mouth of the oesophagus with an extraordinary powerful forward pull. Between the horizontal fibres of the cricopharyngeus and the more or less diagonal fibres of Page 77 the inferior constrictor, is a weak triangular area on each side. This is the site at which herniation occurs to form a hypopharyngeal pouche. "Near the distal end of the oesophagus is the 'hiatal pinch-cock'. Here again the lumen is kept closed by the constricting action of a muscle outside the oesophagus—in this case the crura of the diaphragm. The function here, of course, is to allow food to pass downwards and to prevent regurgitation of gastric contents. "There is no constriction at the cardia. This is an important point. "Congenital anomalies may exist in various forms. The oesophagus may be double. It may open into the trachea, its lower part being absent. There may be a fistula between the oesophagus and the trachea and annular strictures have been found. Congenital diverticula have never been reported. "The term 'cardiospasm' is a relic of the days before the oesophagus was examined by sight. Jackson and the Philadelphia groups have long maintained that the site of cardiospasm is at the hiatus and not the cardia—and further, that it is caused not by spasm of the diaphragmatic pinch-cock so much as lack of co-ordination whereby the approach of a bolus of food fails to produce its normal effect of opening at the right momeint the door to the stomach. "Mosher of Boston lays particular stress upon the more or less tunnel of liver through which the abdominal oesophagus passes, so that hepatic abnormality in this area greatly influences the passage of food. He also maintains that a web or stricture at the level of the liver tunnel is a frequent cause of cardiospasm, especially when associated with an exaggeration of the bend or twist of the lower end of the oesophagus, a condition which to some extent is present in the normal. "Recent, Hurst, Brown, Kelly and others have found in post mortem examinations of a number of cases of cardiospasm inflammatory and degenerative changes in the ganglia of Auerback's plexus, whose function is to contract the oesophageal musculature and relax the hiatal pinch-cock. This lesion then explains the neuro-muscular incoordination whose presence was deduced by Jackson from oesophagoscopic observation. "The symptoms all result from the inability of food to pass out of the lower end of the oesophagus. There is a feeling of fullness of the organ and perhaps of pressure behind the lower end of the sternum. If the condition is mild, the symptoms will pass off as the food gradually enters the stomach. This may be aided by the taking of a warm drink. A cold one will tend to have the opposite effect. As the closure of the hiatus progresses, the diet becomes more and more restricted, and more and more liquid. Vomiting of retained food now occurs with increasing frequency and there is increasing loss of weight. A sudden blockage of the lumen may at any time precipitate a surgical emergency. The onset is generally after 3 5 years of age, and the symptoms have generally been slowly progressing for years when the patient seeks medical advice. I had to do with a patient who had been unable to swallow anything more than softs for over 20 years. "As regards treatment, there are two main types. One is some form of gradual dilation. Many techniques have been devised and in general the results are good. The other methods are surgical. An anastomsis with the stomach may be necessary, in cases where there is firm fibrotic closure. G. C. Knight, among others, has obtained good results in cases where there is no hypertrophic stenosis, firm adhesions, by doing a left gastric sympathectomy. The idea of this is to control the autonomic imbalance, and therefore incoordination, which was mentioned above. "The patient whom I mentioned, as having had symptoms for over 20 years, was operated upon thus. The operation was entirely and dramatically successful, but the patient died. "Diverticulum. There are two types. The first and commoner is due to a herniation of the mucous membrane through the lower part of the inferior constrictor or through the weak triangular space where, at the upper end of oesophagus, the longitudinal fibres leave the circular fibres unsupported. These so-called pulsion diverticula generally lie on the postero-lateral wall of the oesophagus—most often on the left. "Many cases have been specified, but none proved. However, it would seem likely that at least in some cases the anatomical weak areas are caused to bulge outwards due to the abnormal pressure effects of late or inadequate opening of the cricopharyngeus. Page 78 "The chief symptom is obstruction to the passage of food through the oesophagus— the degree of this being dependent upon the size of the full sac which compresses the oesophagus. If the pouch is large, food tends to enter this more readily than the oesophagus, and the patient lives on the overflow from the diverticulum. When he takes food he is never sure of retaining it. Lying down to sleep may be impossible because overflow from the pouch is apt to enter the larynx and cause sever spasms of choking and coughing. "In making an examination with any instrument it must be remembered that the walls of a diverticulum are no thicker or stronger than the single layer of mucous membrane of which they are formed. Even in quite small sacs, it may be difficult to find by direct vision through an cesophagoscope the noimal passageway of the gullet, so that the blind passage of a bougie is nothing short of recklessness. "Diagnosis by means of fluoroscopy and x-ray with a barium drink can be quqite exact. The larynx should be included in the x-rays so as to place the diverticulum. "As regards treatment, dilatation through the cesophagoscope has been used with a fair measure of success. For every large diverticula, various operations have been devised for obliteration of the sac. Obliteration has been accomplished endoscopic ally, but the operation of choice is generally the two-stage external one. The sac is first mobilized through an external incision and fixed with the mouth down. If deemed necessary the sac is later removed in a manner which is roughly similar to that used for the removal of the appendix. "The second type is called the traction diverticulum. It occurs almost always at the bifurcation of the trachea. Turner