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History of Nursing in Pacific Canada
Vancouver Medical Association
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BULLETIN OF The Vancouver Medical Association EDITOR dr. j. h. macdermot EDITORIAL BOARD DR. D. E. H. CLEVELAND DR. J. H. B. GRANT DR. H. A. DesBRISAY DR. J. L. McMILLAN Publisher and Advertising Manager W. E. G. MACDONALD VOLUME XXIX. SEPTEMBER, 1953 NUMBER 12 OFFICERS 1953-54 Dr. D. S. Munroe Dr. J. H. Black President Vice-President Dr. George Langley Hon. Treasurer Dr. E. G. McCoy Past President Dr. F. S. Hobbs Hon. Secretary Additional Members of Executive: Dr. R. A. Gilchrist Dr. A. F. Hardyment TRUSTEES Dr. G. H. Clement Dr. Murray Blair Dr. W. J. Dorrance Auditors: R. H. N. Whiting, Chartered Accountant SECTIONS Eye, Ear, Nose and Throat Dr. W. M. G. Wilson Chairman Dr. W. Ronald Taylor—Secretary Paediatric Dr. J. H. B. Grant Chairman Dr. A. F. Hardyment Secretary Orthopaedic and Traumatic Surgery Dr. W. H. Fahrni Chairman Dr. J. W. Sparkes Secretary Neurology and Psychiatry Dr. A. J. Warren Chairman Dr. T. G. B. Caunt Secretary Radiology Dr. W. L. Sloan Chairman Dr. L. W. B. Card Secretary STANDING COMMITTEES Library Dr. D. W. Moffat, Chairman; Dr. R. J. Cowan, Secretary; Dr. W. F. Bie; Dr. C. E. G. Gould ; Dr. W. C. Gibson ; Dr. M. D. Young. Summer School Dr. S. L. Williams, Chairman; Dr. J. A. Elliot, Secretary; Dr. J. A. Irvine ; Dr. E. A. Jones ; Dr. Max Frost ; Dr. E. F. Word Medical Economics Dr. E. A. Jones, Chairman; Dr. W. Fowler, Dr. F. W. Hurlburt, Dr. R. Langston, Dr. Robert Stanley, Dr. F. B. Thomson, Dr. W. J. Dorrance Credentials Dr. Henry Scott, Dr. J. C. Grimson, Dr. E. C. McCoy. V.O.N. Advisory Committee Dr. Isabel Day, Dr. D. M. Whitelaw, Dr. R. Whitman Representative to the Vancouver Board of Trade: Dr. J. Howard Black Representative to the Greater Vancouver Health League: De. W. H. Cockcroft Published monthly at Vancouver, Canada. Authorized as second class mail, Post Office Department, Ottawa, Ont. Page 511 Qortove ACETATE (CORTISONE ACETATE Merck) The many indications for Cortone highlight its therapeutic importance in everyday practice Primary Site of Pathology and Indications 1. EYE—Inflammatory eye disease. 2. NOSE—Intractable hay fever. 3. LARYNX—Laryngeal edema (allergic). 4. BRONCHI —Intractable bronchial asthma. 5. LUNG—Sarcoidosis. 6. HEART—Acute rheumatic fever with carditis. 7. BONES AND JOINTS—Rheumatoid arthritis; Rheumatoid spondylitis; Acute gouty arthritis; Still's Disease; Psoriatic arthritis. 8. SKIN AND CONNECTIVE TISSUE—Pemphigus; Exfoliative dermatitis; Atopic dermatitis; Disseminated lupus erythematosus; Scleroderma (early); Dermatomyositis; Poison Ivy. 9. ADRENAL GLAND—Congenital adrenal hyperplasia; Addison's Disease; Adrenalectomy for hypertension, Cushing's Syndrome, and neoplastic diseases. 10. BLOOD, BONE MARROW, AND SPLEEN—Allergic purpura; Acute leukemiat (lymphocytic or granulocytic); Chronic lymphatic leukemia.t 11. LYMPH NODES—Lymphosarcomat; Hodgkin's Diseaset. 12. ARTERIES AND CONNECTIVE TISSUE—Periarteritis nodosa (early). 13. KIDNEY— Nephrotic Syndrome, without uremia (to induce withdrawal diuresis). 14. VARIOUS TISSUES —Sarcoidosis; Angioneurotic edema; Drug sensitization; Serum sickness; Waterhouse-Friderichsen Syndrome. f Transient beneficial effects. Cortone is the registered trademark of Merck & Co. Limited for its brand of cortisone. MERCK & CO. Limited Afanufacturing Chemists MONTREAL • TORONTO • VANCOUVER • VALLEYFIEID HOSPITAL CLINICS VANCOUVER GENERAL HOSPITAL Regular Weekly Fixtures in the Lecture Hall Monday, 8:00 a.m.—Orthopaedic Clinic. Monday, 12:15 p.m.—Surgical Clinic. Tuesday—9:00 a.m.—Obstetrics and Gynaecology Conference. Wednesday, 9:00 a.m.—Clinicopathological Conference. Thursday, 9:00 a.m.—Medical Clinic. 12:00 noon—Clinicopathological Conference on Newborns. Friday, 9:00 a.m.—Paediatric Clinic. Saturday, 9:00 a.m.—Neurosurgery Clinic. ST. PAUL'S HOSPITAL Regular "Weekly Fixtures 2nd Monday of each month—2 p.m Tumour Clinic Tuesday—9-10 a.m Paediatric Conference Wednesday—9-10 a.m Medical Clinic Wednesday—11-12 a.m Obstetrics and Gynaecology Clinic Alternate Wednesdays—12 noon Orthopaedic Clinic Alernate Thursdays—11 a.m. Pathological Conference (Specimens and Discussion) Friday—8 a.m. _. Clinico-Pathological Conference (Alternating with Surgery) Alternate Fridays—8 a.m Surgical Conference Friday—9 a.m . Dr. Appleby's Surgery Clinic Friday—11 a.m Interesting Films Shown in X-ray Department SHAUGHNESSY HOSPITAL Regular Weekly Fixtures Tuesday, 8:30 a.m.—Dermatology. Monday, 11:00 a.m.—Psychiatry. Wednesday, 10:45 a.m.—General Medicine. Friday, 8:30 a.m.—Chest Conference. Wednesday, 12:30 p.m.—Pathology. Friday, 1:15 p.m.—Surgery. BRITISH COLUMBIA CANCER INSTITUTE 2656 Heather Street Vancouver, British Columbia SCHEDULE OF CLINICS—As at June, 1953 MONDAY: 9 a.m.—10 a.m Nose and Throat Clinic TUESDAY: 9 a.m.—10 a.m § Clinical Meeting THURSDAY: 11 a.m.—12 a.m.._||L Gynaecological Clinic (not during summer months) FRIDAY: 9 a.m.—10 a.m. | Skin Clinic 9 a.m.—10 a.m. Lymphoma Clinic DAILY: 11:45 a.m.—12:45 a.m - Therapy Conference Page 513 in the successful management of epilepsy.,] DILANTIN a most effective and widely) used anticonvulsant In grand mal, psychomotor seizures, Jacksonian epilepsy and focal convulsions, DILANTIN is a therapy of choice.1 It "offers the special advantage |if... specificity for the motor cortex . . . without producing dullness of apprehension, lethargy, and lassitude. "2 DILANTIN |.. is particularly adapted for use in combination .. ."3 and "... produces a spectacular result in grand mal attacks, particularly when combined with phenobarbital. .. ."4 Dilantin Sodium (diphenylhydantpin sodium, Parke-Davis) is supplied in Kapseals® of 0.03 Gm. (% gr.) and 0.1 Gm. (1% gr.) in bottles of 100 and 500. (1) Krantz, J. C, and Carr, C. J.: The Pharmacologic Principles of Medical Practice, Baltimore, The Williams & WilkinsCompany, 1949 (Reprinted 1950),p. 518. (2) ibid, p. 515. (3) Carter, S.: Epilepsy, in Conn, H. F.: Current Therapy 1952, Philadelphia, W. B. Saunders Company, 1952, p. 612. (4) Salter, W. T: A Textbook of Pharmacology, Philadelphia, W. B. Saunders Company, 1952, p. 231. [zrawe, ^Dai/id * ^om^anufjbh WALKERVILLE. ONTARIO Page GREATER VANCOUVER PUBLIC HEALTH Metropolitan Health Committee Dr. Stewart Murray, Sr. Medical Health Officer, City Hall, Vancouver, B.C. Population (Estimated) !Vancouver 390,325 Burnaby Municipality 61,000 North Vancouver City 16,000 North Vancouver District Municipality 16,000 West Vancouver Municipality 14,250 Richmond 19,186 University Area § - 3,800 District Lot 172 1,469 TOTAL --. I ! 522,030 Poliomyelitis The following figures show the incidence of polio in the Metropolitan Area up to August 31st; 1953. In addition to local cases tjiirty-one from outside points have been sent in for treatment. Although the number of bulbar cases has been rather high, only one death has occurred up to August 31st. Cases Vancouver 3 5 Burnaby 17 North Vancouver 10 Richmond 2 Total—Metropolitan Area 64 From Outside Points 31 Total Treated I 95 Mount pleasant djapsl 1 FUNERAL SERVICE Kingsway at Nth Ave. — Telephone EMerald 2161 Vancouver 10, B.C. fl&t. pleasant TttnbertaMng Co. Xto. Page 517 PAGE FROM THE ALBUM ACETOPHEN Brand of acetylsalicylic acid COMPOUNDS WITH CODEINE "222 TABLETS" (White) Acetophen 314 gr. Phenacetin 214 gr. Caffeine citrate 14 gr. Codeine phosphate 14 gr. "282 TABLETS" (Yellow) The 222 Tablet formula modified to contain Codeine phosphate 14 gr* "292 TABLETS" (Pink) The 222 formula modified to contain Codeine phosphate 14 gr. DOSAGE: One tablet 2 or 3 times daily. When mild anaesthesia is required, particularly for the dull, gnawing type of pain, the combination of Acetophen Compound with codeine phosphate gr. Vz gives excellent results. For severe pain, this combination modified to contain codeine phosphate Va or Vi grs. is available. Chanted &_fa*at&&>. MONTREAL CANADA Page 518 A PAGE FROM THE "moid' ALBUM RW w F 1 FLAVEDRIN Antiseptic decongestant Flavedrin applied to the mucous membrane of the nose reduces congestion and permits good ventilation of the accessory sinuses. Its antiseptic component is effective against a large number of pathogenic organisms. Aqueous and isotonic, Flavedrin provides quick relief and comfort for the patient with congested, running nose. "FLAVEDRIN" 'Ephedrine hydrochloride 1.0% Aminacrine hydrochloride B.P. 0.1% MODE OF ISSUE: 1 oz. bottles with dropper. Complete therapeutic information and samples will be sent promptly on request. "FLAVEDRIN" MILD For Children Ephedrine hydrochloride 0.3% Aminacrine hydrochloride B.P. 0.1% MODE OF ISSUE: V_ oz. bottles with dropper. METHOD OF ADMINISTRATION Drop 3 or 4 drops into the nostrils, or spray through an atomizer, every 3 or 4 hours. MONTREAL CANADA Page 519 -C CONNAUGHT > LIVER EXTRACT INJECTABLE (20 MICROGRAMS OF VITAMIN B12 PER CC) i Liver Extract Injectable is prepared specifically for the treatment of pernicious anaemia. The potency of this product, which was formerly expressed as 15 units per cc, is now expressed in micrograms of Vitamin B12 as determined by the Lactobacillus! leichmanii test. Liver Extract Injectable as prepared in the Connaught Medical Research Laboratories. —contains 20 micrograms of vitamin B12 per cc. derived directly from liver. —is carefully tested for potency. —is low in total solids and light in colour. —is very highly purified and therefore can usually be administered without occurrence of discomfort or local reactions. Liver Extract Injectable (20 micrograms of vitamin B12 per cc. is supplied in packages containing single 5-cc. vials, in multiple packages containing five 5-cc. vials, and in 10-cc. vials. Dry Liver Extract for Oral Use is supplied in packages containing ten vials, each vial contains extract derived from approximately one-half pound of liver. CONNAUGHT MEDICAL RESEARCH LABORATORIES University of Toronto Toronto, Canada Established ia 1914 for Public Service through Medical Research and die development of Product* for Prevention or Treatment of Disease. DEPOT FOR BRITISH COLUMBIA MACDONALD'S PRESCRIPTIONS LIMITED MEDICAL-DENTAL BUILDING, VANCOUVER, B.C. Page 520 We have recently been privileged to read a report which we seriously think represents one of the most important pieces of work that has ever been done in