has shown from post mortem records that practically all of these are of tuberculous origin. Their formation is due to an adjacent tuberculous gland, which suppurated and then healed. The resultant contraction of scar tissue attached to the oesophagus pulled out a part of the wall to form a pouch. These seldom cause symptoms and do not enlarge to the extent of the first type, which may extend to below the clavicle. "Carcinoma, At the present time the oesophagus is an unusually fatal site for the development of a cancer. This is so for two reasons. Firstly, the condition is seldom even suspected, far less recognized, as such until the growth is far advanced. Secondly, the relations and general situation of the oesophagus throughout the greater part of its length makes for great difficulty in the treatment of this condition. It should, however, be stressed that until the tumour has reached quite an advanced! stage, it remains localized, tending to spread along the submucosal lymphatics rather than to metastasize. This does not occur until the muscular coats of the organ have been broken through. "Oesophageal malignancies are nearly always squamous cell carcinoma. Occasionally, adeno-carcinoma is found at its lower end. Other malignant growths are rare. "The region of the crossing of the left bronchus is the favorite site, the post-cricoid area being next in frequency in general, though the commonest site for this condition is in women. "The symptoms cannot be anything but vague to begin with. There is very often a history of many months and sometimes a couple of years. Prior to actual obstruction of the oesophagus the symptoms range from an indefinite feeling of abnormality behind the sternum to actual dysphagia, the result of oesophageal irritation and spasm at one or both of the pinch-cocks. "There is a gradual increase in the severity of the symptoms with eventual slow starvation, except in the event of mechanical sudden obstruction. "In treating the condition, the overcoming of this state of starvation is of prime importance, no matter what other form of treatment is used. Even with no treatment, other than keeping up the nutrition, there are cases on record of patients who lived for as long as two years, after establishment of the diagnosis. Malnutrition must be considered a serious complication. It is treated generally by the making of a gastrostomy or by the insertion, in the oesophagus at the site of the growth, of some sort of tube for maintaining the necessary lumen. Repeated dilatation of the region of the growth has been abandoned as being both dangerous and not very satisfactory. "As regards eradication of the tumour, the multiplicity of methods speaks for their general lack of success. Page 79 "Radium or deep x-ray therapy has given many good palliative results, and a few cures have been reported. "Due to the technical difficulties involved, as well as to the advanced state of nearly all growths when diagnosed, surgery has not been a success to date. However, a few cures have been reported as resulting from resection in the early stages. "I may say there is a good summary of this condition in the Handbook on Cancer, which has recently been issued by the Canadian Medical Association—it ends with this statmeent: 'When there is difficulty in swallowing, try an cesophagoscope and barium with x-ray . Pictures were shown on the screen at different intervals during the address: 1st—Diagram of oesophagus from incisor teeth to cardia. Four constrictions were demonstrated as with the cesophagoscope at the aorta, left bronchus, hiatus and cardia. 2nd—Diagram showed the danger of passing a bougie blindly into the oesophagus. 3rd—Sixteen normal and abnormal views of the oesophagus as seen through the cesophagoscope. 4th—Illustrated peptic ulcers at lower end of oesophagus. 5 th—Showed lye burns—acute stage, healed scar, lumen blocked by scar, etc. 6th—Showed malignant growths of different forms of the oesophagus. Diagrams were drawn on the blackboard demonstrating the weak spots in the oesophagus. Mr. Murphy thanked Dr. Scott-Moncrieff for his very interesting presentation of the subject of the oesophagus. Dr. Murphy then showed a number of films demonstrating lesions of the oesophagus that Dr. Scott-Moncrieff had spoken of. These films were taken from cases that had recently passed through the Radiographic Department. B. C. MEDICAL ASSOCIATION LECTURE TEAMS (Continued from page 74) All happiness has some sorrow and so it was that Dr. (Mc) Baird was put on the early train en route to Rochester and Doctors (Mc) Huggard and (Mc) Thomas lost a good driver and a really merry travelling companion. It was a case of home via Creston, Gray's Creek to Fraser's Landing to Kaslo and along the road to New Denver and on to Nakusp that night. The next morning to Fauquiers and by ferry to Needles and over the Monashee to Vernon. Sunday evening was spent by the fireside of Dr. and Mrs. Osborne Morris and two tired trippers enjoyed the comforts of home that night. A cheery send-off saw them safely on their way to Revelstoke, where a Thanksgiving dinner awaited them at the home of Dr. and Mrs. Llewelyn Jones. After dinner all went to the Hospital where the citizenry had met in spite of a deluge of rain and Thanksgiving Day. A large meeting heard Dr. Huggard's address on cancer and the unit at that point was formed. The next morning saw Doctors Huggard and Thomas on the way to Sicamous and Salmon Arm, where Doctors Beech and Harry Baker were seen, and then on to Kamloops and on and on towards Vancouver without hitting but one rock in a> pluvial slide near Boston Bar. The lecture team had done well and left warm friends and open doors and hearts all along the route. Doctors Baird and Huggard made a splendid contribution and deserve the thanks of us all. Penticton Unit No. 31 of the Canadian Society for the Control of Cancer is now well organized and an active drive for membership is under way. All organizations are cooperating fully. Page 80 Preventive Medi cine Secti SYPHILIS IN PREGNANCY I. A Pregnant Syphilitic Woman has a 16 per cent Chance of a Healthy Living Baby. The Birth of Syphilitic Babies is Preventable. The Public Health responsibility for eradication of Prenatal Syphilis lies largely on the shoulders of the physician. II. The Diagnosis of Syphilis in Pregnancy can be made only by Routine* Serodiagnostic Tests because: 1. Few pregnant syphilitic women have lesions. Pregnancy has an ameliorative influence on the infection, reducing the clinical evidences of it. 2. Syphilis run a milder course in women than in men. It is difficult, therefore* to get a history of primary or secondary manifestations. 3. A routine blood Kahn should be taken early in every pregnancy, preferably before the fifth month. (Although the existing facilities of the Division of Laboratories, Provincial Board of Health, are greatly overtaxed, Dr. Dolman recognizing the importance of use of the routine Kahn in pregnancy has permitted the Division of V. D. Control to recommend this procedure routinely throughout the province.) III. The Treatment of Syphilis in Pregnancy: 1. It must be instituted early, preferably before the fifth month. 2. It must be continuous throughout, at weekly intervals. 3. The pregnant woman tolerates arsentcals and heavy metal well and may be given full doses for her weight. 4. A woman who has had syphilis, even though apparently cured, must have treatment throughout every subsequqent pregnancy to avoid the possibility of birth of syphilitic baby. 5. Therapeutic abortion is not indicated. Pregnancy has a beneficial effect on the mother's infection. Adequate treatment gives the baby a reasonable chance of being healthy and non-syphilitic. 6. Outline of Prenatal Treatment: (a) Third and Fourth months—Ten neoarsphenamine, eight bismuth, ten neoarsphenamine. (b) Fifth and Sixth months—Eight neoarsphenamine, eight bismuth, eight neoarsphemine. (c) Seventh to Nine months—Concurrent treatment with neoarsphenamine and bismuth, that is one injection of each weekly. 7. Outline of Postnatal Management: (a) Mother—continue treatment as for non-pregnant women. (b) Baby—no treatment till diagnosis made. (i) Take cord blood—if positive it may mean syphilitic infection of the baby or passive transfer of anti-bodies from mother's blood to baby's without syphilitic infection of the latter. (ii) Repeat blood Kahn at two weeks and thereafter monthly for six months and every six months for two years. If the Kahn remains negative throughout or if the cord blood is positive at birth but becomes negative by the third month and remains so, the baby may be considered non-syphilitic. (iii) X-ray the infant's long bones at two weeks. (iv) If blood Kahn is persistently positive after the third month, or x-ray reveals evidence of syphilitic epiphysitis, or ciinical evidence of syphilis ensues, start routine treatment for prenatal syphilis. IV. The Birth of Syphilitic Babies can be Prevented by: 1. Premarital examination for syphilis. 2. Routine blood kahn taken early in every pregnancy. 3. Institution of continuous weekly treatment before the fifth month in every pregnancy of every known syphilitic or apparently cured syphilitic woman. Page 81 V ancouver G enera H os pita Case: Intestinal Obstruction—Dr. W. L. Graham. At the request of the Vancouver Medical Association I have been asked to present some cases from my service at the Vancouver General Hospital. At first I wish to offer my appreciation to Dr. Seldon, the Chief of the Surgical Service, for permission to publish these cases. We are presenting three cases which we think will be of some interest to the profession. The case histories will necessarily be short, but we hope that they will give you a picture of the case as we see it and our ideas of treatment. These cases offer divergence from those usually seen in the ordinary surgical practice. These cases were shown at a Staff Clinical Meeting of the Vancouver General Hospital, and the conclusions ond observations will be summarized. The first case presented is one of a partial intestinal obstruction due to post-operative adhesions. He was a young man of 34, who was admitted to hospital on May 3, 193 8. He complained of recurrent atatcks of nausea and pain in the abdomen for the past six and a half years. He gave a history of having his appendix removed seven years previously. Whether it was acute or chronic we do not know. His convalescence was prolonged with periods of nausea and vomiting. Since then he had has nine abdominal operations. Five operations were for adhesions and four for intestinal obstruction. Since October, 1937, this man has been a patient in the Vancouver General Hospital on six occasions. His hospitalization has been from one to four days, and he has been relieved by enemata and pituitrin. At other times he has presented himself to the Emergency Department for relief of abdominal cramps which enemas have relieved. He has repeatedly come into the Emergency asking for a hypodermic. The family history is negative. His past illnesses include encephalitis in 1920, and he now presents a Parkinsonian syndrome. This man has periodically worked in the Occupational Therapy Department and has been reported as being industrious and efficient. The physical examination of this patient apart from the abdomen and the associated encephalitis is essentially negative. The abdomen presents numerous abdominal incisions on the righ half of the abdomen. During acute attacks of pain visible peristalsis can be observed beneath the scars. He was admitted on May 3, 1938, and the previous history reviewed. On October 1, 1937, a barium enema was negative. Just previous to admission a gastro-intestinal series showed suggestion of some obstruction to the lower small bowel. After consideration of this case it was decided that some form of operative treatment might be of value to the patient, either multiple anastomosis or a block resection of the involved bowel. On May 14th a left rectus incision was made and the terminal five feet of the small bowel was found to be involved in dense adhesions. The remainder of the small bowel was free. A resection was done of the lower five feet of the terminal ileum and an anastomosis from the proximal end of the resection to the small bowel proximal to the cascum. Recovery in this case was uneventful and he was discharged from the Hospital on June 26, 1938. Since discharge the patient has been working and has enjoyed good health. He has been married within the last month and has been readmitted to Hospital with a fracture and laceration of the nose [! ? Ed.] but no symptoms referable to his digestive tract. His subsequent blood count will be carefully followed. His pathological report was a section of the small bowel superficially hemorrhagic and patchily congested showing many fibrous tags. There is no evidence of any specific process such as tuberculosis or malignant lesion. Remarks.