Canada on the subject with which it deals—the income of doctors, salaried or otherwise—what it should rightly be, for men in varied positions, with varied length of experience, specialists or otherwise. The report to which we refer is a first instalment, and will be followed by others. It is titled "A Report on Medical Salaries" and is the result of many months of intensive work and study by a special Committee of the Canadian Medical Association, B.C. Division, under the chairmanship of Dr. J. Ross Davidson. This Committee has had the invaluable assistance of Mr. D. G. White, C.A., "without whose assistance," we are told, this report would have been impossible. The value and importance of this report will be immediately evident to anyone who reads it. For many years, salaried medical men have been paid on a purely arbitrary basis—and any standards that have been applied have been chiefly based on the attitude that they are paid personnel, just as stenographers and carpenters are paid personnel. No account whatever has been taken (a) of their long, expensive training, (b) of the actual loss of earnings that they have had to face for anywhere from seven to ten years before they can earn, (c) of the highly specialized nature of their work, and so on. The one clear rule is that they must not in any case be paid more than the very minimum that they will accept. The medical profession hitherto has had no facts or figures and no standard based on these, with which to bargain, or with which to support the cause of those who work on salary, or indeed in private practice. With great foresight and wisdom, the B.C. Division has seen the cardinal necessity for obtaining these facts and figures at the outset. The Division has had the extreme good fortune to have been able to secure the services of a chartered accountant, Mr. D. G. White, as stated above. Without him, nothing could have been done. We consider this an outstanding contribution, one of its many, by the B.C. Division, to the economic welfare of the medical profession—not only in B.C.—but throughout Canada. We understand that this Report is being eagerly sought in many centres in Canada and the United States. Of course, we congratulate the B.C. Division most sincerely—And then, what? Let us point out certain features of this Report that we think every medical man in B.C. should carefully ponder. First, it is of value, and will be of increasing value, to the whole profession, and every member of it. Secondly, this Report has cost a good deal already in money (provided at great sacrifice by the Division). It has cost an amount that we cannot.estimate in the time and effort devoted to its preparation by the members of the Committee, who have given up their time and leisure without a single cent of remuneration of any kind. Thirdly, Mr. White has given us his time and effort absolutely gratis. Fourthly, this Report is not finished. It must be finished. The subsequent parts deal with the remuneration of the private physician, the Fellow in Medicine, and so on —and the whole Report will be of immense value to us all. So we are faced with an inescapable conclusion—money must be found wherewith to finish this Report, to pay those non-medical people whose services we must have, and we would further say, to provide, at least, some small recompense to those members of our own profession who are giving so much in time and devoted effort, at a definite loss to themselves financially. Page 521 As we said, money will be needed to complete this report. How it is to be obtained, and from what source, we cannot say—that is for others to decide—perhaps on a national level to some extent. But there is one thing every medical man in British Columbia can do, and in our opinion should do, and that is to do what he can to pay his share of this, and of other ( expenses that the B.C. Division has assumed. One way he can do this at once, is to become a member of the Division, and pay his dues. This would go a long way, from j the financial point of view. It would have other connotations. It would help to solidify the work of the profession—it would redound to the benefit of the member himself— it would be a mere acknowledgement of a debt that we all owe to the Division. Consider what the B.C. Division has done in less than two years of life. It has raised our general fees—it has secured higher payments from the Workmen's Compensation Board, it has obtained an increase from the Provincial Government for indigent cases and it is still working for improved economic conditions. Every single medical practitioner in B.C. has benefitted by this. The Division is no longer in the experimental stage. It is now the recognized mouthpiece of the profession in B.C.—and every medical man owes it to himself to be a member. Only thus has he any say in the doings of the Division, which, with or without him, influence his income now, and his future prosperity and status. Only thus can be do his share in promoting professional unity, and presenting a strong front to the community in which he lives. And the Division, and indeed its parent body, too, the Canadian Medical Association, need the support of every medical maifc, if they are to do the work for which they are designed, and to protect our interests. We have many things threatening us as a profession. The clamour of certain very influential bodies for state medicine—the continued pressure from all sides for relief from the ever-increasing cost of medical care—the threat of possible recessions, hard times and so on. Our only defence in these matters lies in the fact that some of us are willing to work continually and unwearyingly on behalf of their profession, and to solve its problems. The least each one of us can do, and the least that each one of us ought to do, is to pay our share. Membership will at least pay our just debts—but more, it will give each one of us a voice in the discussion of these vital problems for which we must, as a profession, find a fair and adequate solution. If we do not work together towards this end, we run a grave risk of failure and defeat, and we shall all suffer very greatly. We must have a strong, completely representative organization to do our work. The B.C. Division of the Canadian Medical Association has proven its worth, and will do so increasingly—but it can only reach its full stature if we all support it. And this applies equally to the Canadian Medical Association, which is our representative on national levels. DOCTOR'S OFFICE NURSE English Graduate Nurse, highly experienced in lab work including Chemistry ECG's, BMR's, report typing, filing and accounts, would like suitable post. Please phone MArine 1481. Page 522 RADIOTHERAPY OF CANCER OF THE LARYNX By PROFESSOR B. W. WINDEYER, M.D., B.S., F.R.C.S., F.F.R., D.M,R,E, Director, Mayerstein Institute of Radiotherapy, The Middlesex Hospital, London, England The object of any form of treatment of cancer is firstly the preservation of life, secondly the preservation of function, and thirdly the accomplishment of these two with the minimum of discomfort and risk of subsequent complications The whole value of radiotherapy in cancer of the larynx rests on the fact that the normal voice can be preserved and tracheotomy can be avoided. To do this without prejudice to the patient's chances of survival and without producing intolerable sequelae, is the yardstick by |which radiotherapy in cancer of the larynx should be measured. It is a complicated assessment and it is necessary to consider the various methods of radiotherapy available and their suitability in comparison with the appropriate forms of surgical treatment in each of the various stages of advancement of the disease. (Methods of Radiotherapy Available The following methods of radiotherapy can be used: 1. The Finzi-Harmer method of implantation of radium needles. In this technique j the ala of the thyroid cartilage on the affected side is removed and also in some cases a portion of the cricoid cartilage. Radium needles of suitable strength and dimensions are fixed in position in a vertical palisade in the gap where the cartilage has been removed. They are separated from the tumour on the vocal cord by the inner or laryngeal perichondrium of the removed thyroid ala. Crossing needles are placed horizontally at right angles to the vertical needles at their upper and lower ends to provide better homogeneity of dosage, as is done in any single plane radium implant. The radium is closer to the cord and the growth at the anterior end near the commissure than at the posterior and near the vocal process of the arytenoid. With suitable needle strengths and distribution an average dose in the centre of the cord of 5000-5500 roentgens is given over a period of seven to eight days. The dose at the anterior end is higher and that at the posterior end is lower. 2. Direct irradiation by low voltage X-rays. A surgical approach to the lateral side of the affected vocal cord is made in the same way as for the Finzi-Harmer method of radium implantation. Through this exposure a suitably sized applicator of a superficial X-ray machine, working at about 100 kilo volts j is applied to the perichondrium immediately over the cord and tumour and a single dose of X-rays is given, varying from 2000 to 2500 roentgens according to field size. 3. X-ray Therapy in the 200 to 250 kilovolt range with half value layer in the neighbourhood of 2 mm. cu. has been used extensively in laryngeal cancer. Owing to the superficial situation of the lesion and its enclosure within the cartilage box of the larynx it is possible to use small fields, two or three in number, and to direct them accurately to deliver a homogeneous dose to the region occupied by the tumour. 4. Supervoltage X-rays have not yet been used to any great extent in Great Britain and not long enough to obtain an evaluation of long term results. It may appear that with this superficially placed lesion there is no necessity to use such a hard quality of beam with such a large depth dose but such work as has been carried out indicates some advantages, particularly in ease of planning, and less discomfort for the patent. It is possible to treat a suitable lesion by a single unilateral field. 