—Since 1932 this man has had at least nine operations for intestinal adhesions and intestinal obstruction. He suffered tremendous pain in the last three months. He did have peristalsis and did have distention. He would appear in Emergency every other night for an enema. Page 82 Operated on May 13th. The right abdomen was a mass of scar tissue, so we went in on the left side and found the last five feet of bowel involved in this granular adhesive type of plastic peritonitis. It looked almost acute. We did think of doing multiple anastomosis to relieve the obstruction, but felt that it probably would be only temporary relief. I took out the last five feet of ileum and did an end-to-end anastomosis. One wonders what the future will be. He has been surprisingly well and is very grateful for relief of pain. This man has a Parkinsonian syndrome as well. He is age 34. In this case an anastomosis was done over a tube. STAFF CLINICAL MEETING I.—GASTRIC LUES VERSUS INOPERABLE CARCINOMA OF THE STOMACH. The first case—Gastric Lues versus Inoperable Carcinoma of the Stomach—was presented by Dr. J. E. Walker. This patient complained of pain two hours after eating. He came to Outpatient Department in the spring, and at that time showed 2800 red blood cells, 3 8% haemoglobin, plus one small cell and plus one large. He was admitted to hospital at that time. Apart from a rasping cough, the physical examination showed nothing of importance. Blood pressure was 140/72. An x-ray showed no enlargement of the liver. The heart was slightly enlarged. Blood Kahn was plus one. The Throat Department diagnosed his hoarseness as "chronic laryngitis." Examination of the thorax showed no specific reason for this. The patient was given anti-syphilitic treatment. Cough mixture was given for his cough. No cause was demonstrated for his anaemia. He then left hospital in June and went up north, where his diet gave him some trouble. As a result of eating fried foods, etc., he began to have indigestion. The patient states that this was his first attack since 1930. He was re-admitted to hospital on July 17th, and was in until September 9h. The pain in the epigastrium is recent. It came on after eating and was relieved by eating. After a while the pain was present all the time and was not relieved by anything. By the time he came to hospital it was present all the time. On examination he was found to have no true rigidity; there was some tenderness above the umbilicus. The Surgical staff said that he had a mass, but the Medical staff never found that mass. An x-ray taken after the administration of barium meal showed the stomach to be empty after five hours. The pyloric end showed marked definite irregularity. The duodenum was spastic. Blood count showed 2,300,000 R.B.C. and 25% haemoglobin; colour index .5. On admission showed plus 2 blood in stool and in the next showed plus 4. He was started on iron and a month after coming to hospital his blood count was up. Due to the fact that he was looking and feeling so much better another x-ray was taken. Five hours after the ingestion of a barium meal the stomach was empty. The stomach showed no evidence of irregularity. Discussion. A doctor enquired how long after the first x-ray was the second x-ray taken. Dr. Walker replied: "Exactly one month." The patient was discharged on August 9th and was referred to the Outpatient Department. He was admitted again a couple of days ago because of cough. The Nose and Throat Department still diagnoses his condition as "chronic laryngitis." In reply to a question about the patient's weight, Dr. Walker said that the patient claims to have lost about 20 pounds while up north, but he is putting it all back on again. On April 6th, the patient had a plus one Kahn;; on April 27th, plus 1; on July 22nd it was negative and on October 21st doubtful. Colloidal gold was negative. No dilatation of the aorta. The nervous system shows no signs of syphilis. Dr. Walker said that he looked up some facts on syphilis of the stomach. This man, he said, does not seem to fit into it. Haemorrhage is rare. This man shows a one or two plus blood on gastric analysis; there was blood in his stools. His stomach contents are within normal limits and he has a cough. Dr. Harrison says this is a case of gastric hypertrophy. "On physical examination at present," said Dr. Walker, "I do not think there is much to find." At this point the patient was brought in and questioned by Dr. Walker. He said that he had pain after eating every day, but that it is much better than it was two months ago. His laryngitis is also improved. In reply to a question, Dr. Harrison said that x-ray diagnosis of hypertrophy of the gastric mucosa is not very common. Dr. Hodgins said that gastric hypertrophy is much more common than gastric syphihs, which is a very rare disease. Gastric hypertrophy can have many forms. It is caused by poor food, alcohol and exposure. It can occur in any situation, of any extent, and can Page 8} come and go in the matter of a month or two at will. It comes and goes without treatment. The x-ray may show it to be in the greater curvature. After washing out the stomach for a month or two it will be completely gone. It may go through the pyloric ring and take the form of a polypus. Dr. Hodgins asked whether there was pressure on the stomach, and Dr. Harrison said that there was not. Dr. Hodgins said that he did not think the patient could have syphilis of the stomach. Good food and rest cured him. Gastritis is very uncommon without hypertrophy; it is relatively common with hypertrophy. Dr. Hatfield asked whether it is impossible to make a direct examination of the stomach. He said that in a case of this type a direct examination would give some idea of the diagnosis and asked whether it would not be possible to develop this work on the staff. Dr. Graham remarked that the man may have two concurrent diseases, but that the two must be related in some way. He suggested that the Nose and Throat might investigate the cause of the patient's laryngitis further. Dr. Davidson asked whether they should continue with the anti-syphilitic treatment. Dr. Walker said that they were more concerned with the stomach trouble at that time. As far as treating for syphilis goes, Dr. Walker said that he did not think it was doing the patient much harm. It did not matter a great deal whether anything was done for the syphilis—his blood Kahn is certainly very weak. The case was then discussed by Dr. Harrison. The lesion of this man was rare and interesting, as it did not follow the type usually seen. ''There were several large plaques protruding into the lumen of the stomach associated with some constriction which is quite different to the picture of mucous membrane which one sees in cases of hypertrophy gastric mucosa. The first picture did not suggest hypertrophy. There is, however, no reason why a hypertrophy cannot be complicated. This man, according to the history, had evidence of gastric tenderness. Assuming that he had a gastritis to start with, the original picture can be accounted for by rupture of the mucosa with gastric inflammation. In the ordinary case of hypertrophy of the mucous membrane there is not necessarily any superficial erosion of any great size. There are frequently some small superficial erosions." Dr. Harrison said that he is not quite satisfied with this case. He has seen malignant cases of that degree of severity improve within a few months. This patient still has a certain amount of rigidity. "This is, I think, one of the types of cases in which the correlation of radiology and gastroscopy is essential to a full diagnosis, and, since the invention of the flexible gastro- scope, I see no reason why we cannot have it in the V. G. H." Dr. Harrison concluded by saying that it is his present opinion that neither radiography nor gastroscopy is enough 7 ltSe f" II.—A CASE FOR DIAGNOSIS. Dr. Lyle Hodgins. Dr. Hodgins' case was presented by Dr. Munroe. The patient was a young man of 24 years, admitted to hospital on the 24th of September. He had a history of diarrhoea, nose bleeds and vomiting. The patient said that he was in good health until 17 days ago, when he developed a cough and sore throat. Towards the end of the week he had several nose bleeds, vomiting and diarrhoea after meals. Towards the second week of his illness—before admission—the diarrhoea stopped. Vomiting occurred ten or twelve times a day. There was no blood in the stools or vomitus. On examination the patient was found to be a well nourished young adult male, extremely hydrated. B.P. 120/80; T. 100; P. 60; respirations 20. He had no pain, the only symptom being vomiting. The abdomen was scaphoid— negative except for a possible enlarged spleen. Two days after admission the spleen was easily palpable. The dehydration was slightly overcome but he was still vomiting. He did not complain of nausea. For the first seven or eight days he was vomiting 70 to 80 ounces per day. He was given atropine, grs. 100, for six days with no effect. Dr. Carder at this time considered that the possibility of typhoid had been eliminated. He was given intravenous two a day at first, and; later three a day. On admission, leucocytes 15,900; four days later, 10,800; today about 6000. A spinal puncture was done; pressure was 16 and was reduced to 9. The laboratory work was entirely negative. Cultures were negative for typhoid. Sinuses negative. This case, therefore, is one of acute upper respiratory infection follewed by diarrhoea for one week, after which there was a week of obstinate constipation. The patient ran a slow pulse. On Saturday last he was seen by Dr. F. Turnbull, who stated that there was a slight papillcedema and slight mystagmus of the lateral fields on both sides. He was also seen by the surgical Staff. At the present time the spleen is no longer palpable. Dr. Hodgins said that he has no idea of the nature of the infection. The patient is improving now. Page 84 Dr. Palmer stated that he saw the patient on the 16th or 17th day of his illness. The case was very suggestive of typhoid fever. His temperature was never very high, but he has a surprisingly slow pulse. He had a little bit of headache, but was rather inclined to be a little drowsy. Dr. Palmer thought he could feel the spleen. The desquamation of the hands and feet ws very marked—as in scarlet fever. The most probable diagnosis is typhoid fever. While it is true that in most cases of typhoid fever—something over 95%—the blood agglutination is positive, there are a few cases that do not follow the rule, particularly if the patient is seen after the first week. However, the diagnosis is much more likely to be that which Dr. Hodgins suggested—a marked generalized response to the severe upper respiratory infection. Dr. Palmer concluded by saying that he still feels that it would be well to do a blood agglutination test. Dr. Turnbull said that the neurological examination showed nothing apart from that reported above and he did not consider the case primarily neurological. Dr. Williams asked how they had ruled out scarlet fever, as it is not uncommon to find a palpable spleen in cases of scarlet fever. Dr. Gillies said that he is quite interested in this case, as he had seen another case of upper respiratory infection about three weeks ago in which the patient had a slow pulse very much like the present case. However, the patient was a woman of about 60 years of age, and it is just possible that there was a certain amount of myocardial involvement which would account for the slowness of the pulse, which was around 44 to 58. She was too ill to be removed to the Heart Station, so the portable machine was transferred to her room. However, there was too much static and she could not register properly. It would be interesting to explain why there was desquamation. It is extremely unlikely that a case of scarlet fever should run a slow pulse—it is never seen. The usual association with scarlet fever is a rapid pulse, more often out of proportion to the temperature. In typhoid fever we often see a slow pulse not in proportion to the temperature, and associated with a very low leucocyte count. Dr. Gillies said he could not put a label to it, but, if anything, the case seems to be in the typhoid group. Dr. Harrison remarked that one point had not been emphasized—what is the cause of the vomiting? With regard to the x-ray history, Dr. Harrison pointed out that while the patient was on his back they could not get the food around through the duodenal pool, but as soon as he was turned over on his side or face it went straight on. SIR DAVID WILKIE—1882-193 8 The news