5. Teleradium with units which have gradually increased up to 10 grams has been used in Great Britain for the last 20 years, and in particular for cancer of the larynx, which is a most suitable situation for this form of treatment. There may be advantages in the use of the harder quality of the gamma ray beam in reducing the risk of cartilage necrosis after heavy dosage. The relatively low depth dose from the teleradium apparatus is an advantage in planning treatment for the larynx, the accessibility Page 523 of which makes it readily possible to obtain accuracy in opposition of fields and in dosage distribution. I prefer teleradium to 250 kilovolts X-rays in the treatment of cancer of the larynx, but have no statistical evidence of any superiority in results. Choice of Case and Method of Treatment 1. Early, limited, unilateral. Early growths commencing on the vocal cord which have not reached the commissure anteriorly nor the vocal process posteriorly and have not infiltrated so as to produce impairment of movement of the cord have a good prognosis, whatever the method of treatment employed. Such growths are those which are suitable for removal by excision of the cord after laryngo-fissure. As laid down by Negus and others, they fulfil the requirement that they can be removed with an adequate margin of healthy tissue. In such early cases the results of limited surgery are excellent. The patient is out of hospital in ten days or two weeks and has a useful voice, but one which is always impaired and husky. These limited growths are also suitable for the Finzi-Harmer radium implantation technique. The curative results are about the same and the operation is of about the same severity as that of laryngo-fissure, with perhaps a slightly longer period of hospitalization. The resultant voice is better than that following excision of the cord but is seldom perfect. The technique of treatment by low voltage X-rays described by Lambert and Watson was used for limited unilateral growths, but has fallen into disuse as it has not been found to be as effective as other methods of radiotherapy. External irradiation by X-rays or by teleradium is also used. The curative results! are comparable with those of excision of the cord or the Finzi-Harmer technique, but the voice is better than that following any other method of treatment. It is usually perfect though there may be some slight alteration in tone. The choice of whether surgery or radiotherapy and what method of radiotherapy should be used in these early cases is a debatable one and will undoubtedly be solved in different ways by different people and may depend largely on the facilities, experience and skill of those on whom the decision rests. It may depend on the occupation of the patient or his suitability for operation. We have preferred external irradiation in almost all these cases. Certainly for those patients such as clergymen, advocates, politicians and actors, who depend on their voice in the exercise of their profession, it has a definite advantage. 2. & 3. Involvement of the commissure and extensive growths of the cord. Growths which involve the commissure and extend to both cords present the same problems in choice of treatment as extensive unilateral lesions that have spread along the greater part of the cord to involve the vocal process or the commissure or both. Both types are unsuitable for limited excision. In the former there is a choice between anterior hemilaryngectomy and total laryngectomy. We do not think that there is any case to be made out for hemilaryngectomy, either for curative or functional results, and it really comes down to total laryngectomy as the possible surgical method of treatment. In the latter, total laryngectomy is the only suitable surgical procedure. In both these groups of cases radiotherapy is the treatment of choice, provided the growths do not infiltrate deeply, causing fixation. Subglottic extension is no contraindication if the cord is still freely mobile or if the movement is only partially restricted. The curative results are not so good as in the early localised lesions, but are at least comparable with those of total laryngectomy. The decision to use radiotherapy is made because it has the enormous advantage that by this means the natural voice can be retained and a permanent tracheostomy can be avoided. Page 524 After total laryngectomy many patients, by perseverance and training, can develop | useful oesophageal voice and some may use an artificial larynx. This may serve ade- ■lately for ordinary social contacts, but at best is a considerable handicap. The development of such an artificial voice is greatly dependent on the age, the intelligence and the courage of the patient, and the presence of a permanent tracheostomy prevents the iontinuance of heavy manual work, such as lifting and digging. The method of radiotherapy which is most suitable for extensive unilateral growths ind for those of the commissure and involving both cords is undoubtedly external irradiation by teleradium or by X-rays. I prefer teleradium. The Finzi-Harmer technique has been used mainly before the days of the development of the present techniques of teleradium and X-rays. It is not really suitable for this type of case. In those with posterior extension to the vocal process the growth is at an Increasing distance from the radium and there is the danger of recurrence at the posterior ind. Those which have extended around the commissure can be treated by removing the front of the thyroid- cartilage as well as the ala, but the dose distribution becomes ^difficult and there is a risk of laryngeal stenosis. 4. Deep infiltration and fixation of larynx. When the growth has. infiltrated deeply, causing fixation of the cord, the results of radiotherapy are much worse. In such cases there is frequently involvement of [thyroid cartilage and there is a risk of perichondritis, oedema and necrosis following Radiotherapy, in addition to the fact that the recurrence rate becomes much higher. iTotal laryngectomy is the treatment of choice. Frankly extensive growths with fixation of the cord, involvement of cartilage, oedema and dyspnoea, are poor risks by any form :of treatment but total laryngectomy offers a better survival rate and avoids the probability of aggravation of the patient's discomfort and distress. 5. Diffuse hyperkeratosis and hypertrophic laryngitis. Cancer of the larynx may occur in a patient who has had a condition of hyperkeratosis of the larynx for many years, or who has had a persistent hyertrophic laryn- fgitis. Such cases do not respond well to radiotherapy. They develop oedema with diminu- Kon of glottic space or even complete obstruction, and there is a high recurrence rate. ■They are better treated by radical surgery. 6. Sub-glottic growths. Sub-glottic growths are also unfavourable for radiotherapy. They are usually advanced before the diagnosis is made, because the symptoms produced are usually later in appearance than is the case in glottic tumours. They are also the least favourable in [situation for radical surgery and, particularly in those with poor histological defferenti- jation, there is a high recurrence rate. Total laryngectomy may be chosen for those phich are well differentiated and radiotherapy tried for the more anaplastic types. 7. Supraglottic growths. Many supraglottic growths have a high degree of radiosensitivity, a fact which was noted by Coutard in 1927. Some arising in the ventricle cause swelling of the false cord and by their bulk produce limitation of movement of the true cord. They appear to be more advanced than in fact they are and respond well to radiotherapy. Others, extending upwards from the glottic region with infiltration of the false cord do not respond well. The numbers which we have treated are not sufficient to draw any dogmatic conclusions, but I think that all such cases, unless there is obvious cartilage inva- sion, should be treated in the first instance by radiotherapy and that radical surgery should be used in cases of failure. ^Influence of Histology In all cases of suspected cancer of the larynx a biopsy should be taken and repeated [if necessary, to prove the diagnosis before any radical treatment, either' surgical or [radiotherapeutic, is undertaken. The histological appearances have also been used as Page 525 part of the evidence in choosing the appropriate method of treatment. Histological grading based on the degree of differentiation does not appear to be of much help in assessing the indications for radiotherapy. Well keratinised growths and undifferentiated ones appear to have the same type of response. Such grading may be of greater value in deciding the contra-indications for surgery as the more anaplastic growths, after operation undoubtedly have a higher recurrence rate than the well differentiated ones. Technique of Radiotherapy The technique of external irradiation, whether by X-rays or by teleradium, follows; the same lines. Cancer of the larynx in the stages of the disease which are suitable for radiotherapy is a localised lesion close to the surface of the body and can be treated by the irradiation of a localised volume of tissue. Small fields are used, just large enough to encompass the tumour, and an adequate surrounding margin of healthy tissue. Usually two opposing fields or a three field arrangement, an anterior and two lateral fields, are used. The maximum field size used is not greater than 7 x S cm. and usually is smaller, perhaps 6 x 4 or 4 x 4 sq. cm. The treatment of every patient is planned individually and the dose distribution from the selected field arrangement is measured and charted. With X-rays I believe there is an advantage in using heavy filtration to produce as hard a beam as possible, and think that this is material in reducing the incidence of oedema and the risk of perichondritis and necrosis. We use a beam of 3.5 mm. Copper half value layer. With both X-rays and teleradium it is necessary to use some method of beam direction to ensure accuracy of alignment. This may be done by the adjustment of fixed entry and exit points in the central axis of the beam, or by some form of jig which ensures that the applicator is maintained in accurate position relative to the patient. It is usual to treat every field every day either five or six days a week. It is not possible to be dogmatic about the dose given as it varies in individual patients. The average tumour dose may be of the order of 1000 roentgens per week and the total tumour dose given