of the death of Sir David Wilkie, on August 28th of this year, came as a great shock to the medical profession, especially in England. He had been a speaker at the Annual Meeting of the British Medical Association at Plymouth in July. Born at Kirriemuir, in Scotland, the "Thrums" of Sir J. M. Barrie, 56 years ago, he graduated from the University of Edinburgh. He became a Fellow of the Royal College of Surgeons of Edinburgh in 1907, and of the Royal College of Surgeons of England in 1918. He was made an Honorary Fellow of the American College of Surgeons in 1926. He was a brilliant surgeon and held many important appointments. His genius as a teacher was outstanding. It was in the operating theatre, however, that he was seen at his best. There, with a technique which was faultless, with a dexterity that was equally complete, he operated and demonstrated in a manner that called forth sincere admiration. He was a personal and close friend of Sir James Barrie. Indeed, he seems to have had a great capacity for friendship, as evidenced by the warm tributes paid to him in the October number of the British Journal of Surgery, and the British Medical Journal for September 10th, 1938. Drs. White, Parmley and (Bill) White have moved into their new offices, which they share with Dr. F. Parmley, dentist, who is a brother of Dr. J. R. Parmley. Page 85 St. Paul s Hospita MEDICAL STAFF MEETING Doctor Lynch presented three cases of carcinoma of the stomach, and he opened his remarks with the following quotation: "Where there is everything to lose, one must dare much." This, he went on to point out, is nowhere so true as in dealing with cases of cancer of the stomach. When one realizes that cancer of the stomach has the melancholy distinction of holding first place as a cause of death of all cancers that afflict the human body, one realizes the necessity for drastic action. Death from cancer of the stomach comprises about one-third of the total from all forms of cancer and 2.6% of the deaths from all causes combined. In other words, out of every hundred thousand individuals 28.8 will develop cancer of the stomach. The operation for cancer of the stomach must of necessity be a radical one and never less than three-quarters of the stomach and gastro-colic and great omentum must be removed. Even in high circles it has been so usual of late to bemoan or even decry the results of operative treatment of malignant disease that many members of the profession are deterred from advising surgical interference. As Gray Turner says, "There is a real risk of a generation of medical men arising who are ignorant of what surgery can offer in the treatment of cancer. At the present time we are living through one of those periods in which the medical profession and the general public is being encouraged to grasp at remedies which hold out hope of cure or alleviation without mutilation, and it was never more necessary to have in our ranks bold gastric surgeons with wide experience and balanced judgment, who can determine which cases can reasonably be selected for such conservative treatment and which must be treated by thorough and not half-hearted surgical methods. The history of surgery of malignant disease is neither so discouraging nor so discreditable as many would have you believe." Dr. Lynch's own personal experience convinces him that there is no place for pessimism in the treatment of early cancer by surgery. Therefore, in dealing with cancer one must ever be bold, remembering the inevitable mortality if surgery fails, and with courage do what one feels to be right. Cancer at its inception is always a localized disease, hence early diagnosis is of the utmost importance. It is discouraging to the gastric surgeon to find that 50% of the cases referred to him are inoperable and of the 50% remaining only one-half are really resectable and come into the five-year cures. All patients between the ages of 40 and 60 complaining of vague gastric symptoms should be carefully studied from the radiological standpoint and a complete gastric analysis for free and combined hydrochloric acidl should be done. "Some things are hard to say," went on Dr. Lynch, "and it is often easier and pleasanter to leave them unsaid, but, in my opinion, radium has no place in the treatment of malignant disease of the stomach, and for that matter of the alimentary tract, and deep x-ray therapy of the upper abdomen for advanced inoperable cancer is only a therapeutic straw and causes irreparable damage to the normal tissues of the alimentary tract and frequently to the abdominal parietes as well. Cancer of the stomach must be recognized early if the percentage of our five-year cures is to be increased. The operative risk in the majority of cases will be from 30 to 35% and the five-yeat cures range from 10 to 25%." Doctor Lynch gave it as his opinion that gastroenterostomy as a palliative operation in dealing with advanced cancer of the stomach has no place in surgery. The operative mortality in such cases is over 24% and the longevity of the patient is increased only 2.8 months. As W. J. Mayo said many years ago, "it merely enables the patient to live longer and suffer more." This palliative operation for advanced carcinoma of the stomach only brings disrepute on gastric surgery and is largely responsible for the present fatalistic attitude not only of the laity but also among many members of the profession as well. Page 86 "In operating on cases of cancer of the stomach," said Dr. Lynch, "I never allow myself to think of a radical cure and I am always satisfied if these patients are alive and well five years after the resection. Cancer of the stomach is undoubtedly of a high grade of malignancy and survival from three to five years is about as long as we dare to expect." In a series of over two hundred gastric resections, most of which were done for carcinoma of the stomach, the speaker admitted a mortality of 32%, and a five-year cure of not more than 11.3%. Starving to death is extremely unpleasant, but thirsting to death is intolerable. Therefore, most cases of cancer of the stomach which can be resected ought to be attempted. The patient has everything to gain and nothing whatever to lose. The vast majority of cases who survive extensive resections for malignancy of the stomach will live on the average four years and nine months, and those who have recurrence within that time die of metastases, usually in the liver, a comparatively speaking painless death compared to death from starvation and thirst. (Several pre-operative and post-operative slides were shown, some of cases surviving eight years, one five years and one two years.) In the speaker's experience all cases of carcinoma of the stomach which the pathologist reported as Grade 4 will be dead within eighteen months to two years from the date of resection. The speaker pointed out that a careful rectal examination should be made before planning any gastric resection in a case of cancer of the stomach to eliminate a rectal shelf. Also the umbilicus must be carefully palpated and the Virchow Mikulicz gland felt for in the left supra-clavicular fossa. Any or all of these are absolute contraindications for surgery. There are no classical symptoms of early cancer of the stomach, and a more careful, painstaking history is of great importance, and the physician consulted should be always suspicious of the possibility of a cancer being responsible for the symptoms complained of and take appropriate steps to eliminate this possibility. Dr. Lynch paid a tribute to the roentgenologists as giving an 8 5 % absolutely correct diagnosis in cancer of the stomach. In his opinion, in reading the plates, stomachs that lie largely to the left and low in position are resectable. Radiograms showing high-placed stomachs with carcinomatous involvement indicate metastases in the lesser omentum and are frequently found to be inoperable. Gastrectomy, even when not permanently successful, is a very satisfactory palliative for cancer of the stomach. Dr. J. Stuart Daly of Trail has been visiting in Vancouver and is back at practice after a deserved vacation. Dr. Daly was re-appointed reporter of the West Kootenay Medical Association. Dr. H. F. Tyerman of Nakusp visited Vancouver in October. He missed seeing Drs. Huggard and Thomas. Dr. Arnold Francis of New Denver visited Nakusp daily in Dr. Tyerman's absence. Dr. G. A. B. Hall of Nanaimo is at Carmi, near Penticton, on his annual hunting trip. He will visit Nelson before his holiday is ended. Dr. J. R. Parmley and family are leaving for Montreal. They will spend a month at Mrs. Parmley's home. Dr. Parmley will db some special work at the Royal Victoria Hospital. The newly formed Penticton Medical Association elected the following officers at the first meeting: Honorary President—Dr. R. B. White. President—Dr. H. McGregor. Honorary Secretary-Treasurer—Dr. W. R. Walker. The Penticton profession felt that it required to deal with some of its problems in a united way and to speak as one voice. Page 87 MEMBERS of THE GUILD Wt of PRESCRIPTION OPTICIANS of AMERICA Always Maintain the Tithical Principles of the Medical Profession Guilder aft Opticians 430 Birks Bid?. Phone Sey. 9000 Vancouver, Canada. ADEQUATE I IRON for HYPOCHROMIC ANEMIA Excellent hemoglobin response results in most cases front the daily dose of three Hematinic Flastules Plain. This provides 15 grains of ferrous iron. Small dosage, easy assimilation and toleration favor the use of Hematinic Flastules for hypochromic anemia, because they produce maximal results, at low cost, without discomfort or inconvenience to the patient. . Hematinic Flastules provide ferrous iron and the vitamin B complex of concentrated yeast, in soluble gelatin capsules. They are issued in two types—in bottles of fifty—Hematinic Flastules Plain and Hematinic Flastules with Liver Concentrate. JOHN WYETH & BROTHER, Inc. WALKERVILLE, ONTARIO For Complete BINDING OF THE BULLETIN A phone call will bring immediate attention. Sey. 6606 Roy Wrigley Printing and Publishing Co. Ltd. 300 West Pender St. Vancouver, B. C. A PRESCRIPTION SERVICE . . . Conducted in accord with the ethics of the Medical Profession and maintained to the standard suggested by our slogan: Pharmaceutical Excellence N\\CG ftOfmo LIMITED ^—' FORT STREET (opp. Times) Phone Garden 1196 VICTORIA, B. C. The New Synthetic Antispasmodic Trasentin "Ciba" (Diphenylacetyldiethylaminoethanolester-hydrochloride) SUPPRESSES SPASMS OF THE GASTRO-INTESTINAL TRACT, GENITO-URINARY SYSTEM AND OTHER SMOOTH MUSCLE ORGANS Tablets—bottles of 20 and 100. Ampoules—boxes of 5 and 20. 1 tablet or 1 ampoule contains 0.075 grm. of the active substance. CIBA COMPANY LIMITED MONTREAL SssasS* Xwi*X*XC"SOOC«X"Xss* 13 th Ave. and Heather St. Exclusive Ambulance Service FAIRMONT 80 PRIVATE AMBULANCES AND INVALID COACHES WE SPECIALIZE IN AMBULANCE SERVICE ONLY J. H. CRELLIN W. L. BERTRAND THIAMIN CHLORIDE SQUIBB Indicated in all degrees of Vitamin B1 deficiency, especially the more severe forms. Permits adequate dosage in small volume. Stable and convenient to use. Bottles of 50 tablets in 2 potencies—300 (1mg.) and 1500 (5 mg.) International units per tablet. Boxes of 6x1-cc. ampuls—each ampul containing 3000 I.U. (10 mg.) of the crystals in solution; also in 5-cc. vials containing 3000 I.U. per cc. SQUIBB VITAMIN B COMPLEX SYRUP For Patients Needing the Several Factors of the "B Complex" The therapeutic usefulness of Squibb Vitamin B Complex Syrup depends upon the fact that it supplies an abundance of naturally occurring Thiamin (Bj), Riboflavin (B£)> Vitamin B6, the filtrate factors and the pellagra-preventive factor (nicotinic acid). There is also qualitative experimental evidence suggesting the presence of factor W and Vitamin B4. INDICATIONS: Anorexia, Chronic gastro-intestinal mal-function, Constipation, Pregnancy polyneuritis and vomiting, Lactation, Alcoholic polyneuritis, cardiovascular disturbances, Retarded growth in infants, Retarded growth in older children, Infant feeding, Pellagra. DOSAGE: Infants, V2 teaspoonful a day; children, 1 to 2 teaspoonfuls a day; adults, 2 to 4 teaspoonfuls a day. Supplied in'3 and 6-oz. bottles and 12-oz. jars. Vitamin Content as Shown by Multiple Physiologic Assays: VITAMIN Bi—50 International units per 1 cc. Thiamin, as it occurs naturally. VITAMIN B2—10 gammas per 1 cc. "Riboflavin" is the accepted ne w term for the artificial vitamin B2. In Vitamin B Complex Syrup, riboflavin is present in naturally occurring form. VITAMIN Bc—100 gammas per 1 cc. This vitamin can be prepared in crystalline form; here it occurs in its natural form. FILTRATE FACTORS—Jukes-Lepkovsky factor value of 27 per 1 cc. PELLAGRA—Preventive Factor contains an abundance. Recent literature refers to this factor as nicotinic