with X-rays may be somewhere between 4800 and 6000 roentgens in from five to seven weeks. With teleradium the average dose given is somewhat higher than with X-rays, in the ratio of six or seven to five. The smaller noninfiltrating growths are usually treated in a shorter time and the more extensive lesions may have a higher dose, given more slowly. Baclesse has shown the advantage in extensive, growths of giving doses up to 9, 10 or even 12,000 roentgens and spreading the total time over as much as 12 weeks. Management of the Patient Jf|f| The management of the patient during treatment is of the utmost importance. Many of them, provided they have not far to travel, can be treated as out-patients. Those who are elderly and more feeble and those with more advanced growths should be hospitalized. Whether in-patient or out-patient they must be kept under constant supervision. The state of the larynx and their local and general reactions must be carefully watched and the conduct of the treatment adjusted according to these clinical findings. There should be close and constant collaboration between the laryngologist and the radiotherapist during the whole process of treatment, from the first diagnosis, during the period of treatment and in subsequent follow-up examinations. The first step, on which the choice of treatment is decided, is a thorough clinical examination with accurate assessment of the extent and extensions of the tumour. This is followed by radiographic examination and by biopsy. Regular and frequent examinations by indirect laryngoscopy are made during the course of treatment and the rate of dose input and the total dose given are determined by the clinical appearances. Diminution in the tumour, alterations in mobility of the arytenoids, the appearance, extent and distribution of fibrinous reaction must be accurately noted. A fibrinous reaction may be entirely avoided by the technique adopted by Baclesse with prolongation of the overall time. There may be commencing oedema at some period and this may mean a lowering of the daily dose. Page 526 In some patients, the question of tracheostomy may arise either at the beginning or during the course of treatment. A large and hypertophic growth causing narrowing of the glottis may improve rapidly with relief of obstruction. Sometimes there may be rapid development of oedema during treatment, and urgent operation may be necessary. The presence of a tracheostomy is usually somewhat of an embarrassment during X-ray or teleradium therapy, particularly if the trachea is irritable and causes frequent bouts of coughing. It is better if it can be avoided, but in those cases where tracheostomy cannot be avoided it should be done early, so as to avoid the prolongation of respiratory obstruction and damage to the heart. Oedema is more likely in those with infiltrating or with necrotic and infected growths. Routine administration of penicillin during the course of treatment has undoubtedly caused a reduction in its incidence. Attention must be paid to general supportive treatment, especially to nutrition and the adequacy of fluid and protein intake. Blood transfusions may be indicated. Patients are advised to give up smoking to reduce unnecessary irritation. Complications and Sequelae Apart from oedema with the necessity for tracheostomy and the risk of bronchopneumonia in an aged and debilitated patient, both of which are uncommon, there are few complications which occur during treatment. Following treatment when reactions have subsided, there are usually no symptoms and the larynx may appear completely normal. It may not be! possible to see where or on which side the tumour had been. Telangiectasis on the cord which had been affected may be the only obvious abnormality. In some patients there may be a dryness which persists for some months and which may give rise to some irritation and discomfort. Persistent oedema following treatment may cause restriction of the airway. It is usually associated with some degree of perichondritis. It may persist for some months and then slowly subside or, particularly when infiltrating growths have spread to cartilage, it may develop into necrotic ulceration, the most serious complication to be feared. Perichondritis, depending on its extent, is associated with pain which may be of any degree of severity from a niggling and irritating local discomfort which occurs on swallowing, to intense and persistent local pain and neuralgia extending up into the ear. Necrosis of laryngeal cartilage, always accompanied by the most severe and prolonged pain, is usually associated with persistent or recurrent cancer and is most liable to occur after the radiotherapy of advanced growths with infiltration, oedema and fixation. It may, however, occur as the result of injurious treatment in early growths or following local trauma or infection. An example of this is the case of a soldier treated during the war. There was a suspicious nodule remaining on the cord following treatment and direct laryngoscopy was to be done under general anaesthesia. He got a spasm of his larynx and had a tube pushed between his cords. This precipitated a necrosis with exfoliation of the whole larynx over a period of months. He now appears to have had a total laryngectomy with no operation scar. The incidence of perichondritis and necrosis is much less than it was before the introduction of penicillin and other antibiotics. It causes such pain and misery that it has rightly earned a fearsome reputation and has been held up as a reason against the radiotherapy of laryngeal cancer. This attitude has no longer any real basis, as by better selection of patients suitable for radiotherapy, by better knowledge of radiation reactions and dose distribution, by careful individual planning and conduct of treatment, and by the use of penicillin and similar drugs, the incidence of perichondritis and of necrosis has been greatly reduced. It is necessary, however, that these patients should be treated by a well experienced and well equipped team, and the radiotherapy of malignant disases of the larynx must be concentrated in a relatively few large centres where adequate experience and adequate facilities for all methods of treatment are available. Treatment of Recurrences Cases of recurrence after radiotherapy should be treated by total laryngectomy. There may be some delay in healing and the flaps will stand less tension than in unirradi- Page 527 ated tissues, but the operation can be carried out without real difficulty and is the onr$ posible way of saving the patient. Any atempts at a second course of irradiation aftej a first one has failed almost always leads to disaster and extensve necrosis. When recurrences occur after laryngo-fissure, external radiation can sometimes be; carried out with success, but there is always increased difficulty due to scarring with itsj effect on radiosensivity and on limitation of the glottic space. The alternative is total laryngectomy. Recurrences after total laryngectomy are always desperate problems. They usually arise in scar tissues or in cartilage of the trachea and do not respond well. They may finish by deep ulceration and massive haemorrhage. Results The results obtained from different institutions are difficult to compare. Theyj depend not only on the quality of treatment but on the material which comes and on the selection of that material. Our own results at the Middlesex Hospital, obtained inj association with C. P. Wilson during the years under review, were obtained by using radiotherapy for the great majority of the causes whom we saw, as we were learning andj trying to find out the value of external irradiation in various types of case. In laterj years we have adopted the criteria for selection which I have detailed, and more patients j who are unsuitable for radiotherapy are now treated primarily by laryngectomy, with anj improvement in total results. The gross five year recurrence: free figure is 35 per cent, but if the cases withi deep infiltration and fixation, those arising on previous hyperkeratoses and subglottic! growths are eliminated from radiotherapy, the five year recurrence free figure rises toj over 50 per cent. INTRINSIC CARCINOMA OF THE LARYNX RESULTS OF TREATMENT Middlesex Hospital 1930-45 Westminster Hospital 1940-46 Royal Cancer Hospital 1933-46 Christie Hospital 1940-44 *Baclesse 1940-46 Leborgne I 1933-44 Neilsen \ 19 31 -44 Harris 1931-46 * 3 to 9 years recurrence free. Total 5 yr. Rec. Free Percentage 83 29 35 55 22 40 82 33 41.4 103 28 27 132 49 37 86 29 33.7 153 75 49 67 — 58 Well trained CANADIAN GRADUATE WANTED to take over long established general practice in City on Coast. Doctor retiring. Fine hospital, good offices and residence available. Good opportunity for surgery. Excellent terms to right man. Reply to: The Bulletin of the Vancouver Medical Association. 675 Davie St. MArine 7729. Page 528 DIAGNOSIS, CHOICE OF METHOD OF TREATMENT AND SURGERY IN CANCER OF THE LARYNX By SIR STANFORD CADE, K.B.E., C.B., F.R.C.S., M.R.C.P. Surgeon, Westminster Hosptal, London, England F.F,R, In the diagnosis of cancer of the larynx, the general practitioner has a great opportunity. Most, if not all, cases show some alteration in the voice, usually hoarseness. It is a commonplace which cannot be too often repeated, that any alteration in the voice which persists more than three weeks should be fully investigated. A diagnosis r of "laryngitis" is merely a label and fits only the transient acute infective condition. Chronicity of laryngitis denotes a major disorder—tuberculosis, syphilis or cancer, and j delay in diagnosis must be avoided. Two benign conditions which present difficulty in diagnosis and add to the complexity of the treatment are pachydermia of the vocal | chords or hyperkeratosis and benign papillomata. The former is a disease of adult life and affects chiefly men, the latter may occur in childhood or adolescence and is also more common in the male. Both these benign conditions give rise to a hoarse voice and may after many years undergo a change into a carcinoma. Both pachydermia of the chords and benign papillomata are radioresistant and it is very doubtful if radiation is a justifiable method of treatment. Repeated radiation is certainly undesirable and may, in fact, preclude adequate treatment should cancer develop subsequently. Accurate diagnosis and adequate treatment of laryngeal cancer require complete familiarity with the normal and abnormal appearance of the larynx. Nomenclature and Classification It is customary to subdivide malignant tumours of the larynx into intrinsic and extrinsic. These two terms although widely used and time-honoured are not satisfactory, as all extrinsic lesions are in fact not laryngeal but pharyngeal. A more useful term is "endolaryngeal," and it should imply that the lesion is within the framework of the laryngeal cartilages. Such lesions are less likely to metastasize to the cervical lymph- nodes, and the dominant clinical symptom is connected with the voice and not with swallowing. The tumour originates from the vocal chord and can spread in all directions. A classification according to the exact site and extent of the disease is of importance, specially in the decision as to the choice of method of treatment. The earliest stage of the disease, which may aptly be called "carcinoma in situ" or stage O, is in fact only detected by biopsy and occurs mostly in cases with pre-existing disease of the chords, such as hyperkeratosis. It is similar in every way to the leukoplakia familiar in the mucosa of the mouth and sometimes elsewhere (the bladder, the vagina, etc.). The commonly accepted classification is as follows: |f|| Stage I: Lesion of anterior two-thirds of one vocal chord. Stage II: Involvement of both vocal chords and anterior commissure. Stage III: Extra-chordal extension with fixation of vocal chord. Stage IV: Involvement of other parts of the larynx. An early lesion, if allowed to grow without treatment, generally spreads forward to the anterior commissure and across the midline to the opposite chord. More rarely backward spread occurs, towards the arytenoid cartilages; such spread sooner or later gives rise to the cervical lymph node enlargement. The disease can also extend proxim- ally to the ventricle of Morgagni, to the false chord and to the laryngeal aspect of the epiglottis. The most significant extension is distally to the subglottic space. Such spread should be diagnosed very early, as lesions with subglottic extension or primary subglottic carcinoma are difficult to control by radiation and many of them eventually require laryngectomy. The accurate diagnosis of the site and extent of the disease is of great importance in the management of the patient. Page 529 Histological Varietes. Biopsy. Broder's classification of epithelial cancer is applicable to the larynx. It is a^ grading of degree of malignancy, has a bearing on radiosensitivity, affects the natural evolution of the lesion and influences the choice of treatment. It is based on the degree of differentiation of the cells and ranges from keratinisation with numerous cell-nests J to anaplasia, where the cells are round and immature. Histological diagnosis is essential and hence a biopsy is unavoidable. A biopsy] should provide the pathologist with a representative piece of tissue, preferably both abnormal and normal. Biopsy by itself presents no risk to the patient; if negative for cancer in a case where the clinical or macroscopic appearances are those of a growtlS it should be repeated, if necessary more than once. 'Mm Method of Diagnosis The logical sequence of investigations of a lesion in the larynx is: (1) Clinical examination and indirect laryngoscopy. (2) Radiological studies, and (3) Direct laryngoscopy and biopsy. Clinical Examination and Indirect Laryngoscopy This routine investigation implies familiarity with the use of a largyngeal mirror. The clinician on whom falls the responsibility of diagnosis of laryngeal lesion—whatever his specialty, such as general medicine or surgery, laryngology or radiotherapy—must be familiar with the appearance of the lesions as seen on indirect laryngoscopy and should be able to carry out this examination with skiH and ease. In the majority of cases, gentleness and patience enable the examination to be carried out without preliminary local anaesthesia. The macroscopic appearance of the lesion can be that of a node, a cauliflower or papillary mass or an ulcer. Site and extent of the lesion must be noted; also the presence of oedema, the range of mobility or fixation of the chord, the presence of a pool of frothy saliva or mucus behind the arytenoids or in the pyriform fossae; the effect of the lesion on the airway, specially its narrowing. Mobility of the chord can be affected by oedema or by an actual invasion of the pericordal tissue with growth. It should be remembered that subglottic extension cannot always be assessed or even detected by indirect laryngoscopy. Radiological Studies There are two important methods of X-ray diagnosis of lesions in the larynx and pharynx. A plain X-ray film in the lateral view, preferably with air inflation (Valsalva) shows up the soft tissues of the neck. It gives a profile view of the vallecula, epiglottis, pre-vertebral space and trachea. Abnormalities due to the tumour or to oedema are shown up. Antero-posterior tomographs of the neck give in addition a very clear indication of the size and position of the tumour. Tomographs show the true and false chords, the pyriform fossae and the ary-epiglottidean folds; they give as a rule a clear picture of any subglottic extension. Direct Laryngoscopy and Biopsy This can be done in the majority of patients under local anaesthesia. It main object is to ascertain with greater accuracy the position and extent of the disease, specially any downward extension. It gives an opportunity to perform a biopsy and to obtain material for histological confirmation of the diagnosis. Choice of Method of Treatment Carcinoma of the larynx can be treated by surgery or by radiotherapy. From the patient's point of view radiotherapy is to be preferred as it avoids any operative procedure with its concomitant risks, discomforts and disabilities such as tracheotomy or loss of voice. Nevertheless, radiotherapy, specially in the stage of development and by the use of conventional X-rays (viz. 200 - 250 K.V.) has many disadvantages such Page 530 i as prolonged treatment, local reactions in the mucosa and skin, unpredictable effect on | the tumour and subsequent post-radiation effects. It is therefore very important for the patient to have an unbiased opinion as to the advantages and disadvantages of both surgery and radiotherapy and such a choice is of course dependent on the surgical judgment and skill of the laryngologist as well as on the radiotherapeutic facuities available, both in skilled personnel and in the technical facilities. The great change in the choice of treatment during the last few years is a reversal of policy. Whereas previously the early and favourable cases were treated surgically and the advanced cases referred for radiotherapy, the position today is reversed and early cases of endo-laryngeal cancer are confidently submitted to radiation and the advanced cases are preferably treated by surgery with or without the help of preoperative radiotherapy. The methods of radiotherapy available have passed through the stages concomitant with the development of radiation technique. The Finzi-Harmer method of fenestration of the larynx and insertion of radium needles was a great advance. The operation consists of the removal of the laryngeal cartilage and placing in position of suitable low intensity radium needles close to the lesion. The larynx is not opened and tracheotomy is avoided in most patients; with the development of teleradium this method was gradually superseded by the external method of radiation which is now considered the method of choice when radium is used. During the same period in the hands of William Harris of New York, of Baclesse in Paris, of Nielsen of Copenhagen, and others, X-ray therapy has been shown to be of great value and capable of eradicating the disease. Tables I and II show the results obtained at Westminster Hospital, London, by teleradium and by fenestration of the larynx and radium needles. TABLE I INTRINSIC CARCINOMA OF THE LARYNX TELERADIUM 1935-1950: 103 Patients Total 10 years Alive Alive 3 years No subglottic extension Subglottic extension Post-operative recurrence. 60 2 out of 5 22 out of 38 (40%) (58%) 31 1 out of 6 2 out of 18 (16%) (11%) 12 2 out of 5 5 out of 10 (40%) (50%) TABLE II INTRINSIC CARCINOMA OF THE LARYNX FENESTRATION 1928 - 1939: 27 Patients Number Percentage Alive 5 or more years 13 Died of Disease 9 Operative death 1 Died from Radium Necrosis 2 Untraced (counted as dead) 2 H4 48 52 Page 531 Indication for Surgery Surgery for early cases when the growth is limited to one vocal chord and when the mobility of the chord is unimpaired should consist in laryngofissure and removal of the affected chord. In cases where the vocal chord is fixed, and in more advanced cases, specially with subglottic extension, if surgery is decided on, laryngectomy is the operation of choice. In patients with oldstanding pachydermia of the chords where the carcinoma is a metaplasia of the pre-existent pre-cancerous condition, surgery is preferable to radiation, which can only be of palliatve value. Laryngectomy is also indicated in radiation failures. If the disease is not controlled by what is considered a maximum total dose (600r - 8000r by teleradium)- it is unlikely to be controlled by repeating radiotherapy and laryngectomy should be advised. Although the earlier the case and the smaller the lesion the more suitable it is for radiotherapy, even advanced cases should be given the benefit of radiation as a preoperative measure. Some advanced lesions prove radiosensitive, others regress partially; some show no response at all. In advanced cases it is important not to prejudice the patient's chances for surgical treatment, by delay from protracted radiation. In such patients a predetermined maximum total dose given in a predetermined maximum period of time should be decided on. If at the completion of the treatment there is clinical or histological evidence of active malignant disease and there is no improvement at the end of a period not exceeding 4/5 weeks, laryngectomy should be undertaken. By careful planning of the radiotherapeutic treatment, it is possible to select within a reasonably short period of time those patients who will prove radiation failures and give them the benefit of surgery. Summary and Conclusions Radiotherapy can control cases