acid. For descriptive literature address Professional Service Department, 3 6 Caledonia Rd., Toronto, Ont. ER: Squibb & Sons of Canada, Ltd. MANUFACTURING CHEMISTS TO THE MEDICAL PROFESSION SINCE 1858 Doctors- YOUR PRESCRIPTION AND RECOMMENDATION Is Our Guide Always- OUR MECHANICAL and SCIENTIFIC ORTHOPAEDIC EQUIPMENT Is At Your Service Avail Yourselves of our experience in last making to aid correction in Minor Foot Ailments. PHONE Pierre Paris FOOT CLINIC Sey. 3 778 51 W. Hastings Colonic Irrigation Institute Superintendent: B. M. LEONARD, B.N. Post Graduate Mayo Bros. Up-to-date treatment rooms; scientific care for cases such as Colitis, Constipation, Worms. Gastro-intestinal Disturbances, Diarrhoea, Diverticulitis, Rheumatism, Arthritis, Acne. Individual Treatment $ 2.50 Entire Course $10.00 Medication (If necessary) $1 to $3 Extra 631 BIRK8. BUILDING, VANCOUVER, B. C. Phone: Sey. 2443 506-7 CAMPBELL BUILDING VICTORIA, B.C. Phone: Empire 2721 STEVENS' SAFETY PACKAGE STERILE GAUZE is a handy, convenient, clean commodity for the bag or the office. Supplied in one yard, five yards and twenty-five yard packages. ESTABLISHED NEARLY A B. C. STEVENS CO. Phone Seymour 698 730 Richards St., Vancouver, B. C. s. BOWELL & SON Distinctive Funeral Service Phone 993 > 66 SIXTH STREET 1 *EW WESTMINSTER, B. C. Breaks the vicious circle of perverted menstrual function in cases of amenorrhea, tardy periods (non-physiological) and dysmenorrhea^ Affords remarkable symptomatic relief by stimulating the innervation of the uterus and stabilizing the tone of its musculature. Controls the utero-ovarian circulation and thereby encourages a normal menstrual cycle. • MARTIN H. SMITH COMPANY Ik 1M IAFAYITTI STRUT. NIW TOM, N. T. Full formula and descriptive literature on request Dosage: 1 to 2 capsules 3 or 4 times daily. Supplied in packages of 20. Ethical protective mark MHS embossed on inside of each capsule, visible only when capsule is cut in half at seam. Because of the difficulty encountered in obtaining breast milk, all infants (in the Premature Department, Cincinnati General Hospital) are on a formula of evaporated milk, water, and beta lactose. The results with this feeding compare most favorably with those of the preceding years using breast milk."—Proceedings: Meeting of Region III, American Academy of Pediatrics; J. Pediat., 710, May, 1937. 7?2 The success with which evaporated milk is employed in the feeding of premature infants is due in large part to the soft-curd quality imparted by O. BOOKLET FOR PHYSICIANS —You are invited to- write for "Simplified Infant Feeding," an authoritative publication treating of the use of Irradiated Carnation Milk in normal and difficult feeding cases. . . . Carnation Company, Ltd., Toronto, Ontario. the heat treatment of sterilization. . mity of Irradiated Carnation Milk in this respect is assured by exact control of sterilization time and temperature, and is one of the reasons why this product has become the evaporated milk of choice with many pediatricians. The unifor- IRRADIATED C arnation ^fc^^^^r A CANADIAN PRODUCT — "from contented cows Milk // RADIO-MALT (Standardised Vitamins A, B^ B2 and D) In reporting on his experience with Radio-Malt, the medical officer of a well-known residential college states: ". . . for years I have prescribed Radio-Malt; I look on It as invaluable." The administration of Radio-Malt builds up the body's resistance against any attacks of invading organisms and maintains throughout the winter months the vitality and robust health usually associated with summer time. Stocks of Radio-Malt are held by leading druggists throughout the Dominion, and full particulars are obtainable from: THE BRITISH DRUG HOUSES (CANADA) LTD. Terminal Warehouse Toronto 2, Ont. ZZZZZIZZZZZZZZIZZ^^ RM/Can/3812 flDount pleasant XHnbertakinQ Co. %tb. KINGSWAY at 1 lth AVE. Telephone Fairmont 58 VANCOUVER, B. C R. P. HARRISON W. R. REYNOLDS H Antiphlogistine .. always indicated in TONSILLITIS, PHARYNGITIS, LARYNGITIS, BRONCHIOLITIS "Write for sample and literature THE DENVER CHEMICAL MANUFACTURING CO. 153 Lagauchetiere St. W. Montreal Made in Canada. \\ 5 How Much Sun Does the Infant i Really Get ♦ Not very much: (1) When the baby is bundled to protect against weather or (2) when shaded to protect against glare or (3) when the sun does not shine for days at a time. Oleum Percomorphum offers protection against rickets 365 % days in the year, in measurable potency and in controllable dosage. Use the sun, too. Oleum Percomorphum is an economical source of vitamins A and D. We purposefully selected a classic name which is unfamiliar to the laity, or at least not easy to popularize. Oleum Percomorphum is supplied without dosage directions. Samples are furnished only to physicians. Mead Johnson^ Co. of Canada,Ltd.,Belleville,Ont., does not advertise any of its products to the public. Pharmaceuticals-plus! We have built up connections with sources of supply during these last thirty years that enables us to offer you a most complete stock of medicinals—and with these, seven trained, experienced pharmacists to compound them for you. Open day and night—Seymour 2263 i—mm GEORGIA PHARMACY LIMITED W. OIOROIA STRBIT Only One Store (&mt?t $c ijMwa $tu Established 1893 VANCOUVER, B. C. North Vancouver, B. C. Powell River, B. C. Hollywood Sanitarium Limited For the treatment of Alcoholic, Nervous and Psychopathic Cases Exclusively Reference—B. C. Medical Association For information apply to Medical Superintendent, New Westminster, B. C. or 515 Birks Building, Vancouver Seymour 4183 Westminster 288 ROY WRIGLEY PRINTING a^^^oft PUBLISHING CO. LTD."""@en ; edm:hasType "Periodicals"@en ; dcterms:identifier "W1 .VA625"@en, "W1_VA625_1938_12"@en ; edm:isShownAt "10.14288/1.0214410"@en ; dcterms:language "English"@en ; edm:provider "Vancouver : University of British Columbia Library"@en ; dcterms:publisher "Vancouver, B.C. : McBeath Spedding Limited"@en ; dcterms:rights "Images provided for research and reference use only. Permission to publish, copy, or otherwise use these images must be obtained from the Digitization Centre: http://digitize.library.ubc.ca/"@en ; dcterms:source "Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625"@en ; dcterms:subject "Medicine--Periodicals"@en ; dcterms:title "The Vancouver Medical Association Bulletin: December, 1938"@en ; dcterms:type "Text"@en ; dcterms:description ""@en .