of cancer of the larynx. Both teleradium and X-raytherapy are effective measures. When the lesion does not respond to radiation, surgical treatment should be undertaken. In radiation failures and in advanced caseS laryngectomy is the most suitable surgical procedure. In advanced cases, pre-operative radiation is indicated. Page 532 iTn tttsh Columbia IKtriaion Canadian Mthxtal Association 1807 West 10th Ave., Vancouver, B.C. Dr. G. Gordon Ferguson, Exec. Secy OFFICERS-1952-1953 President—Dr. J. A. Ganshorn____ ; President-elect—Dr. R. G. Large Vice-President and Chairman of General Assembly—Dr. F. A. Turnbull Vancouver Hon. Secretary-Treasurer—Dr. W. R. Brewster New Westminster -Vancouver -Prince Rupert Members of the Victoria Dr. G. Chisholm Dr. E. W. Boak Nanaimo Dr. C. C. Browne Prince Rupert and Cariboo Dr. R. G. Large New Westminster Dr. J. A. Sinclair Dr. W. R. Brewster Yale Dr. A. S. Underhill Dr. C. J. M. Willoughby Standing Committees Constitution and By-Laws. Finance Legislation- Board of Directors Vancouver Dr. F. A. Turnbull Dr. A. W. Bagnall Dr. F. P. Patterson Dr. P. O. Lehmann Dr. G. C. Johnston Dr. Ross Robertson Dr. R. A. Gilchrist Dr. J. Ross Davidson Dr. R. A. Palmer Kootenay Dr. J. McMurchy Chairmen Dr. R. A. Stanley, Vancouver __Dr. W. R. Brewster, New "Westminster -Dr. J. C. Thomas, Vancouver Medical Economics . Dr. P. O. Lehman, Vancouver Medical Education Dr. T. R. Sarjeant, Vancouver Nominations Dr. J. A. Ganshorn, Vancouver Programme and Arrangements Dr. Harold Taylor, Vancouver Public Health Dr. G. F. Kincade, Vancouver Special Committees Arthritis and Rheumatism- Cancer -Dr. F. W. Hurlburt, Vancouver Dr. Roger Wilson, Vancouver Dr. John Sturdy, Vancouver Dr. J. C. Moscovich, Vancouver Civil Defence 1 \— Hospital Service _ Industrial Medicine j Dr. J. S. Daly, Trail Maternal Welfare Dr. A. M. Agnew, Vancouver Membership I Dr. E. C. McCoy, Vancouver Pharmacy Dr. D. M. Whitelaw, Vancouver Public Relations - Dr. G. C. Johnston, Vancouver LABOR DEMANDS HEALTH INSURANCE At the recent annual convention of the Trades and Labor Congress held at Ottawa, one of their biggest headlines was achieved by their demand for an independent government board, to control national health insurance and hospitals. This Labor group had, in the past, been comparatively quiet on this subject, and now with them taking up the fight and announcing their intentions to combine with the Canadian Congress of Labor to fight for Health Insurance, we must all consider the possible results. These men are a high source of potential votes, and though their statements, that they intend to back the CCF, will have some effect in reducing their influence, yet one cannot under-rate the possible consequences. Page 533 There is no use in the medical profession taking the viewpoint that things can go on indefinitely as they are at present. While it is true that it is the politicians and" the Labor Union leaders who are demanding Health Insurance, yet they will in time, stir up a demand from the average person, to convince him that this is a good thing.?. We can appreciate that probably the main reason behind these demands of the Labor*? Union leaders and politicians is to get control of the medical profession—a desire for power. This struggle for power appears to be dominating all phases of life at the; present time, with the greatest objection against individualism, or individual freedom.^ Any student of economics can understand that the actual cost of medicine must go up under these systems because there is another large batch of unproductive workers to act as clerks and supervisors of every new scheme. In addition to our present cost of medical care, there will be the salaries of the numerous hangers-on, plus the many unnecessary calls and extra laboratory examinations which will be demanded when they^ are free. One feels that the Australian system may have something to be said for it. Basically, as I understand it, the Australian system assures the patient. He pays his doctor in the usual way and then produces his receipt to his insuring society, which reimburses him up to 90 per cent of this amount. This system is to be discussed at the meeting of the Assembly in September—unfortunately not until after this is written, though before it is published. One hears complaints about doctors on many sides. The greatest number of these; appear to be due to misunderstandings which could be straightened out by two minutes of explanation. Of the remainder, most difficulties seem to arise from medicine becoming too much of a business rather'than a profession. It is unfortunate that the corrective measure suggested—that is National Health Insurance—will tend to increase the impersonality of the relationship between the doctor and his patient. The Public Relations committee, on instruction of the executive, are doing everything in their power to improve relations between the public and ourselves. However the greatest Public Relations are between the individual doctor and his patient, and too many of us are falling down in this regard. It is not for us to argue the merits of National Health Insurance with the T.L.C., but perhaps this might also be done with mutual benefit—but if we can individually regain the position whith the physician has traditionally held in the community, then even if National Health Insurance comes, it will be on a basis that will be most advantageous for our patients, and least irksome for ourselves. The Annual meeting of the B.C.M.A. is now over. It is not possible to have reports in time to include in this issue, but for next month we hope to give you something of what was accomplished, and to show how our Association is really working for the benefit of us all. There is need for more and more men to take an interest in, and work for the Association. In the past, it has always fallen on the shoulders of too few. I am appending a communication from the Washington Heart Association. I think you will find it of great interest. August 31, I95i. FIFTH ANNUAL SYMPOSIUM ON HEART DISEASES WASHINGTON STATE HEART ASSOCIATION and WASHINGTON STATE DEPARTMENT OF HEALTH University of Washington, Medical School Auditorium, November 6th and 7th, 1953 For the fifth year the Washington State Heart Association and the Washington Page 534 State Department of Health join to bring the physicians of the Northwest some of the latest developments in the field of Cardiovascular Disease. We have again secured outstanding authorities in their respective fields: Doctor Hen-man Blumgart of Boston; Doctor Howard Burchell of the Mayo Clinic; Doctor David Rutstein of Boston; and Doctor Paul Wood of London, England. Among the topics to be discussed will be "Treatment of Acute Myocardial Infarction and Congestive Failure," "Selection of Congenital and Valvular Heart Disease Patients for Surgery," "Rheumatic Fever—Prevention and Treatment," "Recent Advances in Congenital and Valvular Heart Disease." The speakers will conduct panel sessions and discuss questions from the audience, as well as present their scheduled papers. This Symposium is the equivalent of nine hours of formal post-graduate training lor members of the Academy of General Practice. Details of the programme will be forthcoming. There will be no registration fee. We hope you will be able to attend. Again, may we remind you to save these dates—Friday and Saturday, November 4th and 7th, 1953. CLEMENT | KRANTZ, M.D., President, Washington State Heart Association. FRED E. CLEVELAND, M.D., Chairman, Committee on Professional Education. July 30, 1953 July 30, 1953 August 3, 1953 August 3, 1953 August 5, 1953 August 5, 1953 August 5, 1953 August 5, 4953 August 5, 1953 August 5, 1953 August 5, 1953 August 5, 1953 August 5, 1953 August 5, 1953 August 10, 1953 August 10, 1953 August 10, 1953 August 10, 1953 fAugust 10, 1953 |August 11, 1953 August 12, 1953 August 12, 1953 August 17, 1953 August 19, 1953 August 19, 1953 August 19, 1953 August 21, 1953 August 24, 1953 |August 24, 1953 August 27, 1953 August 31, 1953 NEW REGISTRANTS D'ESTRUBE, Pierre F., 1029 Douglas St., Victoria, B.C. HARRIS, Gordon Sheffield, Indian Health Services, Fort Rae, N.W.T. BIRO, Louis, Box 280, Hilltop, White Rock, B.C. PEET, Robert Michael, 3195 Humber Rd., Victoria, B.C. BORSMAN, Charles Hubert, 1029 Douglas St., Victoria, B.C. CARR, Stephen Frederick, Skeena Health Unit, Box 1428, Prince Rupert, B.C EHMAN, Donald Michael, 216 Scollard Bldg., Victoria, B.C. JONES, Neville Clegg MIRABEL, Dudwik, 3833 Rupert St., Vancouver, B.C. PARI2EAU, Polina, No. 422 Scollard Bldg., Victoria, B.C. SMITH, George Alexander, Royal Inland Hospital, Kamloops, B.C. Certified Specialist in Diagnostic Radiology, Royal College of Physicians & Surgeons of Canada—March 9, 1952. WASSER, David Alexander, Crease Clinic, Essondale, B.C WEST, Chris Alfred, H, 659 Admirals Rd., Esquimalt, B.C. YOUNG, Somerville Bruce, Shaughnessy Hospital, Vancouver, B.C. BLACKLER, Chesley Frederick, Osoyoos, B.C. HOLLAND, Ernest Harold, Provincial Mental Hospital, Essondale, B.C. McIVER, Cecil, No. 212 Hycroft Medical Bldg., Granville & 16th, Vancouver, B.C MURPHY, Terrance John, Haney, B.C. LIPSETT, Walter, Pioneer, B.C. SOLONIUK, Victor Joseph, 1125 E. Hastings St., Vancouver, B.C. GARDNER, Wm., 92 Lonsdale Ave., North Vancouver, B.C. SHEPHERD, Gordon H., 736 Granville St., Vancouver, B.C. FIDDES, Ian Herbert, Essondale, B.C. McMAHEN, Willard John, 2181 McNeill Ave., Victoria, B.C. Certified Specialist in Urology, Royal College of Physicians & Surgeons of Canada— 1952. MASON, John Townsley, C. S. Williams Clinic, Trail, B.C. STIRLING, Roderick John, Ladysmith, B.C. WARSHAWSKI, Edward, Port Alice, B.C. JONES, N. S., 2222 Nelson Ave., Burnaby, B.C. SANDILANDS, James, 552 Columbia St., New Westminster, B.C. NEILSON, Thomas Hood, 481 East Columbia St., New Westminster, B.C TATE, Robert Garfield, H.M.C.S. Naden, Esquimalt, B.C Page 535 PUBLIC HEALTH AND MENTAL HEALTH NEWS G. F. AMYOT, M.D., D,P.H., Deputy Minister of Health, Province of British Columbia A. M. GEE, M.D., Director, Mental Health Services, Province of British Columbia GUIDE FOR REFERRAL OF CHRONIC ALCOHOLICS ^B FOR PSYCHIATRIC TREATMENT^ In planning treatment for alcoholism, an important distinction must be made between alcoholic intoxication and chronic alcoholism (or alcohol addiction). The distinction can be compared to our position in treating the peptic ulcer. Attacks of ulceration with pain, bleeding, and other complications can be treated very well by medical and surgical means; these, however, can give no definite protection against recurrence. The long-term ulcer diathesis is in fact quite a different problem. It requires planning the patient's way of life and dealing with those personality tensions associated with the "ulcer type." Alcoholism, too, has two distinct aspects. Acute intoxication; and its sequelae of hangover, delirium tremens, and the like, can be treated by medical means quite quickly and satisfactorily. They do not require specifically psychiatric care, and neither does treatment of these conditions have any particular influence for or against recurrence of drinking. Chronic alcoholism or alcohol addiction is a long-term pattern or recurring compulsion to resort to uncontrollable and destructive drinking. It is in some instances amenable to psychiatric treatment. As the psychiatric syndrome is deep-rooted and intractable, the treatment at best is tedious and frustrating. It is because alcoholism is a chronic condition that no alcoholic is considered treatable in the Crease Clinic. The Provincial Mental Hospital, at Essondale, permits voluntary admission of persons seeking help from chronic alcoholism. Of all such applicants a significant number are unsuitable as patients, because of poor motivation, or other factors; frequently they are referred in acute intoxication and in their misery appear good prospect, but soon show evidence that their chronic alcoholism cannot be affected. The following criteria are presented for the help of physicians in referring alcoholics. They imply the above important distinction between acute and chronic alcoholism. Patients Most Suitable for Treatment Practically men and women who soberly recognize an uncontrollable drinking problem, and request psychiatric help for it, can to varying degrees benefit by that help. The best prospects— 1. Are sober at the time of consultation, 2. See their alcoholism as a psychiatric problem, 3. Are relatively young—under thirty-five, 4. Have been drinking heavily only two or three years, 5. Are intelligent, and other than drinking, show good judgment and ability, 6. Are worried, anxious, dissatisfied with themselves, and may show borderline symptoms such as depression, fears, and sleeplessness, 7. Have personal, marital or social difficulties to deal with, 8. Have wives, husbands, friends standing by them in their difficulties, 9. Have been active members of Alcoholics Anonymous. Patients Unsuitable for Treatment Some patients do well who do not satisfy all the above criteria. However, the following are contra-indications to referral, and the hospital may refuse admission to persons who— Page 536 ll. 12. [4. |5. 7. 8. 9. 10. Are drunk or suffering "hangover." (Note that treatment is given for occasional cases of toxic psychosis, but admission is by committal. Later, a few of these patients may be selected for treatment of chronic alcoholism.) Deny that they have a psychiatric problem, Have drunk heavily for over five years, Are below average intelligence; show confusion or other signs of brain damage; have serious mental symptoms. These may require committal under other psychiatric categories, but cannot be treated for alcoholism, Are not visibly dissatisfied with themselves, with no signs of worry, depression or tension, Have no definite personal, marital or social difficulties, Have no fixed home or interested family or friends, Never maintained steady affiliation with Alcoholic Anonymous, Have had multiple hospital admissions for alcoholism. FLUORIDATION OF WATER The following article on Fluoridation was prepared by Dr. Richard Cline, Chair- ban of Vancouver and District Dental Fluoridation Committee, at the request of the Health Branch of the Provincial Department of Health and Welfare: DO IT NOW! If someone promised a simple, economical and perfectly safe method of preventing ttwo-thirds of all the polio cases in Canada—the public would clamour for it—and the medical profession would heave a sigh and cheerfully endorse such a public health [measure. Curiously, however, the dental profession, the medical profession, the public [health departments, and many other accepted health organizations have all endorsed [fluoridation of community water supplies as a means of reducing dental decay by two- thirds—but the public, far from clamouring for fluoridation, has maintained a puzzling pir of detachment. They don't like dental decay. They don't like paying their dental Bolls. They appear to long for an escape from this annoying affliction that sooner or slater attacks nearly every member of the family. The writer believes that the failure [to implement fluoridation at once through their elected community councils stems from pa lack of knowledge, and he urges the medical profession to become conversant with the [facts. Fluoridation of all Canadian community water supplies is inevitable, and the [program will eventually be recognized as one of the greatest public health measures of all time. If you yourself know the facts of fluoridation, you will be enthusiastic about its early implementation in your community, and the enthusiasm of the medical [profession will do much to hurry the advent of this program. Here, briefly, are the fascinating facts of community fluoridation programs. 1. What is it? Fluoridation of community water supplies means the raising or lowering of the fluorine content of the water to its optimum level of 1 to 1.2 parts per million. Water works engineers have already installed hundreds of feeder systems in various cities throughout the continent, and it is a safe, practical, and economical procedure. 2. What does fluoridation accomplish? Generally speaking, it reduces dental decay liy two-thirds. More specifically, this partial immunity is passed along only to teeth that are being formed while the individual is living in a fluoridated area. In other words, the fluorine becomes an integral part of the newly formed enamel, which then is two- ^thirds more resistant to decay for the remainder of that individual's life. The benefits thus show first in the child population of a community, but, as successive groups of pbildren become adults, eventually the whole community enjoys the two-thirds reduction in decay rate. Page 537 3. Has it been adequately tested? About four million Americans have been drinking naturally fluoridated water for several generations. The fluorine content of these communities has varied from mere traces up to 12 times the one part per million that we recommend as optimum. Beyond the ideal level of 1 part per million, the only! ill-effect produced was a mottling or staining of the teeth. Of course, fluorine is al poison, but to get a lethal dose from one part per million drinking water, a person would have to drink 500 gallons within a twenty-four hour period. There is a hugef safety factor! Fluoridation has a background of more scientific data based on human experience than' any other public health program enjoyed at the time of its adoption. Since 1945, several pilot studies have been conducted in Canada and the States to determine if artificially supplementing fluorine-deficient water supplies would produce the same benefits as natural fluorine. Every study has had identical results, and all are favourable. 4. Why not administer fluorine in the form of tablets, or by adding it to salt or milk? The drinking water is the best known vehicle. Consumption is more uniform than for any other material. Control is removed from the hands of the consumer— overdose or under-dose are both impossible. The mass of-evidence favoring fluoridation as a method of partially controlling dental decay is based on its known action when water is the vehicle. To consider any other method of administration would require several decades of experimentation before the optimum dosages and the required safety factors could be established. 5. Is fluoridation expensive? To fluoridate the Greater Vancouver Water District (serving 600,000 people) would cost less than 20 cents per person per year. This works out to $14.00 for a total average life span of 70 years in order to obtain a two-thirds reduction in dental decay. 6. Who opposes fluoridation? The opposition in all areas where fluoridation has been proposed falls generally into four broad groups: (a) Food faddists, and a few who object on religious grounds. (b) Pseudo-scientists, and some ill-informed scientists. (c) A few individual dentists, physicians or chemists who oppose it as a means of obtaining personal publicity. (d) The un-informed lay people who are led astray by the alarmist tactics of the above groups. All new measures that affect large numbers of people meet with some opposition. Measures that have been operating successfully for many years are still being opposed. The four groups above are identical to those who opposed pasteurization, chlorination, vaccination, and many other accepted public health programs. In conclusion, the writer asks your cooperation in spreading the truth about fluoridation. By the end of 1953, more than 25,000,000 Americans will be drinking fluoridated water. Every year that goes by without fluoridating Vancouver Water Supply condemns, unnecessarily, another block of our population to the ravages of dental decay. What are we waiting for? Let's do it now! NOTICE In line with the recent policy regarding the five-day week, the Saturday morning clinics as operated by the Division of T. B. Control and the Division of V. D. Control will be closed. Page 538 I ewd an d i loted Dr. J. W. Anderson of Victoria is taking a Postgraduate course at the Royal Victoria jHospital, Montreal. . ■■-' * Dr. S. Marinker of Victoria is holidaying in California and Utah. Dr. J. F. B. Cupples- formerly "off Shaughnessy Hospital is now in practice with f>r. D. M. Whitley, Victoria. Dr. R. B. Burroughs of Vancouver is now practising opthalmology in the Broadway IWest Medical district. Hycroft Medical Building, a new office structure with suites for 50 doctors, will be opening next month on South Granville in Vancouver. BIRTHS Born to Dr. and Mrs. R. C. Coleman of Victoria, a son. Born to Dr. and Mrs. H. N. Watson of New Westminster, a daughter. FOR SALE SUITABLE HOME FOR DOCTOR 41st and Cypress St. Due to a sudden bereavement in the family, we have just listed a lovely 7-room home in this select area very popular with professional men. There are 3 bedrooms and den, all in perfect condition, presently occupied by a retired Railroad Executive. Inspection by appointment only with S. A. Walmsley, KE. 0857-Y (evenings). KE. 0019 POINT GREY INVESTMENT CO. Exclusive Agents KE. 4288 Page 539 jpltes KITSILANO PRIVATE HOSPITAL A new modern Private Hospital—Medical,! chronic and convalescent. Best of homej cooked food and care with a fully experi-j enced staff at reasonable rates. Fori further details apply to the Matron. 2336 West 3rd Ave. CEdar 54431 Managed and Distributed by Investors Syndicate of Canada Ltd. Representatives from coast-to-coast INVESTORS Mutual of Canada Limited H HEAD0FHCEWIHIIIPE6 ;^«TONaML CITIES DOCTORS . I. § With an Investors Syndicate Plan you set aside a definite suni of money regularly over the years. During that time, the steadily mounting benefits of time and compound interest combine to make your savings grow. J J, S^undU id a cJLtd. vectors S^undicate of L^anat /estord Irlutual of K^anada cLtd. NEVILLE ASTLEY Strict U anaqer f* 313-744 West Hastings Street - MArine 5283 Page 540 INDEX TO THE VANCOUVER MEDICAL ASSOCIATION f BULLETIN—VOLUME XXIX (1952-1953) A ADMISSION OF PATIENTS TO CREASE CLINIC, INFORMATION REGARDING r 91 AINLEY, W. E., CORRESPONDENCE...- - 18 ALCOHOLICS—Guide for Referral of Chronic for Psychiatric Treatment 536 ALEXANDER, J. D.—Significance of Discharging Nipple 163 ALL ABOARD—Mortimore, G. E _...M„ 51 ANEURYSM OF ABDOMINAL AORTA, TREATMENT WITH CELLOPHANE— Rees-Davies, P. E _ 408 APPENDICITIS, THE DIAGNOSIS OF—Austin, W. E ..„ 445 APPLEBY, LYON H.—The Hush of Retirement 15 AUSTIN, W. E.—The Diagnosis of Appendicitis 445 B BAIRD, DR. MURRAY—Notice of Honorary Degree 346 BAKER, H.—Growth in Children 118 BARTEDS, ELMER C. and KEPKAY, PAUL H.—Current Management of the Gouty Patient with BenemideR 306 BONE TUMORS—TREATMENT OF—Cade, Sir Stanford 481 BONE TUMORS—TREATMENT OF—Windeyer, Prof. B. W 484 BOOK BE VIEWS: Guyis Hospital, 1725 - 1948 437 Research in Endocrinology by August Werner 71 The Life and Work of Astley Cooper by C. R. Brock '. 13 C CADE, SIR STANFORD—Diagnosis, Choice of Methods of Treatment and Surgery in Cancer of the Larynx 529 CADE, SIR STANFORD—The Treatment of Bone Tumors 481 CAMPBELL, K. A.—Overweight in Children 119 CANADIAN ARTHRITIS AND RHEUMATISM SOCIETY, Physiotherapy Services 52 CANADIAN MEDICAL ASSOCIATION, B.C. DIVISION 21, 87, 132, 170, 218, 265, 318, 359, 397, 492, 533 Annual General Meeting, Minutes i 26 Annual General Meeting, Programme 450, 490 B.C. Telephone Employees 267 B.C. School Teachers 270 Canada's Developing Health Plan 318, 363 CU. & C. Health Services Society 266 Doctor's Viewpoint 219 Economic Committee, The 133 Elections i 320, 362 Excerpt from Talk by A. Lexington Jones of New Zealand .' 361 Fraser Valley Medical Dental Society 271 General Assembly, Minutes 36 General Assembly, Report by Chairman 23 Government Employees, B.C 268 Labor Demands Health Insurance 533' Lusty Infant, A 170 Medical Aid to Mariners and Fishermen _ 454 Medical Code of Ethics, Extracts from 70, 173, 323, 374 M.S.A. Notice 173 M.S.A. Cover for Employees in Doctors' Offices 453 Narcotic Addiction, Report on , 171 National Health Insurance, Implications of 360 Operation Secret 132 Prepaid Medical Care 265 Public Relations 88 Public Medical Forums ■. 452 Social Assistance Medical Services 90, 270 Vancouver, Post Graduate Centre 218 Vancouver School Teachers 269 What Do YOU Want....„ 359 CANCER DRESSINGS, FREE 217 €ANCER, EARLY RECOGNITION OF, OF FEMALE GENITAL ORGANS— Douglas, R. Gordon and Finn, W. F : 207 CANCER, OF LARYNX, DIAGNOSIS, CHOICE OF METHOD OF TREATMENT AND SURGERY IN—Cade, Sir Stanford __ 529 CARCINOMA OF THE LOWER LIP, TREATMENT OF—Evans, A. Maxwell 401 CASE REPORT CHONDRODYSTROPHY—Stockton, H 127 CHEST, INJURIES OF—Saxton, G. D 404 CHONDRODYSTROPHY—Gayman, G. A 127 CRETINS, THE RELATION OF THE HYPOTHYROID STATE TO GROWTH AND DEVELOPMENT—Krivel, H _ _ 125 CYTOLOGICAL DIAGNOSTIC LABORATORY 225 DEKABAN, ANATOLE S.—Medical and Social Aspects of Certain Hereditary Disorders.... 494 IPOUGLAS, R. GORDON and FINN, W. F.—Early Recognition of Cancer of the Female Genital Organs'__ 207 DWARFISM IN CHILDHOOD, TWO CASES OF—Shuman, B 129 Page 51 EDITOR'S PAGE 11, 69, 115, 159, 203, 249, 297, 345, 395, 435, 497, 521 ENDOCRINE THERAPY IN CHILDHOOD 122 EVANS, MAXWELL A.—Treatment of Carcinoma of the Lower Lip 401 T FARISH, J. C—Obituary 137 FEE SPLITTING FROM THE SURGEONS' VIEWPOINT—Hawley, Paul R 176 FERGUSON, G. GORDON—The'Present Status of State Medicine 258 FINN, W. F., DOUGLAS, R. GORDON—Early Recognition of Cancer of the Female Genital Organs - 207 FLUORIDATION OF WATER—Cline, Richard 537 6 GAYMAN, G. A.—Chondrodystrophy 127 GOUTY PATIENT, CURRENT MANAGEMENT OF THE, WITH BENEMIDER— Bartels, Elmer C, Kepkay, Paul 306 GROWTH IN CHILDREN—Baker, H 118 GUNN, LYNN—The Compulsory Welfare State 179 K HARRISON, W. E.—Surgery in the Treatment of Pulmonary Tuberculosis 81 HAWLEY, PAUL R.—Fee Splitting from the Surgeons* Viewpoint 176 HEBB, FRANK—Notice of Appointment 346 HEBB, FRANK—The Vagaries of Mumps \ „£.-. 76 HEREDITARY DISORDERS, MEDICAL AND SOCIAL ASPECTS OF CERTAIN— Dekaban, Anatole S : 494 HODGINS, DR. G. C. LYALL—Obituary | 325 HODGINS, DR. G. C. LYALL—"Doctor G. L. H.—In Memory"—Kidd, B 438 HOSPITAL BED INCREASE IN B.C 370 I INCOME TAX RETURNS, DOMINION, BY MEMBERS OF THE MEDICAL PROFESSION 262 INFLUENZA VIRUS VACCINE, FIELD TRIALS OF . , \ 321 K KEPKAY, PAUL H. and BARTELS, ELMER C.—Current Management of the Gouty Patient with Benemider 306 KIDD, MRS. R.—"Doctor G. L. H.—In Memory" 438 KRIVEL, HAROLD—Cretins, The Relations of the Hypothyroid State to Growth and Development 125 X, LARYNX, DIAGNOSIS—Choice of Method of Treatment and Surgery in Cancer of— Sir Stanford Cade „ 529 LIBRARY NOTES { 12, 70, 116, 161, 205, 250, 295, 347, 396, 437 M McAMMOND, E. N. C.—The Importance of Proctologic Investigation „ 73 McCOY, E. C.—Trans Canada Medical Plans : 1 * 253, 439 MALLEK, JOSEPHINE—Endocrine Therapy in Childhood 122 MATHER, JAMES M.—The Teaching of Preventive Medicine w....... 413 MELANOMA, THE TREATMENT OF MALIGNANT—Musgrove, J. E 487 MEDICAL SERVICES ASSOCIATION AND SOCIAL ASSISTANCE MEDICAL SERVICES (Prepaid Plans) 261 MENTAL DEFECTIVES, INFORMATION REGARDING THE ADMISSION OF, TO THE MENTAL HOSPITAL 273 MORTIMORE, G. E.—All Aboard 51 MOYNIHAN, I. W.—Public Health Aspects of Epizootic Rabies 441 MUMPS, VAGARIES OF—Hebb, Frank 76 MURRAY, STEWART—International Certificates of Vaccination and Inoculation ._2 162 MUSGROVE, J. E.—The Treatment of Malignant Melanoma .-. 487 XT NATIONAL HEALTH INSURANCE, THOUGHTS ON THE IMPLICATIONS OF 360 NELSON, JOHN A.—Public Health Aspects of Epizootic Rabies : 441 NEWS AND NOTES £jp 93, 137, 180, 226, 274, 324, 373, 417, 457, 539, 502 NEW REGISTRANTS IN BRITISH COLUMBIA 480, 535 NIPPLE, SIGNIFICANCE OF DISCHARGING—Alexander, J. D 163 OBITUARY: Day, Dr. Isabel m 499 Farish, Dr. J. C . 137 Hodgins, Dr. G. C. Lyall „„...„.... 325 Orr, Harold ; . ;.. 181 Ridewood, Harold Edward (1878-1952) „ 138 OPHTHALMIA NEONATORUM, PROPHYLAXIS OF. 175 ORR, DR. HAROLD (Obit.) 181 OSLER DINNER, P. G. F. DEGREE 317 OSLER LECTURE—Pitts, H. H , 308 OVERWEIGHT IN CHILDREN—Campbell, K. A *$... 119 Page 52 MIN, TREATMENT OF—IN MALIGNANT DISEASE—Turnbull, Frank _ 302 HlTTS, H. H.—The Osier Lecture (1953) _. . 308 ■bLIOMYELITIS, APPROACH TO THE CONTROL OF PARALYTIC 500 POLIOMYELITIS PATIENTS IN BRITISH COLUMBIA, PLAN FOR HANDLING 399 ■&EPAID CARE, THE BRITISH COLUMBIA DIVISION AND—Ferguson, G. Gordon.... 265 iPREPAID PLANS, M.S.A. AND S.A.M.S 261 PREVENTIVE MEDICINE, THE TEACHING OF—Mather, James M 413 [PROCTOLOGIC INVESTIGATION, THE IMPORTANCE OF—McAmmond, E. N. C 73 K>UBLIC HEALTH AND MENTAL HEALTH NEWS 18, 90, 135, 175, 225, 273, 320, 370, 399, 455, 500, 530 RABIES, PUBLIC HEALTH ASPECTS OF EPIZOOTIC—Nelson, John A RADIOTHERAPY OF CANCER OF THE LARYNX—Windeyer, Professor B. W._. REES-DAVIES, PETER E.—Treatment of Aneurysm of the Abdominal Aorta with Cellophane RETIREMENT, THE HUSH OF—Appleby, Lyon H RIDEWOOD, HAROLD EDWARD—Obit : JSAXTON, G. D.—Injuries of the Chest BCHUMAN, B.—Two Cases of Dwarfism in Childhood ESARJEANT, T. R.—Treatment of Varicose Ulcers ESTATE MEDICINE, THE PRESENT STATUS OF—Ferguson, G. Gordon. ■STOCKTON, H.—Case Reports TELEPHONE EMPLOYEES, BRITISH COLUMBIA TRANS-CANADA MEDICAL PLANS—McCoy, E. C 253, _TJRNBULL, FRANK—Treatment of Pain in Malignant Disease 441 523 408 15 138 404 129 77 258 127 267 439 302 VACCINATION AND INOCULATION, INTERNATIONAL CERTIFICATES OF— Murray, Stewart - , * 162 VANCOUVER HEALTH DEPARTMENT, STATISTICS 113, 157, 201, 245, 293, 393 iVANCOUVER MEDICAL ASSOCIATION: Annual Meeting Reports , 348 Executive Committee Meetings—Report of Chairman 14 Golf Committee 71 Summer School Annual Report 1952 17 Summer School Programme 1953 251 VANCOUVER SCHOOL TEACHERS 269 | VARICOSE ULCERS, THE TREATMENT OF—Sarjeant, T* R 77 W [WELFARE STATE, THE COMPULSORY—Gunn, Lynn 179 WINDEYER, PROFESSOR B. W.—The Treatment of Bone Tumors 484 WINDEYER, PROFESSOR B. W.—The Treatment of Bone Tumours 484 [WINDEYER, PROFESSOR B. W.—Radiotherapy of Cancer of the Larynx , 523 ^WORKMEN'S COMPENSATION BOARD, VANCOUVER—Naden, J. R 252, 372 Page 53 FOR SALE BECKLEE ELECTRO-CARDIOGRAPH TWELVE LEAD Phone TAtlow 2640 j| WANTED Temporary or permanent work in doctor's office, as receptionist and clerical staff. Kathleen McCalla 1330 Pendrell 8 years experience TAtlow 7850 Managed and Distributed by Investors Syndicate of Canada Ltd. Representatives from coast-to-coast INVESTORS Mutual of Canada Limited W HEWOFnCMNUNiprG m You will find the ideal answer to your savings and investment problems through,Investors Syndicate and its affiliate Company, Investors Mutual — Canada's fastest growing Mutual Fund. ^rnveitori Syndicate of L^andda cJLtd. ^rnuedtors rr/utual of Canada <=JLtd. NEVILLE ASTLEY cJJLitrict ft(onager 313-744 West Hastings Street - MArine 5283 Page 54
Periodicals
W1 .VA625
English
Vancouver : University of British Columbia Library
Vancouver, B.C. : McBeath Spedding Limited
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Original Format: University of British Columbia. Library. Woodward Library Memorial Room. W1 .VA625
Medicine--Periodicals
The Vancouver Medical Association Bulletin: September, 1953
Text